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 Textbook of
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OBSTETRICS
(PHYSIOLOGIC & PAniOLOGIC OBSTETRICS)

3rdEditi.on

Walfrid:o W~ Sumpaico, MD
Ed~tor--,in-chier

~fessor .
Departmer.:' 9! Obstetrics & GynecOlogy
. College ofM~cine
MtUlilaCentral'Univecity-
"t
Fhemo:o.D. Tanchoco Medical Foundation -

< Associate Editors

.
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. .l1n.elda -S . Ocainpo-Aridre-s, MD,. MHPE d , Lourdes R.-..Bian.Qo-Caplto, MQ

A~stant Frof~-8id ~hair Profeswr and:Chair '.
Depar!:rilentofObst<!trics and Gynecology Department ofObs~~and'~logy .
.College ofMedicibe COllege ofMedicine-'Philippirie Gene:nlll{O$pitaJ.
Mani!aCcr:rlrnl Univ.ersity- File:D).o:a D. Tanchoco Univei-sity of ili.C't'bilipj>ines. Manila: --
Me~ Foundation

~ ...... __ , . ...... -.- -- - - .... . - ........ ...- . . - .

. .
~!via d.e l as Alai!S-.arnero, MD Arcangel N .. Diam~:te,, .MD .
:M;soc:iate.l'rofessor ~d Chair . ProfeSS9r and Chair. .. .
'. Depa:r:tment ofO.bstetiics and Gynecology Depaitri:len~ of Ob Stetrics and QynecolOgy
lnstltute'ofMedicirie Co1lege .ofM'edicine
Far Eastern University.- Pr. Nicanor.Reyes University of the Ea~-Ra,mor!:Megsa~
Medical F.ound'~J:i:on Memorial Medical Center .......

Za1da Noblejas~Gamilia, ~D
Professor a:nd Chair
Department of Obstetrics =d Gynecology
Faculty of.Medicine and Surgery
Universftj- Jlf Santo 'Tomas

~ A~sodation of Philippine
~ -~e~cal Co~eges Foundation, Inc.
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 ,.,. DEOICATlON

To :afl. our mentors

for guiding usth:toughthe paths
of acaaemic and clinical obstetrics

and

to a:U .mothersand
their unborn children
for entrusting us with their lives
as fheir caregivers~ .

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PHYSIOLOGlC & PATHOLOGIC OBSTETRICS

Dedication . :; - vii
Foreword XV
Contributors xvii

PHYSIOLOGIC OBSTE'TR!CS

Section I

CHAPTER--1
Ove.r vlew .of MatemalPhiltppine Obst~trks_-(Epidemiotogy) 1
I

Mario ltFesttn,MD,MSiMHPEd -.
CHAPTER2
Un4erstanding and Using-the'Medk~J Ut~rattrre. . . 1-9
Lora .Garda-Tan~ngco, M,D; M$c
-CHA:P-lER 3
Anatomy ofthe;Female Repro.cluc;:tive tr.aet 47
Raul 'M ...Quillamor, MD and Espe@nza 'J;J. Ca!og.ue -lan.sang,MO

CHAPTER4
. ..
-P-hysiolo:9Y -of th:eN~:mnaiM~:nstnr<ti-C.ydce 61
Del~n A.@n,M_O
C:HAPTER5
. .R eptodudiv:e Ge.n-ctk.s . _8 1
Cdrrhendt;~ Davici..:Padilla1_MD, MAHPS a_n9 Eva Mana .Lu:ti'Ongco--de Ia Pat,. MD.

CHAP]J:Ro
Reptod~dive immunology 103
w...
W..ilfnd~ Sumpaic.o,~Mo
. CHAPTER7 .
A~ststeQ R~prdudive Technol:o gy 111
Le0na.rdo A. Almeda, MO
.... r
--CH,APTER- 8
..

Psycholo.g y (if-Pregnancy '. 125
Aquilino 8. Esguerra, MD
CHAPTER_9
Bioethk-s )3 9
Jose.phine-M,_Lumitao, MD,.MHPEd

Section II Physiology of Preg-nancy- .

CHAPTER 10
Enqometriufn and,Deddua 147
Aida Villarama-.5an _Jose, MD ,'

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 CHAPTER 11
Placenta and Fetal Membranes
Ma. Socorro M. Solis, MD 165

CHAPTER 12
Placent-al Hormones
. . .
Ulia Pagtakhan-Luna, MO J91
CHAPTER 1~
F~tal Morph:ologkal.andPhysio.logical Development
Lyra Ruth CletnentE7Chua, MD .. 207

CHAPTER 14
Mater,na!Adaptations to.Pre.g_nancy 23l .
Ma. CrrStina
. ~
Pelaez"-(;risologo, MD
~-

S~tion . lll Ciin~cal J\ppro~ch to Pieg nancy

'CH~PT&R 15
Diag{losis of Pr'e.g n.anc.y
lmeida $. bcainp<rAriclr~~ MQ, MHPE..-1 .
247
CHAFTERl6 ..
-Prenatai:Car~:ohhe:Healthy:Woman..-.
. :257.
Areta~ 'P.'.$ings'orr.A!Ci~y;Mo .
:cHAPTER l7
td.entifica~ion of:High .Risk Pre_gr.ancy
:Ro5endo ~:P,oqu~.-MD 279

-CHAP:fER ~ 8
tlo~~tn.vasi;re.J\ntep.attum As~essmen.t offetal'Weli-.Being -.287
ArtaAf:fei-'N.;ei:amanter ME>
CHAPTE-R 19
Pre.natalOi.a_gnosis.andlnvasive Te.chniqu~s.toM9nitor ~h .Fetus 303
. -Leah S~orro .N:Rivera ,MD
CHAP~R20
.O hstetri.c .IJttrasound
Ma. Tdnidaa .R.Veta>MD 323

.CHAPTER 21 .
Drug~, Medications and lmmunhations Dur.!ng Preg nan cy 34 1
Maria Stephanie Fay.S. Cagaya n, MD.

Section IV Clinical Approach to Labor/DeH'very

CHAPTER 22
Parturition: Biomolecular and Ph)rsi'ologic Pr.o cesses ' 357
Ron;3.ldo.R.Santos, MD :.

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:CHAPTER 23
The Passages. 379
. '~orazon Medlna-Quesada, MD
GlAPTER 24
The Passenger 389
Anne Marle C. Trinidad, MD

CHAPTER 25
Mechanism .o"f La bot in the v~rtex PresentMion 397
Patria P."Punsalan, MD

CHAPTER 26
Conduct of Normal tabor and Delivery 405
Jocelyn M. Zamora-Marianci, MD

CHAPTEH 27
Intrapartum Assessment 423
Virgilio B. Castro. MD
CHAPTER 28
Obstetric An~sthesia 437
Roland s. Capfto, MD
CHAPTER 2~
. . .i-. ..
The Normal Newborn 445
. .-. :"' .
Jacinto S!as V. Manta ring Ill, MD,-MSc
Ma,Asundon A. Silvestre, MD
Ma.Esterllta V. Uy,MO
';',

Arnell~ R Fernandez. MO
Rachelle M. Perez. MD
CHAPTER 30
The P~erpeclum 461
Mii.c:lflf;Q$ J~"Da:J.ots.on, MD

PATHOLOGIC OBSTETRICS
SectionV Hemorrhages iii Pregnancy
CHAPI-ER J1
Abortion (Miscarriage) . 471
Zaida Noblejas-Gamilla,MD
CHAPTER 32
.Recurrent Pregnancy loss 479
Ana Ma rle ~ Madamba-Burgos, M_D
.CHAPTER 33 .
Ectopic Pregnancy 499
Regta L Pichay, MD

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 CHAPTER 34
Abnormalities-of the,Pl~centa,. Fetal Membra:n~s and Amniotic Fluid 515
Susan R:Pelea-Nagtilon,MO ..

CHAPTER 35
Gestationai'TrophobJastic Disease. 527
Lourdes R.Sianco-Capito,MO and Agnes L Soriano-Estre lla, MD
CHAP~R 36 .
Pfacenta Previa 553
Hamon M. Got~lez,.MD
cHAPTeR 37
Abruptio 'Placenta 561
Evelyn p. Pataypayo"':AAD
,,
CHAPTffi 38 '
OiSse.i ninated.'lntt-a"ascular Co~gufatio.n'in Ol;>stetrlc5 573
Corazon T.Um.MD and Carmen T.N3raso, MD

Section VI Complications in Pr~:gnancy

-CHA.mR 39
Hyperte.o$iV.e.Ptsea$"es.in P.r~nauc-f. : sas:
~lfridoW;.S~mp,oico, Mt) .

CHAPl'Ea-40
Mul6f~i --~~ncy 605.
. Val~e:tlempo .i;u1nto,MD .
.CHAPl'ER 41 .
Pr~term '4a'r. 623
Ma-rio'X llema:Hoo, MD
.CHAPTER 42
.:P osttetm :P r9n.ancy :641
.Ma: V;~ .s..Vaimonte-Torre~,-MD

~HAPTER 43
Jnappr.c;~p~t~~~~lGrowth 651
Maria 'l ourdes &Cbloma;MO
.CHAPTER :44
P.relc-i'bur Rupt1,1re:of M embranes 665
Ruth VllfanueihGutierrez. MD
CHAPTER 45
<;ongenttal Malformations and Inherited Dise ases
Ana Marie R-Mada.mba-Burgos, MD

CHAPtER 41?
. Diseases and. Injuries o~ the fetus and Newbo rn Infant 701
Virginia R 'de .Jesu5,MD, MHPEd

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Section VII Dystocia
CHAPTER 47
.Dystocia Due to Abnormalities of Powers 715
Sylvia de las Alas-Ci3rnero, MD
. CHAPTER 48
Dystoda Due to Abnormalities of the Fetus 727
Angel-ita R.Teotico, MD '
CHAPTER 49
.DystoCia Due to Abnor:malities -o f the Bony and
Soft :Pa-1-ts. Passag.e s 753
Ditas Cristina 0. De-c-en a, MD
;..- .
Sect1onVliJ Operative Obste~r~c:s
.
CHAPTER 50
Br.ee~h-D.etive-ryT&hniqu~s 165
Emesto S.Uic:hpnQ?,MD .

CHAPTER .51 _. .
lnstrumental Vaginal 'Oe livety: Forc~ps <md \!~cuum Extrac-tion 779
PiJ-arT..Laginan-Dy,MD
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CHAPTER 5;2 . . - ..:. ~

Cesarean SectiO"n-~nd Cesarean Hyste-re-ctomy . 793

carmendta ,s. Ton-ge(), MD
, , ; .

Abn-ormalltiesof the P.uerpetium

CHAPTER 53
Abnorma'liti-es.ofthe Third Stage of Labor 819
:FJorae:nzat;;rsartazar,-Mo -
Q-1APTER 54 .
Puerp.erai-lnfection and other:Abnormalities ~ofthe-:P..uerperium 835
QscarV. Resurrecdon, MD

CHAPTER 55
-h~judes of the Birth Canal 845
Nora A.. Martin, MD

Section X Medical, St_rrgka.l ar.d Repr0ductive lllP..esses Affecting Pregnan~y

CHAPTER .56
Cardiovascular Diseases 855.
O)ristia $. Padblina, MD
CHAPTER 57
Pulmonary Disorders 865
Patrick Gerar~ L Moral, MD and Judith M:Sison, MD

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Endocr:ine. Disorders . 877'
Anna Belen lgMtio-Afensuela, MD
CHAPTER 59
Infections 901
Ricardo M.Manalastas Jr, MD
CHAPTER 60
Trauma and S\Jrgkal;Complkations 923
Man!Jel M.Ramos.Jr.,.MC>
CHAPTER 61
Can-cer 933
:G11 S.'Gonzaiel..MD ..
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CHAPTER 6l '
Renal 'Dr~as~ . ~947

Mana.Teresa C..lur~a,Mo and Melvin R. MarciatMD

CHAP~R 6.3
Gastr~int~nal Abnormaiities 967 .
. Marlyn T.p~,:MO,MhPJi:d and Melchor.M.Chan,M~
CHAP-:1. 8{~:64: '
Hemato"togi~lOlroriteT$ . 9.81
Honora~V;'$~<tO::S<lyton/MD

C"tAPTl:R -65
Oennat~ses:otP.regh~mey:. 995
Gi!orQlna-t:~otfide:~D::.i. ~ <.: .

S~~ionXI Family Phin'nin:g

CHAr'fat 66 .
Overlew ~~family PI ann ing lOll
Enrko
.
.GHC. 0blepJaS,,MO .an9, Virgilio..
.
R.Oblepias.ND
'.

CI::IAPTER 67
Co nt~<:eptio n
Al~j"andr<J fL .San P~ro, MD

CHAPTER ~
steriliution 1045
Enrico 'Gil COblepias, MD ah9 Virgilio R. Oble pias, MD

CHAPTER -69
Naturalt=amHy Pla nnln.g 1057
Ernest9 G~ Moreno,MD

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 Foreword to the Third Edition
r .... -.

It~ bten more th4il a decadt since the I~ edition of the textbook was printed'
but Its editorial ~n retnalns as dear as ever. A t~books basic goal ts to .g:vi .
information on th~ subject at h2nd. The;efore. this teXtbook is aimed at giving
lnform.ctlon on .til ,aspects of normal dlid abnormal obstetrics. The .authors were
task....-.d to apply 'infannation at the ievd of:~ Jn(:dlcal graduate.

\Nh:at .gives meaning to a textbook ls that ~. contents are correct .and current.
Wr'iting .on .medical ~hets which haVe :~ the 16t: of time gives continu.i~ and
stablli9' to the contents:but what e:xciteswiU be .the new and updated m.edmnisms,
tethn1Q!Je$ .and .proceduFes lli ihe s.jmclal~

What puts cha:-acte; to a tex!boo'k is tts rdcvance to the readersh!p. Any topic, no
matter how esoteric. will find wide readecllip because the obstet.Jic:car~giverfeels
the ir,npact ofth~ words on his cbi!Y clinical practice in .todo/s Philippine milieu .

.fwai!J.'..''!h;!!. ~~-e_kg:m~Jo.:a..b.ookJs...the:fluidi!y. .of expression of.the.writkn

word Jn the var.ous topics contained ln the textbook. .Great pains were taken to
ensure easy readabilio/ In language. grammar and s_ryk.

lt is therefore the right mixture qf correct, current and relevant lnformatlon writte.n
w'ith Huldiry of expression that shall ensure the succt!S;S of a t~book.

With :every neweditlon.. w~ bid goodbye to~ writers of the prCvious ,edition and
we say welcome to the new authors. We thank them all for their commitment. time
and ialent. Spedal thanks to Mr Nelson P. ~o'for his proofre<iding skills and to
Ms Susan 0. Howdl and MS' Jenny G. De Guzman\ our ever-efficient secretaries.
who compiled manuscripts and caJoled authors endless~ wHh timelines and
dead!lnes . .

Maramlng salamat poJ

~~~~
Walfrldo W. Sumpaico. MD

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CONTRIBUTORS .. .::r....

.....

ARETAS SINGSOH-A.LDAY, MD LOURDES R.. BLANCO-CAPITO, MD

Professor 8lld Dean Professor and Chair
JondtaFoundation Sr..hool ofivledlcine Depiutm01~ of Obstetric~ and Gynecology
UniversityofPe:rpetual Help System DA.I,TA ~llege .o fMedicine-Pb.illppine G-eneralHospltru
University of the .P hilippines Manila
~DA.S. OCAMPO-ANDRES, MD, :UUIPEd
ROLANDO SORIANO C!-PITO, MD
Assistant Profe'lSOr ;md Chair
Associate Professor
Department ofObstetrics :and Gyne<:ology .
Department ofktesthesiolqgy
college ofMedici..e ;C<Jllege mMedicine-Philippine General Hospital
Manila Ctntrai.Uni.,ersity, - Filemon D. Tanchoco University' of the Philippiries Manila
Medical Foundation
'SYLVIADE:LAS ~0, MD
uNA.BELElH. ALENSUELA, MD Associate Pr-ofes!0r and Ghair
M&st:aD.tProfessor DepartmentofObstetrics and GynecOlogy
Dtpattl'lientofObstetrics and Gynecology InstitUte of Medicine:.
InstitUte 9!M$cine Far Eastern. University-Nicanor Reyes
rar Eastern University-Nicanor Reyes Medical'Found'ation
.Medical FoGndation
"'1Rli1L10 :B. ~.\.STRO, MD
J;EOHARPQ A. .ALMEDA, 'MD ProfeSsor
~~~ Dq>artment of Obstetrics .a nd Gynecology
Dq!artlnentofObstetiics and Gynecology Faculty .Of Medicine and Surgery
l.1:n:iversit.Y ofthe 'East Ramon Magsay say Univ.,rsity Of Santo :romas
..
;
Memorial Meqkal. Center
.M:ELCH.OR'M. C~, MD
Assi.st...ahProfessor
F.LORDEuzA.M. BALTAZAR, MD
Section ofGastroenterology
Professor
Facultr .oLMedicine and Surgery
:Dep~t ofObstetrics tilld Gynecology
Ur;iversit): of Santo To~
I.nstitUte ofl;ledicine .
F.ar ~l,'iliversicy:- Nicanor Reyes LYRARvn CLE:MEJ'ITE..cHuA, MD
. M~ Fou.ri.dation Associate Professor .
Department ofObtetrics and Gynecology
RQNORnA V. GlbNGCO-BAYLON, MD C<>llege ofMeG:i.cine
~Pr~ . . Manila Central Uil.iversitr- File:nton D. TanChOC<l
Pepaitrll~ oftnteroal Medicine ..~Wical Foundation
COllege'orMeaiCifte .
- u~~Ea:stRamot'fMagsaysay . MARIALO.URDEsB. CoLOMA, MD
Memorial Medical Center PrOfessor
D~artmentof Ob stetrics and Gynecology
KAJUO A.~~ARDmO, MD Faculty of-Medicine and Surgery
Assistant In"fessor University of Santo Tomas
pep.artmen:tofObstetrics and Gynecology
MA... CRIST"iliA PEL.A:EZ.erusOWGO I MD
lnsti_tuteor:Medrcine '
Clinichl-Associatd'rof'essor. . .
Far EaStern University ~ Nica:1or Reyt:.s . .. Dq>artn:ient ofObstetrics and GyneCology
MedicalFo\IDdation
College ofMedlcine-Philippine General Hospital
University of the Philippines Manila
AJJA MARIER. MADAMBA-BURGO S, llill
AsSociate ProfC:SSCr VIRGINIA R. DE JESU S, MD
Department of Obstetrics and Gynecology Professor . .
College ofMedicine-Philippine General Hospital Dcpa..rtrilent of Obstetrics and Gynecology
University.of the Philippines Marilla College of Medicine-Philippine-General Hospita).
University of the Plillippines Manila
AlUA STEP~ FAYS. CAGA7Alf, 1-t~D
Associate Professor EVAMARIACUTIONGCQ-DELAPAZ, MD .
DepartmentofPharmacology and Toxicology and Clinical Associate Professor
Department of Obstetrics and Gynecology .Departtoent ofPediatdcs
College of Medicine-Philippine General Hospital College of Medicine-Philippine General Hospital
University of the Philippin;:s Mf!~nila University of the Philippines Manila .. ~

. -:;!!_

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 C-ONTRIBU-TORS
D.ITA.SCRI.STINAD. DECENt.:. MD.
Associ.ate Prof=or
Dep~tofOh~.cs,~dQylle<?Ology
Faculty of Medicine SJ;id-sut:gecy
University of ~to TotmlS
MAR{.Ylf"T. DEE, lliD. MB:l'Sd :
~Professor
~Cn.toeobstemcs-e.:na oyn~
F~--ul!y of Medicine.a,nd SUrgery
-~of Santo Tomas
.ARCAlf~N.D.~MO
ProfetS30!'~ cnrur
Department of-ObStt!trlcs ~ -Gyneq)logy
CQi:lege OfMediqne . FacUlty. of-Medicine and Sur:gery-
un.iv.Ctsity.of~ East-R!\ix).on Nag~
.M.~-M~~
P.it.AR T."~~DY,.MD
A~.atePmf~
:St:.:Lulce'a -~ .ofMe<fine
:V.'llial:a:iL QUasl:iaM~orlal
"AQunD()B.~:l;:P .
--~~~~tl,Ui,Gyl).eCol<>a'
=::::;r~St;~n~
M~~ -Ci:utd . .
..-~~~~~.i~. ,,ro
~tofobstetrit:a-mid~
~-~Pbftl~e~ifoSpitsl
.Uni.v'erStr.oftiie-~Pfn~~-
..Uttttx:R..~FEruwro~J<ti>
'Pror~~~}
conqeaM~e
lJniY~.oU:h~.:Pliiliwin.:S<M~
:MA.IUo R..FEstm. w, ~ li:lliP:Iw .
-~
~e;ri.t-ofObste.~.mili~!Ogy,
-~e:ot~ed.iclnC,:~ih.e~:H~ltel
unif~ty. tif'the:~PP~~~
ZAlDA.NOBLEJ~ lJ
~fe#>r;:and(l:hai.r . . Assi~i:.antProfes:sOr
Depa$ientof (').bstetrl~ -and:Gy:i:l.eoology
Ffte\!lty ofMedi~e imd~ery
Uhlversi_ty of&mto To~s
GIL B. G<>ZAL"EZ, MD
A.s.3oci.ate .Professor
Department ofObste~~d :Gynecology
Fa<::ulcyo!MedicineMd Surgey
~veni.ty of.Saoto Toma-s
~ ..
lUM{}N M.. GONZALEZ; MD
Associate ProfeSSQr
Dep_artment ofObstetrics and Gynecology
F.acultyoiMedicineand SUrgety
University of Santo Totrul.S
VALE~ TiZMPO Gt:J!NTO, M:P
Clin.ical.As00<;1ate.PJ-ofessor
' IX:partmento'fObst~ andGyri~olqgy
COllege of.Medicme-:Pbilippine General -Hospital
University-of the l'bili.ppme.s.Maillla
.ROTH~.A-.GU1'1EIUmZ, ldD
hot:es=- ::.'
Dei>~entvf6b.steirics s.nd C~co!ogy .
Univers;yr of'Sa.nto Tomas
,Jo~IV.G:ROS J, ~...JOCSON, MD
Associate:ProfcsSc!r
~t ofQbstetrks an<l:Gynecology
Co!legeofM~e .
Manila:Cen~ U:nivetsity-FilemonD. 'Tanchoco
Medical FoUI;~dation
-~U"l'f:.~OE-J;AN~<lMD..,.~' ..
Dean
AMASchoolofMedicii,le
COJL~ 'Ti~MD. .
-~
..~of.O~tric::t ~ Gynecolm -~
. rarolt.r orMedicme;iul(l::su..~e:r -
' '. . Un:iveisity.of ~toTo~
J.OSEP.B:IRE lL Lti'MITAO, M D. MliPE4
~ .
Dei>aitmentofQbst<;~ a.i:ld"Gyn:ectll~
Facultyof-~edidne and Surgery
TJnivty of~to Tom:a.s
LILIA'PAGtAKHAli~L'UliJ,. MD
:ProfesSor
Dcpartlllent of0~;;tetrics..an<,l Gyqecolm .
CO!).ege OCM~<:!ne .
Far ~tem_pniversity- Ni~or :aeyes.
Medicii.l Fou'nd.lll.ion :
M.A.RlA. TEREsA-C. LUNA, MD
Depm:tlent oH:)~stetrics .an~ G::yp.ecology .
Faculty.ofMedicine and .Surgery
University of Sant o Tomas
RICARDO M. MANALASTAS, MD
Professor
Department ofObsteqjcs and-Gynecology
Colleg~ ofMedicine-Pl:illjppin~General Hosp~tal
University of the Philippines Manila .
Scanned By: ~
JACINTO BLA.S V. 'MANTARniG Ill. MD;.M~ C.ARJoll<.:NCITAD~Vli)..P.ADlLLA, MD, MAHPS
Associate Professor of.OJrtJcal EPidemiology and Professor
Clinical .Associate Professor ~?ar-tment of Pediatrics
Department of Pedia:Jric$ . College ofMemciD.e-Pbilippine Gene:ra1 Hospital
College ofMedicine-~ppine GCn.erai Hospitaf University of the Plillippiries Manila
University of-the Philippines M~
CHiUSrlAS. Pl\DOLffiA.l-4D
'ldELVIli R. MARciAL~ MD A5Siitant ?I'ofessor
~tPi.vfessor . ' Depa:runcnt:ofOb&tetrics .a nd Gyne~logy
CollegeofMedicme
Departm~t-of.M-edicine
Fa:Cul!Y ofMedicine and.Sutgety Un.iYttsity ofthe Ea:st Ramun Magsay~
Universi(y of.Santtl Tomas Mem!>rlal Medical Center

~YIUARq::O-PALAYP.AYOlf, MD
.~Yil H. ZAMORA-llfARiAl'O, MD
A~e Profes.!>Or
~tPioft=or
Dep~~-<JfObstetik$~ {jyne<;ology
Depmtmett of0bstetrics-'an~J:Gyneco1ogy
lnst:itUte ofMedi.<;ine
Faarlt;y ofMedicine and S!lr.gey
Far'Wtttn University- Nicanor Rev.es
U.niyer:si9' of;Santo T~mas
MedicalFou.ndati~n ..
!roRAALllER:f()-M:Aklm;'ldD
QEORGP'iA CONCEPCIOlf.:PASToRFIDF.., MD
A:ssista:nrProfSS91" AssQciate P.rofessor
DePamnentcl Ob:rt:e.tr'~ahd~necology ~etit ofi;)ermat;l)logy .
mstitl.ite orMe$cin:e CollegeMM;:ditin.e~~e eeneral Hospital
FatEa&em University-' t-rlCiinor Reyes
MedKal F-oJll)'d~ . . . U$trsityo[i;he ~in~~

PATRIC~ G;:;;R.Aim ~MORAL, .MD

. ~tPrPfess<ir .
.nepartment~~ . . ..
~.ofMi:d;i<::ilie. ~~ery .....
~
lJni~~ty"'o~~tp 'Tomas : ....
. . -REGT~L. PICHAY, -Ml> \ :. '/-,; . .. ~~
SusAl'fR.:PJiiE..."NAGTALOlf: ;MD A.ssoci.ateP.rofessot . .. . ': ~: :ct ~,..,-;.:. .

Associa:tel'tofeS'S';)r Pe:P.e.rtnl.e nt of Ob:s:tetrics and'GjxieoolOgy .

Departm!:nt.oWti~cs. and GYnecology Col!~e .o!Medicine .
~J~fM~e. . Manila'CWfrallfui~ty,. Filem6n D. Tanclidco
~exsityQftb~~.~!m M~~y Medlcal:Foundati.on
MeplOcihl Medical Center
PATRIA P. PUNS:ALAN, HD, MHA.
CARM:ENT- li'ARCISO, MD Professor
~:~!~(Retired) ~t of.ObStet;rics and.Gy.nerology
~entotMedie
FacultyofMewcine and SUrgery .. Faculty.,of.Medicine.and $urgdy .
University of.S anto Tomas
Univeclty of Santo Tcml:"-s
...
.CO~N MEDINA-QUESADA, MD
ENRICO GIL c. QBi;EPIAS, MD Professor
.Associate PI:ofessor ~epartment of Obstetrics and Gynecology
1)epartment.of0bstetrics and Gyn~cology. Faculty of Medicine and Surgery
D>llege.ofMedicine-Philippfue General Ho~pita,l University of $anto Tomas
University of the Philippines Manila
RAUL 11. Q'on.LAMOR, MD
VIRGILIO ;R- OBL'EPIAS, MD A~stant Professor
Professor end: Chair DepartmentofObstetric:s and Gynecology
Department of Obstetrics andGynecology College of Medicine
Jonelta Foundation :Sch ool of Medicine University of the East Ramon Magsa:ysay
University of Perpetual Help S)tstem. DALTA Memorial Medical Center

Scanned 8y: ~
l4AJroEL II. R.UiOS JR., MD WALFRIDO W. SUJIPAICO,; MD
Profe8sor . Professor' ' .
DepartmentofObstetrics and GYQecolQgy . .Department 0( Obstetrics and Gyn~C()logf
{Aj.Uqe of'Medicine College dMOOicine
Univc::mty.ofthe&st Ramon ~agsaysay Manila ~tt81 ~Sity-Filemon D. 1Bncboeo
. Memorial Medical Center Medicalfo\Uldatian

OS(:ARV. RESURRECCION, -M D DEI;FDIA. TAH,liiD

~ .$ectiop Head "
l>e.PartJnentdObstetrica~dGynecology' Reproductive Endocrinology, lnfertility.a,nd G)'lledllogic
Ccl1ete OfMed.ic;ID,e End()S(:Opy
Uni'Yenit;r:Offlle~ IWnon M~~Y 'QepanmentolOb~ -andGynec6J.ogy
M~Nedid\ICeilttt
UnitectDottonMedicalceliter

LORAC1AR:CIA-'l'AX~, .:'IQ).
'J.EAB~RROX. ~.im
A.Aridate Jit9~ Chair
Departmer.toro~~ GyueeoJ.ogy
~ent~Obtt1CJen.ci Gy;neC:ology
F~iy.oCM.edidne ~ Surgery Asian H()$pn.4and 'Mcl!ic:al 'Center .
U.DiV:r$it)' .of8$nto TOiDBS .
AlfGr.uTA&'ftODCOt Jim
ASSistant~
.RQ$E$)0 IL Jr;OQ~ MJ>
~~t:A(~a,nd~ogy
~ COUtgo;of'~
. l>q.ar'bJl~t.~~cs. ~d Gyne<:Qlogy
M~Ctl~'UniVet'$ity-~nt).'J'~bCO
Fac\21t)'~.M~~Surgecy M~ FO\tnd::Qci! .
u . ~.o . r~to~
. .- . . .
. . : . ' .:_. - ' ., : 4 ~tl'A1J..Wlt~trn- ...
A!DA~-$ABJ'O~ :Ml) . ~ate~
~~ .
.~:{)l~mtd.GynecolQ_gy
. ~~~~cs~~Gyn~logy . .

.r=~*~~~i~~-
~elM~
UniVtt$itr~~~~onMagsaysay
MeuiQtih,l~ ~ter .

JIA. 'VlCTO~~AU.IOltJ'&.TO~.J.lb
.aur.:"ID~---.P.EQR~);-Mn' . ._. ~:~ ' .

L~i::m~
~d~~~.
~qf~e
M!ti1!'.!~~1rii-
~;v.:~S!!<!'
. ~.,y~ fi!en;um D. ranQl,oeO
'Medical.FouilautiOn . . I
~~c.'riUIW>Ab,lolD.
e~~.twf10~.t MD . . . . Associate~ .
~att:,ProC~ .. .. .. DepartmentOfOb~ atld ~ynecc:)lqgy
J)ep~ent:Oi:Ql)~cs-and Oyn~lQ,gy , . or
faculty ~~:and:Sutgery
Jnstitl.1U:lil-JI~e . ... ': <' .... : - . Univenity ol:Sahto'tomas
. Far... ~U~tY
. . ~ ~(ii-
. .
Reyes. 'MedicalFoundaiion
. . . . .
ElUJEsTo:S.lJICBAl{CO, Ml.>
PI'Ofessor
. ~~en~oco~ anaGynecc>lbgY ..
,Qollege ofM~e-Pbilippine :(k:nemlH~ital_
Uciversity ofthe 11lilippin~a Manila .

MA. .ts'flilRL!'fA V. UT,IQ>

.JUDlTH)ol. S~N, MD ClinkalAssociate''Ptore~
:Pi-Qce4slir ' Depanme!itofl'e$Uri(:s
DepartmentorAnatomy Philippine GenCi"8,l'Hospi~
FaCulty.of Medicine and Surgery . University of the Pbilippines Manila
UniVersity. OC $anto Tomas
:MA. 'I'Rilm>AD R. VERA, l4D
MA. SOCORRO :!I. SO~IS, MD Associate Professor .
Assistmtl'.roreasor Depaitment o('O.bstetrics and GYQecology
DePartment ot:Ob.s tctrics and Gynecology CJ9llege of Medicine
InstiQ&te~Medidne University of the 'E ast }Wnon Mag~ysay
Far Eastern:{!njversity,. Nicanor Reyes Medical Foundation Memorial Medical Center .
.

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.....

...~''

OVERVIEW OF MATERN_ti~
HEALTH IN THE PIDLIPPINES
MARIO R. FESTIN, MD~ MS, M.HPEd

The Problem of Maternal Morbidity and MortaHty

Definition and Background of Obstetrics

VItal statistics

Reporting Critena

CurrentAntenatal Care .in the Philippines

The Birth Certificate

Past Interventions in the Philippines

The R0le 0f. MidWives in Maternal Care in the Philippines

_The Role of Obstetricians in the Philippine Health Ca re

The Philippine Health lns~r.ance Corporation

banned 8y: C
 SECTION 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

'THE PROSLEM OF MATERNAL MORBIDITY 1. Counseling, information, education,

AND MORTALITY com.inunication arid clinical service.s in Camuy
planning;
. At 1e~.st 40 percent of women experience ;2. Safe. motherhood, including antenatal tate,
cotriplications during p~gnanc;y, childbirth, or :~are delivery care (skilled assistanc~ for
-aftei' delivery, and about 15 percent de'V'elop delivery with suitable referral for women with
, potentially life~threatenin,g problem$.ln fact. ~ore ob stetric complicatioilS) and postnatal care.
than onc-.t hird of the glol?aJ. burden of diseases breastfeeding and infant and women's hetflth
tor women aged 1~-44 and ov-er o.ne'-fiftll. f9r care;
~m.en aged 45.-69 '~ caused by nditions that 3. Gynecological care, including prevention of
affect .women e,xclu:siy.ely. ~ ,p.r:~domimmtly. abortipn, tr-.eatmen-t of -coxnpiieati.oJls o:f
,Clo$e)i ,related to 'the ,ct1li~ -ma~ :peribd i~. a'bofiiQ.n .and -safe te~tion of p~cy
1;he:erifl.ealfitstm9ntb.oflifa iiHhe ri~,~od ruJ ~wed by taw;
.~ . jt. m:ts Ul~':g\lality ()f..Ufe pr 'the im!i~du~. 4 . . Prevention .a.nd treatment oJ s~.xually
"The:Wotfd lieatili Org~ization estimates thJJ.t tr.anstnitted diseases (induding HIV[Al,DS)~ .
-ev.ei;Y y~ more than s million .i nfants .d ie bef~re including condom distri'bution, univ~rsal
'thdt :first birthday. while JD.ore than half sUr\ll:ve . precau:i lons aga inst tr-ansmission . o(
ior:~:js than a xnonth. bloodborne infections, wluntazy testing -~d
c::ounsell.ng;
~us., the ~;arid econon-.iccostscfwomen's 5. PreV'ention and mat. "~gement of se-xual
disabilities .and deaths is enonnou:;: at least 3040 vi'Olence;
' ~tor irifant deaths :rnay be the tesult .o f ~e 6. Active. disco.u ragement of harmful traditional
1'ti(;.tl.t:~ts .pQ!)r .heattb..~a.nd. ,.-po.o:r. ..-car..e. :dllnng:., practices. ~uch:.as female- geri.iW .mutilation; '
. :~ey $la'delivery.' Poor ma~_~h~th -and and .
nutiition contribut~ ~to--low , birth' wei,gbto f about . 7. Reproductive he.alth progr~es for specific
20. ~nt of babif!s, who are at .g reater risk of . ~ro1tps .: such as adolescentS.- indudjng
..: :~~~o~. Jl).$.1:1t.riti;()p.! .,.19~i}~,t~~ . d~S;a))U~t~~$
...iri,d,l.lifing visual~dh~g:nnpsum~ts. team.mg
" infonnatiatr;- ~.ed:u~ation, coXiiinUnication ~ .. ,
serti~s.
, di~tiea . ap:d t::>,ental ret:e.roation, at)d dea~.
MQfbeness ~ -ate 3-times mo:n: likety:.todie
,Wlt'bJn 2ye&rs. or geU~.health care and :educatioJl I!l.vestitlg in reproductive ~ea}th ~<1 ~~
~Jlk;y<p up:It bas been estimated th~t about . in- ,g.:~t ~~!yve efr~cts _for ~h~ .re~t o.f ~cty,..
. ~t ofpn<gnant women m ...e : c u.wppmes . th Dlo.=-t: .
starting with the surV1v~l and education .of
13 ChenucJ which Teduces. thqr e.nergy,
# '
and. can children, in~eased pf(Xluctivity of men, wC)tUen, ..
!d~ their intoPles .(FNRl Research Data~2000). and children (in 5chool)., and reduCe,f.l fertilit;y that
.W",n~n women cannot work becau~e of health absorbs growtl). benefits. Matemal mo.rbilit;y -~
pro1)1~s. the loss Q(t}leir incom~ and _theoo$t-s. af in fact be :reduced without first aChie-ving high
their.'t reabnentcah decrea.se famUy welfare or drive levels of economic developtn'ent sir\ce many or.the
. tb~Jamilies to debt. existing interv~ntions ~'ld .programs in these.
_.- ~~~roductfve
. .. health is a st~t~ -of .complete
setting s hav.e been proven t.o be effective ifutli?;ed
properly. Good maternal health services can 1!.).50
VhY!lal, mental and s~cial well:b~ing. an~ not strengthen the entire h e alth sys tem, since many
,~etely -~e absence of dt~ease or ~nfirnut)', m -all
of the requirements for the health of the f~
iriatt~rs .r elating to the reproductive system and
would provide already more than half of the
t~ ns functions and processes. Reproductive
heAlth the~efore impli~s that people are able to susceptible population,
. have a satisfying and safe .s ex life and that t~ey
The local situation in the Philippines prov.ides
'havethe capability to reproduc~and the freedom a more compelling argument. Efforts by marty
to .d edde if, when and haw often to do so. It also
sectors in the Philippines, oftentimes witp
-intludes sexual health, the purpose of which is
from multi,..lateral ~gencies show-that- . .
.the. enhancement of life and personal relations. assistance the rat~ of improvement of the state of maternal., ~~.
Reproductive health services cover a wide health lags behind some of the countries in the_ , } j ,
rang.e of program ar-eas. Comprehensive region and some countries with the same level o~.; ..;f' .:.
~ei>rOductive health care includes: developmeqt. : .. ; ~
: . ~:;.:,~
. . '-"

Scannec18y: ~
 CHAPTER 1: OVERVlEWO!= MATERNAL HEALTH lN THE PHlllf?P.INES ,..,. 3
--'---------~--------~...,__~---------'-----~-~--------.......-"'~E!~?;

Ten Filipino women are said t o die every 24 In 2-003, the under- fiv e mo~tality wa~!~ ,
h tmrs from pregnancy-relate d causes (SPPR estimated at 40 per 1000 live births. The MDGs
2000) 1 The matemal mortality ratio (MMR}. .or were based on statistics that s howed pregnancy
maternal deathsl per 100,000 live births; was and childbirth related conditions as among the
reported to be 2.0~ ?,n J993 .and 1'12 i.o. 1998 leading causes. of -deatl;l, disease, and disability
(NDHS 1999 and 19:98}. Alth~mgh_world s tatistics among women of r<;_producti~ a ge in d eveloping
on MMR in -2QOO.m the .table ~low s how that the countries :~uch as the .Pbilipp~n:es.
country?~ MMR is le~~ th~ wotld ave rage, the
experience of.Srj I.anka wi.th a 32 MMR shows that Also included-aio..ong :the MI)Gs is to nave
developing countries tan achieve rates that_are . univer~ access by-2015 :t~ the -~d~st possible
close to that of -dev.e loped .co~I.ltries. .ran~~ -of .safe -~nd effective -fami ly planni ng
-:r;neth:o.(;ls, il:lcluding barrier .methts, a..'ld to the
'"'~ The .Philippm~ .-tQvemmep,t, as part .of th:e tolloWing rdat~4 reproduytiv.e . hea1,t h ~ervices :
{)nited N.atkms, has .agreed to follow as part of the -~ssential :Ob-sl~:fric care,. pre~v-~ntion and
.Mill~um Developin,ent Goal,~ ;{ MD($). a po.licy .-i:nanageme~t ot r~proq:uctive tract in fections
to teduce m~tetnal mortalit;y rati!)s by three-. including -sexually trans mitted infections_ 2
-quarters and Und~r.::five m ortality ':by tw.o-th.kd-s Essential, .o bstetric c are erlconip~sses p;eparation
between 1990 and 2015. This ;tneaJlS t.l:lat policy. for pregnancy~ Mtenatal arid dcliv.ery care and
related efforts and ~s.!n thecouilti:Y ~hould ~:are in. -;t#e pesq)artrim period. Preventior.. and
improve the cuir.ent situation with a 172ll 00.eoo management of .a bortion complications are -a lso
liv,e bhihs:lllatert'..al mortality -nttio {NDHS 1_998). included.
. :- ~.:.~ : "'::' .
; .: .

Tal?}.e ~i;~:~~i!.terMl and ncwbom de.a tlisin 2~; F d ?n>po~o.n of ,qL-r:ths. -attemied by slcille.d ~~~Jj~ffi._~~:~sia
Pacific Rep<>_~ . . . ._. , . .. . . . _ . _ . .. . _._' -::.: .
N~ Country PtoP.9ti!o~f/o) .Qfbid.hs att~ded Neonatal mQrtalityrate Ma~emal m ortalitY~tio
..~ :.~.~~.t~r-'".. by s~ed n~lttq:~e-q;oimel" . . {:Per :~000 li"Ye l:Jii:tl:is)~ { pa-100 I?OOTh-c::Oirths)-*
. .
1 ,.. . .. .~gla:desb. 13.4 36 .57o~:. -~<~:';_'' ..
2- .t-:Blihltin '50;9 -30 - 440~.:. ..: . -~:.:-..
3 '.CambcKlia 43.8 :'-48
4 china 82 ..8 18
-~;; -,;~''7:::~~ ' --
. 5 DFRKorea '97.1 22 3 70
6 India - . 48.3 39 4SO
7 lndonesia 66::3 17 .42n -
.8 1.-ao..l?DR 19:4 .-3o- "6mr
9 Malltives 70.3 24 120
10 Mongolia: 99.7 18 %
11 Myanmar 67..5 49 38Q
12' N~- l:S:7 32 83 0
13 '_ Phllippines $9;8 1 s 230
i4 . PNG- -42 .- .. 32 4 70
15 . Sri.Lanka . 96:6 . B 58
19 ~d - . 99.3 ..'' 9 . iTO
17 Tim.or-kste . J8.4 29 . 380
18 vietNam . 85.0 12 .150

Squrce!-Proportion ofb4ths ettended b y skill~- h ealth JX:r sonnel. Es~imates 'b y eountry -- 2007. Last update: April ~007~
WHO. Avai!a?.le from: ~tip;/ /v.:ww..who.int/rep~uctive-health/global_:monitoring/data.html
..., Neonjltai lind-Pe~W-Mortiility: Country, Regional 'a:nd Global Estimates w04, WHO 2 007
*** J.i~teiiral Mottalityin_2005- Esti.IJ?.~tes develop ed by WHO, UNICEFandUNFPA
-~The AO dt~s ~;614 -m~teffiiu deaths per ;eai-, b~sed on a 17.2 M.MR. -
2Matern.al mortlility tends to be- under~or mis.rei>orted for various rea~ons; moreO-ver,- t4e r elative .i nfrequency or small
number ,-of deaths .over a 'Short tim_e-.pe.riod-~es a ccurate estimaliqn diffi!t;ulL The sist.crhood appr-oach tha~ i3 u sed is.
ai.Sl)limited:~ its .ab~o/.to d?tect subs~~ ch<!-!lges over short ~~riod~, and there are ~arge sampling errors invjilved. T~e
-n-um~ of material deaths 1s n9t re()9rted m the 1998 NDHS. C1vil r .cg1stry-data t,abulated by DOH in 1998 r~~all,579
maternal deaths and "1 ;632,8S9 b!rths or-an~ppro~ate 96.7 MMR while m.o r:-e recent data_from FHSIS 20p0 yi~fds a 6.3.7
MMR . . ' - - - ~'
. Life tim~! risk of niateryral oeath is.the-~sk-of an individual w.om~!il)'i.l1g fro in pregnancy or child birth du.rihg h"{i:)if~tirbe.
2

Calculations wen; based on IU?:temal z.nortality a nd fertili_ty rate per co~ntry. A lifetime risk of l .in 3000 -represecits lo'\V nsk
while 1 in -100 is 4igh ris k. ' . ' .- .

Scanned 8y: ~
~~--
..:_, '
4 SECTION t: -BASIC CO.NCEPTS..OF HUMAN REPROPUCT10N .

. 120

~ 100'
:e
z
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80

= . '60'
-f!
. 0.
. == . 40

i
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- c~~\"ftlottilhsJ;~~-~I=d it!tend.tl'nt
.

: ,; .''.;
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. :
:t~=~::1t:';bl)~~-) . ~:
~- 1.1. CoJTe}a:tion ~-lD.a~ &Jtci"neon:llalm11~~Jlrid p~O'noOfbirths :~ bj
.a killech.ttenii!mL .

. So~ PtoMi:tioP or birth!S ~:by~ hea'i.thprsoc.neL'~~tea::ey-~t.-y:.:...,2007~-~

.. ,. uatt\~:Aprif2oo7: wHO.~Availa1;it:efrom:=http:ftwww~b-;mtfreprO<luetivt.:-heatth/~~~ '
datali.tml . .
" Neonatal tl.hdPerinataUdort8lit.Y! Country. Regio~alan!l-O.lo~Eatbnatea2094, WHO 2007
... , Mat-emru-Morttility'in-20()5-'Eafuna.tes developed-by WH0,'0NlEitand UNE'PA

Compar~Uvely . Philippine wome.n !ace a -defic_::iency), m~ltitr:avidity, _ h istory- ()f-~

l -in-.100 lifetime nsk of dying cf matemal causes abortion, ptegnaPcj too .e arly or late jrillk, prtviou~
. (NDHS1998); thereby m~gthe.in slightlY better ce sa-reah -section-s_. and conco.~itru:it :Jnedical
offt hail Ulo~ in tbe.r .e st of the-developmg regions conditiCins s'u n a:s jn,llmona:ry t~bettUloais;
as a
whol~. but much wot.se .off .(h!Ul their h~ J.J"'-'-1- ~-- ' ' J Mthma
...... sion . and
others
' ' Wbkih
' ' ba~ '"""'t
I~

~tni!)'terpa.rt in industr-ialized region. T.h e -~ adequattly managed due to 'tack of:~

_f)llilip.p ines thl,ls_ remains to .h ave QM of the orlack.b fa<xess b aJ>Propri:ate'health .c are. (Rtddoro
highest matemal tnortruity ratio~- m the .;As4m . ~lOQ~).- The. 1998 'NORS :~dicat~:s that at least
region. Poverty ex:ac~rba:tes the problem, bj.ng . 604 0 pettcll~' or pregnancies lrt'the Philip~ are
primary socio-economic factors ln the causation high-risk (:SPP.R 20:00). Of those .whQ tli~ of
of disease, access to health $ervice:J, a nd i:t:Ulterrud cau$es, pregnancy re~ted complk:ation
maintenance of health and (ogether with weak and h~sion wgeUlet aeq>~ted f~r .f,wo ,t hirds
couimunit:Y suppor t. -contributes -lo- poor while-ime~fourth w,a~ 'd~e to bemorr~ (WhiCh can
management or- pregnancy delivery lRecidoro result from ..prolonged labor, uterihe ruptute early
2003). . . . sep'at;lon.of.Ut~ placenta from t,he uterine MD. or
aftetinlsCaniage.or indti~ab6rtion.) (Please refer
.Materilal d~ths are also .incfuectly caused by . to table 1.2); Furthermore, 9 percent .o f nlaternal
hb~-risk conditions that l ead to highrlsk childbirth, deaths -are estimated t9 be :Consequence of-unsafe.
eg. severe -anemia (usually associated with iron Hbortions. (Recidoro 2003).

Scanned lly: C
 CHAPTER 1: OvERVIEW OF MATERNAL H6ALTH IN THE PHILIPPINES ;_;: -s
----~----~--~----~----------~------~--~------.,.~
- ----~

Table 1.2. Maternal mortality by main cause, 1998.

CAUSE NUMBER RATE( deaths per 1000 livebirths) o/o

COmplications related to pregnancy occurring in

the (oU!Se of Jabot:, delivery and puerperium 603 0.4 38.2

Hypertension complicating pregrta.ncy, childbirth,

and pua:perium 425 0.3 26.9

l>ustpartum hemorrhage 286 0.~ 18.1

Pregnancy with aborti7e outcome_ 144 0.1 9.1

Hemorr~e related to rm:gnan~ ~:: 12l 0.1 7,.7

Almost all newborn lie~ths t~ke ptac:e in appropriate obatetri emer.gency servieea in
developing -Cbuntries .artd nearlY twC>-'third~ occur appropriate i'acilitie.s :during :the critical ~od
in the first w eek after birth. i.e . the perinatal ofohild birt1;1 ~d. tbe post-partum-, wbetherh e
period. The causes tit perinatal death inClude.poor or she be a 'medical doctor, midwife or nunie.
maternal health, inadeq~ate antePa!al :are, The more :se~re the .complication, .t he hi_gher.
inapp_topria'tc :me.na~etnent of complicatious level -o ! traini~g or -s peciaiizatio:n is .n eeded.
dUril)g'.pregriancy arid childbirth; poor hygiene Acee.s s to facilities with such ~pe.cial sen.i(:'es
during childbirth; an<llaek:Q!:q urulty newborn care {basic a nd coill.preben-sive emergency o~tetric
dUJipg the~first :24 h ollt3 after birth. care) -h ,as to "be wi~ a reas~mabl~~,-tlnl:~L~d
distanee to be effective. .
.l n th01il998 NUllS. the b:lfant death ratio was
35 }>er --1:~000 live bittb,_s ~J:ille Xl.~naW..l death . . . a,n-d
De-llni&n . . Bae~u.nd
. of Obstetrl~,~:-':'
. .. . . .
re.gis~~~-18 pet tooo live births. Among the . ~ -~ . ': '." t, . ~: . . . ......

re.gions:~ln,~e countiy, the infant'mortality" :tatio 0bf1tetrics is the m and sciene~..~thaif'p~

(IMR.) b highest in ~ '(mayas and lOwest in
~ep;Q Maiill.a ll..Ttd Centtal VisaY,a$o. lnfunt death
is .much:hjgher among.mothers.With ao antenatai
. cate--8.ri.d---with -nO--Skilled---health -pF(jfessionals'
attendance during childbirth.
Traditiortal Birth Attendants (TBNs) are
unSkilled workers who are 'fc:mnd in .most o( the
rural areas of_ili.-e _COUQ.try. ,Atteplpts in the past
th~e to tour decade~ to .t t$1:_TaNs and to ~Uip
-them-with ~<X:e$S&IY _supplie:$-and.equi_pln~pthave
not improved ttic; outeome rates. of deliveries
a~tended by them. While they may be able to
~tte.itd to normal deliverie,s by -their extensive
~rience: they are not ~ble tc detect, manage
and refer problems and complications that may
arise during pregnancy.
Based pn the 2003 NDHS, about 60 percent
of deUverles take pl~ce at home, usually attended
:by TBA's or by midwives. With the realization that
all .pregnant wome.p. are at risk, . management of
pregnancy. -child -birth and Ule period in;lmediately
after child birth i'equire that the heal~h system
ensure adequacy of skilled attendants to p -r ovide
with delivery-, its .antecedents and 8eque.fie; or
. pregnancy, la:bot and puerperium. Tli~-tetin -~
derived-/ rom the Latin word "Obstetrbc ormidW:ife~"'
-The~tCfii}--wasused--as..cearl,Y- as t1ie l5!io century
worldwide: Since the 19th ceri.t ury, the tenn b8s -
been:used in the United States of Ameclca and
Britain. . . .
.The begmning of ObsteL-ics in the Philippihes
dates back to_an unknown p6iod 61.s practiCed by
tradiiion.a-1 ot untr:ai-p:ed birth attendants.
Certainly,.it was part of medical practice as early
as the establishmeQ.t of the first hospital
particularly 'i n the treatment of complicated cases,
but rarely if' at au ior prenatal check.:ups as is ~g
done today. Obstetrics as practiced ih the.
Philippines by. physicians dates back to San Juan
de Dios Hospital; Mariila,before 1908. ThereBfter:
the Sa.i~1t Paul's Hospital, Civil flospital and
-Mary Johnston Hospital were cs6l:blished.
Accdrding to tlie statistics publi:thed by
-_D r. Fernando Calderon in the years betw!en 1908
to 1909, _there w~re -orily 92 obstetriyal~ses ~
all . these hosp1tals. The rest o{ the '.(}irfus m
Man~la were conducted mostly by the traditional

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 SECT~oN 1: BASIC cONCEPTS OF HUMAN REPRODUCTION

birth attendant fl'BA) or. "Hiloe and what were low birth w~ight - less than. 2500 gra.ms
called :qualified "'eomadronas", and perhap~ .very
few physicians. 1-,. very lo~v birth w eight - less than lSOO gtiams
' '

Vital Statistics extremely low birth weight,..;. less than -1 000

grams
National rec.orde ar-e important .in
establishing vital statistics whi-ch state the
Situation of important health ihdicators in the
c ountry. These are important in esi:abtishirfg
Tabl!: 1.3. Shortlist of incji,ca to:rs for global nionitoring of
trends 'in. health,status, on a national level.and' repro4uctive health.
ln .c~I,npariwn with other countries, usually jn'
i;P.e. ng}Gn.{~Table 1.1 -andFi~re L).}''I'hes~ 1. Totalfertilityrate .
statistics are .based bn standard. definition~ of 2. Contraceptive prev'alep:C:e
.te~m~ and fotm~las. The data on maternal 3. Mat~;mal m.or.aiity ratio
mortcllit;y.are mo.;>t importaut thflt the World 4. Antenatal care coverage:
He~lth . As-!!embly i:r.. 19 9 0. :a~opt~d the s. B.ir+..h~ attan'ded by skilled health per:sOnnel
recoriu1:reridanon. that co-p.ritrl:e~ con$id;er. the 6. Avci~:o.bil.ity of.bastc 'esse~tialolmtetric care
in;clu.si~>.n .riP. 4~th certifrcat~~. Of qu~stlon~ 7 . Ava$-bUity of.copft~~shre-es~t:i!ll-obs(etric-~e
. t:e~g curr~nt p:tegnan~y .and pregnap.ty 8. Pennat:a,l ~ct;!iility rnte. . ..
witbib. :.ojre .yee.!" .t)recedi;r;lg death. . . . . 9 . .Prevakilce oflow.b~ ;r.>e~gpt
-~ . -- . .. . , . 10-.._P.rev'a.l~nce''<>r-positt~.e~.hili-s .Sel'P~i\_d.in.p~t
. . n<I)ati_
. '_o~t!l..;~h:.
~lli
..;_ ::/~.,.
6~~itnd"'-.''
.: 1n:ordet;.ti;l;attat: 1
. . .~~~::; . . . ., . ... . . .
aim~ itis:U:npo$.rit4or.~~y;;~ti;f;~-tq. :b{ly:e.;da,t8.,.:. n .. Pr:ev:i.k:nce'Of.~:,~.~~~~ ! , . .
on :death~' M.d::'.bi'tths, -their.'<p;~:moor;::.~4~t:h.e 12. ~Pcir-cent:age.Ofcibstet::ric:$dgyn.aeCQ10gical~on5
-~$talles :Qnder . whic~
t4ey-oeclh.--ied..:: This. .o~iQ:abortioQ.
wjU ~1e~Ule!fo.Q:nulatiowpr:~~~-it:~lJ?.~Y;~nt;, . 13:_;:R~ea-eY~.en~9f:~t:>~~-~ ~tal~~t,ilition
.<>r contr{flthm. -~n~~ -~Fqr . thls' ..p\lr:p9se, . 14. P.revalen~orinf~ty.Jn .~o~e'n . .. . ..
~-:\W~~~--~volv~: in -.c~<{btrlh p~1cP~es lS.. R:e~rtea.mcld~~,_ofr~~~,h;'_,,~~. _,.' .. : ..
hav.-m:})e,~w~ ,to:.mainta1ri;compara'!Jil,ig:;; .16, ~~~of~ iD.fecltoo. ~:.Pn;~t,::V.,omen :
witlij?.-'~~~~- -a~-~:-~t~rft~~tilb'~3 17.. Kp.~e-ofHr~~-~~::p~ri~~ptacli~
-
............... .......... --- . ...... . '.
~ ~ .-; ;-;, . ,.. ,.... '
.
_. Birt'11G-:;th"teo-m-pr~t~-:expu&~~:br~~ctio!):
.:of..a. iet.1i. fr.o~ the .- mother:, -~~~~#ve 9f
,whether- the 'UJ.llb~ cpr.d. has :b eev, c\it .r).r Birth R,ate refers 'to -the ~umber. Of live births
the libi~ta .is sti:11 ~tta'cb~~ ..if'fu fetus is . per 1000 population, Jlsually .afoo ~:efe'rred to' -
less than $00 gra.rn.s,-it-i~ not.consider~as.a aidli~ etude. birth r.a:te. :
-an:
blr,th:; ~th~r ~~s :al?9rtus. Jf no W:e.~g4t was
iU:easu~d. -~ ~Y :length-'{ftop1 dti:>Vt?,t_to :heeU ter:illicy Rat~ ,refei:s :'to the n':ii:l.bet of live
bf:25-~otn ;is usuaJ.fy.eqU~tci,il.Wlth ;$:00~S: biiths Ptri6Po .'fem;llejxJpcla.ti.?!l, 'Of ~e- ::15
to 44 y~s. S0me. rfer.elices. cit~ the upper
.. The vmo ha~ listed the: important .in.dieato'r~ r_ange_ at 49. This ag.e_group is commonly
that nee<l to.-be mo.n itcred by :ail couritri~~ .TW:elve . referred .t o as the worD:e~ ol-reproductive age
~r -the ,r7 ~Qi<;att.;,rs.~e d;Ie<.Y. measuvci durin~ -group :or cbild.bcti.ring ~e; meacing they are
.f ue ~e of pregxW.ncy. (Table i.3) the group most likely to.become pregnant ~d
to deliver an Wan-t.
l3trlh W~lgh:t.,. The.w.e ight or'a rie<Dnate deten:Irined
i.:n:un.e4iately.~er.. delivery or. as soo~ lh~r~er Women of re,Proditctiv_e age refers to all
as f~ible. It should -~ expressed to th.e ~near~_st wotnen ..aged ls-:-49 years. In seme estimates
iram. This weight.should ~- mea~ur.ed: preferaely frqm censuses ~d. .suryeys_; the upper ~e is
of
Within the ;flrst. hour .. .life befo.re.. s1gnifi~ant . taken as 44 years:
.a.t:l<l. the last age. giQU:p is
i)o;st:p.aiat w~'ight. lo.ss
h~s occ'Uj:red . T~ese are. . thus 4o-4.4:ye,ars~ }Jo.i~ recently,' it ha~ been
c}assffieqinto weight- 'categories, regardle~s of the . reco.n imeilded t~at ~otal :fertilitY .rat.e s be
.
. :number .of completed
. we~ks
. of gestation:
.. s h own both by age 15--44 and by ,age 15-49

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~
 CHAPTER 1: OVERVIEW. OF MATE~NAL HEALT[l 'IN THE PHILIPPINES .":' 7
~--------------------------~-----7~------------------~;~
~~ ~

years, . especially when s\!rveY data are. used. and inclu.P,ing 27 .days, 23 hours, and 59.:l;I1inutes
It is common to ..add births to. girls 11Q.der 15 from the moment.of. hir). .
years of age to the 15-19~year ag~ group and
those towomen over 49 years to the 45-49 Neona tal Mi>ftality Rate (NMR,) r.e fers to the
year .age ftroup. number of neonatal deaths per .1000 total Live
births. It may b:e e~ressed ba~d. on a specific
J.,ive Birth - The com.plete expuls'i.o~ or group 6f neon:atal dea_th~and live.birth~ based {)rl
extraction from .the mqthet o.f a _produCt of age of gestation or weigl:lt upon deliv.ery. (Age
human con:ceptibn, krespective of the d~tion Specific Neonata,l M~rta:ijty Rate. an:d weight
of the pregnancy, which, after ~uc~ expulsion . Specific NeonaW Mortality Rate).
.
I ~. a~
. . .I
'
or exf:niction, breafuesor .shows. any eviden~e
of'lif~, such as beating ofLl}e heart,. pulsation
. o.f the umbilical cord~:?r defini~~ovenien(of NMR
. ..:::..
_. ....N. eona.
. . . d . e.. ..x. lOOO I :liv.e .. h.s
blrt . .
v~o!untary muscles w,hether or. .not the .. . .....~--'-~,..__~.....,......_..___~------------~
umbiliCal coni has been cut or the plli.ctn~ is 1

attached. Heartbeats ~e to be distin~shed

fro.:;n transient cardiac contt:actions;
respl;I:ati:a;1s are to be di:stingilis hed from PerinatafDeaths
., -:- All fetal
~ .. ' :of. 20
. ..deaths . :or
..
more .
neeting'':reipira~ry effo~ ..~r ga,.sps. : v.eeks gestation, plu s neone.tal deaths under 1'
. .. .. 'Veek. .. .
_ .: .:(1:'~~~~ -The total.numhex:: of deli\~etjes,
..live b~J:is ph.::.s Jetal .deaths. .. . Feriua.tal Period. commenc~s at..:2o .eompleted
' .' ~ ' ... .. weeks, :140 day.s .or gestation; wh~n: th;~.:i'et.a:l
:sffilliift:h {F~tal Dea,.th} -:- beath prjor-to the weight is-normally 509 grams .aJ,l<t~.3 ~t2~4ays
.; c,o.m,plete expulsion :or extraction. fro~: the after delivery. When perinatal rate~ are Wi&l~on
: mt~ilier <of a proctu~t of hun+an :conception, . gestational .age rather than birth weight. it :.is
fi.ei#~~.P,~~ta, . mspectiveofthe duration recommended ibat. th~ ~~tal~~:,d~~ed.
. . . 20 k .., . ..~ ... . .
.'lbf'~~f.egriaricy; the death is mdicated ~y the to commence at w~. s. . . .-:::. . '~:.::.::~.; :<~ .
~,.;~o.. . . .- ;;
~~r . - . .. ..
~-:"fru::t~trult, .after such expuls1on or e.xtracj:10n, . .: :..:!-....;.. .:~ / f} ":-...... .
: the fetUs d:~s not brea~e -or .shoW' any other Perinatal MortalitY.. Rate refers .t 9;thenuiilt>drof
.evic\epce ofUfe, iuch as ~ting of the"h~ s tillbirths or~ fetal. deathsof 20 week.S' .'!i~tai:ion
pUlsati.Qn.:<;>Lthe..umpilical.. c oni; .. or.: defi.rilte plus the.lmm.ber,of.p.ooriatatikailis..~de~-L.w.eek
.mo.v~eil.t..o f-tn.e-v:o haP.:taij..mu scles.-~=Dhis -pe:r:.';lOOO-total-births.-It-maybe-~es~-based...
deftcltion e5ccJqd~s .ind.uc9- t~rmihation:s of on a specific group of ..perina~ death~:and total
pregnancy~ births baSed on age of g~tatiOn or:w~i.gQ.t upon
d~livety~ (A~~ 'Specific P~rinatal MortalitY Rate and
'F etal l>eath Rate refe:r~ to the numl'>er of Weight Specific :P.erina qu 'Mo~ty Rafr)
.stillbirths or fetal deaths after 20 weeks
ges~tion age per 1o'o'O t()tal'births. It m.ay be
~xpressed based on a .specifi.c group of
.s tillbirths .and birth based .on age of gestation FeW t!tath$ + early I)(;Otlatal dea.th.
: orw~igh~ up0n delivery. (Age .specific Fetal Pctinatal (over 20 wedcJ (defriled 8.3 1;b:o>e under 1 week)
Morta)i ty - x1 ()()()
. .: Death-Rate and .Weight Specific Fetal Death Rate .
'R.ate) .

FeW deaths.x 1000 I total birthS

(live births a.nd stillbirths) Infant Deaths refer to any d eath a t any qme from
birt'tl.up t'O , but riot including, OJle year <>.(?-g~. (364
days, 2 3 hours , and 59 minutes from themoment
. Neo-p.ate- A !iye born infant. of birth)'. . . . . ~~ .. .
~~~
Neonatal Death - .De.ath of iive oom neonate a Inf~nt Mo~ality ~te :- nu~ber <?f'ir?~t d.~aths
. . .

before the ne.o riate tecomes 28 days. old (up to per 1000 livebirths.

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 8 SECT!GiN 1: BASIC CONCEPTS QF BUMAN -REPRODUC"'flON

' 'i\!J

Abortus is an embryo:orrews expelle<i'd:\J.rlng the. Non-obstetric DeathS are matemal deaths dJ;
firs t half of pregnmcy, less than 2{) weeks. lSs as
to tra~tic causes such. suicide, ~cdd~t, gun .
than .5.00 gram;; or less. In many instances, these shot wo:und; 'and siniilat Cd.n~tions..
.cases tl.eect furtb,er iiltervcntion,iha.h ealth facility~ .
skl!!~d Health Attendant (sometimes referre(l.t o
~station Age r:efers to t..'1.~.num:Dc::r of.compled as skilled attendant) is defined as -a.."l accredit.ea.
weeks that have el~scl between :the 'firSt day -of hea!tl?- pr9(essional--osuch as a ID..idwifc, doctor or
the la'!>t normal menstrual _pedQc;i tnot ~he. nurst:!-w:ho has been .educated and i:rai:n.M to .
pr~s\lllled. time Qf c onception)"-and :U.-t-e-date 6f pn~ficien.y in th'e s1dlls r..eeded to -ma.n:age normal
delivery. it:respective of wh:ethr fue gest~tion .{ili:fC9inP.~ted) pregna,ncles, childbirth and the
resuits in a live 'bi:l:'th pr a fetal dea:t:l):. Wh'en the imme4~afe postnatal period, and :in :tll~
dat~ vf the 1~~ n6;mal Rien~trual ~ri~ -1~- not iden-t ifieafion, m.anagem:eri,t. e.:nd rd'errcl .o f
av~lepr~s .perciv~tp be <lnil'ellal?le, ge$tion co~plicatioiis in -won'ien and new.b'om~.- T his
1

age js b'ased ~n the best .cli.n.ic~ -~:3thn~t;e. detiplti()h ~lw: l es :ttadltional birth' atte;nda:nts
vihene"ver possible, calculatio-ns shpuld .in:d;:cat:e wheL~er tra.ip.e<J] or not.,:rrom the categozy ,ofSlt:ilkd.
estimates expressed in ~th- weeks .and day$.. hea:it,h.w6rkb,rs. : . . . .

-Pre~ refers .to-.'le:S.s .th 37- co~leted wk:s

(or 259 days} ot .gestation . . ...
The :1~ ~-v~cw.ts .for tP.e tegi~~ of
fetal deaths.arid Jiv.e .b irths Vary from -~~try to
Tenn:,is'!'.from .37 weeks to, 4:2 .~mpleted v.?~
-countty..:anE;lvev~.-witl;iirl :eOU..'~'ltri~s. If ,pwi$..)>le,
.. . f u 2sit
. (260.-: da~) .
... . ~ a).l .fetuse.s and i.nf~~ :wci~g at l~~~f:~ :~
. . birih .wh~~r-allveo.t .def;ld, . shoU.l:i:.':be.;mcluded ...
Port_,~-z:eren to -mo~:'t~ .4~:w~kB'~or 29~. irt '-fli~ s~tis~'~. -.":rne .Jp.~\lsion. ~f :-retu~ -~d
dav.s or mo~). . . infa...ry.tti -*~~gj:.Jllg. =betw:~eri .~@g. ~d .' i~ 'in:..
. .: ..... , . . . . . . . . ... .... _ . . , .. . . .. . . . nat,i0roil:.-$tati$~-is..~~~~ ~?eca~~:of.i~
M.atcmat De:llfh.rcle:rn~tb -'the~-dea.th--of:>-eJ;wnman ... h ' . , . ~!: ar . . d be' . .. . i" . . . tb
~~-~~~:oi-~h:~41,da~a~:~l-~tro~:: --~~ ~;.0:~-~t-~s;.~~e:~v.~~:: -~ -
<;>fp~cy. =ures.~e>~Nhe-5iu..~tipn<and;the.. .. . . : . ; , . .. :. ~- .. ..
.
~~~ of:t~e :p~~Jjcy,: 'fro_ih ~~.;~~ ~~ .- t~ A b~.~- _-,~~e,~~J ~~~~~:~c;)r ~_bstetnc -~
oc;~vated:'P.y.:.thep,~f:Y.-onts-'IU&nagemen.t &&nf-&.~- -~t . 'tfl .. ~ &htn Ttli
'but-'h~~irn~~cero:eri,~i;~~cld~ta~~~ :. . . i<2~i.~~ s2~~~~:~~3~;:;i~~-,~)~
e.t.lea:::.tJ:>~~.in .th~-:p.teVlOUs :tllree :montb:'S!~
~~cl~rlyin;g -a~s~ ,o.r b~ath- The ~~~rlfin:g 1'.} ad.i::ll:il1Jstr:atiqn t~f ~ntetai antibioti~
oil~~ of;tieafu:is.eith~r th.e .~S:e-:Qr.mW:r,Ywhjcll . 2:) ~~-or an.tieon:vulsants; . . _.'
iliitia:~ea-the ~of evel'tta ,~a.i~g ~y ;t-9 3.) ~~ remoyal of..the. placenta;:.
4 eath or the
cireums~ee-s. -o:c~ accident :pr. 4 ;) rem~-.-~f re~~ .P~'?-cta {e.<g. -~Ua.l
Vi~len~~ which produ~d. the tata:litilt:UY 'It .is vatu~. . asrn=ti.oi1.)
-r-.- I
-and

..
cla:!sifled .acco.'rdfn:g :to th~ lntm:aitio)lal S;) ~ssist~ va~al.ddiy~zy (v~cuum tXttacti6n
Classifi~ti.oh of .P.i~ie~ . Tenth Revisien. of.-the or :fo~ps).-'1 . ..
W.o ild Hc::alth Orgao.i.zation.
!n th~ Philippin~~ .' the 'Deparlment of.Health.
P uectObstetrl~ .De.ath rysults frorp. obsi\:-tric ha~. i.nco.W,o~-t~(:t:. nevilx)I'n. h~alth sery?.ces and
co.mpll~tions of the pregnant .state ~{pr~gr..ancy: modili:ed. the faCility 1?--S with basic essen~ or
il'l.bor ~ruf p:u~rp e~iuro) ft~ni in-tervention.s e~erg e:ncy qbstetric and n ewb orn care.
omissions, incorx:ect tr-eatment or from a chp.in of (B-E -mONC:). The recommend ed minimum
events
. ..
resulfulg from :the abOve . acce.p table. .I~vel is . four B_E mOC facilities per
. . 500,000 population.
ha.cUrect Oh ate trlc De.a.fh ies:ults from
p r.c vious existi~g :disea$e Qr ~other .. h e_a'lth A co-m prehensive e s se.n tial/ em~rgf!~cy
COn4ltlons that .develop.ed- C.uring p r egnancy, . obstetric care (CEOmC) facility is one t:h.i~ h as
-f6~~1H1 . -which was not -due -io -dir.e.c t .. obstetr:ic perfoqned surg~zy (ce.S;atd~ 3ectiori) and- blood
lao, 'biut wh'ich was aggrav:ated J:>y . -t:ransfu.siol}, in,addij:ion to all sixBEmOC service.s;
ologic' -effects of pregnancy. at.leas.t once i.ri.-'.the. p_revious three .month~.!. In

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;..._----~c-HA--=-PTE-:-
--::R::-:-.1-:-:--::0:-:""V:::ER::o:Vl.:-::- -=8/11:--:- 7..A
. . :-:O::-:F:-:M :-::TE:::R=-:NA::- :-:rn::;-;-;l::N-::;TH::-::::-E-:;;P;-:HI:7'"U:-:::P:=Pl::-:N:;:.E::=S-. ~-------;r.i
. :-:-L""':'H'::EA!::-:' ., 9
______,___::.__. :.,. . . ._________:_____ ~___:.-------~---.....:;!
'~'

the,~Philippine:::, the Department of Health ha.s bir.t h weight, sepsis, asphyxia, traunfa''~nd
incorporated newboqJ. health service.s and have congenital anoll\8.lies.
modifi~d . the facility as with .compr.7hensive
essen~ or emergency ?b'stetrlc and ' newb:>m Strategies for reduction of perinatal '1DOrtality
~e. {CEmONC}. The recoi!J.me~ded mi.n;iu).uni
accepta!:>klevel is one CEmOC fa.ciljty:per 500,000 L) prevention of neonatal tetanus and other
population. infectbns
2.} improvement of obstetric -care
It is important to notice th!:l.t t..~ese definition$
3.) commutiity involvement in perinatal and
explic~tly impose the. condition pf functioning"
.facilities. Disti:nction is oade b etween 'facilities neonatal care
:that ~ :ac:tuail.y fu.nctiorilngand those that may 4.} imprQvement of matemal-con<Utioos affecting .
have the. e(!uiptMnt but nevetihei~ m.ay not be. .p erina.!:aldeath it:
performing-as suth~
It hal; been shown that the mateinal c:Onditions
The. 0-6. -dA-ys -old group is our main target as so~~ with perinatal morlali~ -in the .ord,er
therefore~ -in
order tp decrase the neon<!.tal of fr-equ-ency ~e: 1) pretenn l:3:borwbldl giv'e s t he
'm9rtalitY~ This ts the. r~spons:lbllity, of .tj:le most perinata~ deaths. 1) pla.ceati ..Previa,
ob-stet:riian~t tli~ deliveiy .room 1;lS :well as the . ;3) multiple fat;tors, 4) P'Ost-term -pttgnancies,
~tri~ln thede;livery:riX>::na.n4~ursery. "The 5) .c ephalopelvic dispro~rtion. 6)" hy:per- ana
Co~'\l'O~.f;aUses Of -d~th of th~ .necihates : !ow . tension m pregnap.cy~ . "' ;- ~
._ ' . :. . ' l . ~ . . : . ..

,. :

; AV?ilability.~n;,ask:.essentiaJ. -obstetric catt ~EmOC) :

zr .. ::'...
. :t ~e~~:o(f~s With fut:!.ctio~g~~ es~fuil: obstetric Careper sooOOopopulatiOn ~ .. r-;;;~~~ .. ! ~-:-rr. f-T;;~~ . .~ .
t...;~:~:.... ~r ~.;t
' ~ ;-..~-~. ... .~ .-r;i ~~r.:- :...-..!"a:
. l' :ifu.'-7-~r: Ntimbei- of~cilities withfw:lctioUfug basic care x .5 00.000
-.v-.1: ~~ {~~~'::\:~
;,
~r: Total population
.--
~~----~~--~----~--------------------------~~~--------~--------~
. ...... ..... .. . ... . . .. .
... ....
~ ~ ... ~

:
-Av~fy:of cornprefi;ffisiYe':esscntial:. o'bSiei]1c c;re (Ci.EmOC)

'The num~ oHacili'ti.es "V4th ~~tioning comprehensiye es;'.Jcntial obstetric C(ltt per SOO 000 .
. pi>pulah6n . . : . . . . .

Numerate~ Nll;tOber.'offo.cilities with f\uictioili:ng basic cart x.500 poO

, ..peno,ninator. Total_population

P~sitive Syphilis Serology

The percentag~ of pregnant women: aged 15-f4;years attending antenatal clinics with a .IXJsitive sero1ogy
for syphilis

Numemtor. .Number of pregnant women aged 15--24 years attending .antenatal cl.inics, who:;e blood'h a3
~n &ere~ed for syphili$, with a positive fi-Ct'Ology for syphilis dui'ing a specified period x 1'00
. . . .
DeTWminator. Total number of pregnant women aged 15-24 years attending antenatal clinics, whose~ -
. . . . '* '
ha.sbeen screened for syphilisd~g :the specified period. . . . :;~
...~~ .

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 10 SECTION 1: BASIC CONCEPTS OF HUMAN 'REPRODUCTiON .

The above strategies for reduction ofperinatal daJ1gero\}s to them or to their baby so as to allow
. mortAlity. actul;l,lly relate to maternal care -
the early intetven:tion. In ~e 2003 NDHS, -Wbmen
health and nutritional status of the women during who had a live birth in the five year.s pJ"I".N!ding
pregnancy, tbe quality o f care during pregnancy the surv~y were _ask~d - whether in any of their
and delivery, and the immediate care of the ANC visits, their weight, height, and .b lood
newbom. pressure were. ~ea-sured, or .samples of their
urine or blood were taken. They were also asked
Current Antenatal Care hL the Philippines whether during any of their ANC -.i sits for their
last lfdih they_were -i nfot.med of ~yrnptoms of
Antenatal cue service deli~ varies across pregp.ancy c~mplica:.tions.
service providers and income level$.ll'l d1e private
sector. the pattern.observed usu~y fQ~llf .t he P.rcvlou$ intervert.tions have eniph&.'s~
We$tern model, w}).erein women may be .~ less prenatal -c;6are ~d the risk approach. H~. a .
frequently in:the :firsthalfof pregnancy, with Visits WHO reView lcnind th~t risk assess:tnent .h as .n ot f
beComing mo.-e frequent as the expected date of been an effective strategy for preventing Jnatemal
deliVer1 nears. W-Omen wbo have ~n identified d~th~ sinee the broad characterlstiGs U$ed are
to ~ve risk factors .have more tests p~bed not :precise enough to pie(:tict individual. mk. A .
~d have. tnore viSits sched-uled~ large nuinber identi(led as bjgh tisk ci.'d l!ot
developcom,p~tionswhU~ 'those who 'are.JOwriSk .
TheDeps.rttnentofHealth(DOH) .reconlln.tllds f\_evelop.e d complication. Even if a woman ~s
thai ~lt-~t"women hav6 at least.fo.lit .ANC c~t:ly . identified :. :as~:~g, at riak, there .i s no .
v1...&ts-<tunng-.eacb-.-p~ancy.-The2003.Na~. . gu~tee that she.will g~t apj)ropriate -~ The
DemGgtaphic .and: Health: :$prv.ey'rlatashcw, tllat . unde~lyU.t.g. ~lanation<it~ :that .o.nce:a=wo~._geta ... :
seven in ten 'wo~~ -wb.o -:bad a live -.birtlt .iA1;he . -~~-;'She runs .the riskcr."sufferin~trom.a:ny
~ve :years =p~ecUng the su~ crnpleted-tbe . of the C(ttilplicatrol)$.of:pregiU\nc:y and~
teeoiniD~ed ll.Utnber .c~ ,AN.viSits during the but ~U1:1e'tbe :patb:QJ)hy~1ogyof;some. ~
p~cy- ~th tast;~~lbjx:th,i~i :Pe~ll. .ia ,~,<has,n,otbee#.;fult,y,~d~t:O;:~~eJsJlQ.~ .
mucbhighcriJiii:Urb&n;;-at~ ~(76%);;fuan~iUial-'-.'.''and;-q)ecifiC:nietpod..~ .p~9i9t-whichMw~ will
.areaa::t6~)~'?;f>OH..~~~~.i~ttmt;md-o::that<S0r.-~,;f,~.$utt~n:t:;;.tb~~\CQm.pli~tioi}~;;(RecidQr.o.-<l>OH .
.ea:rty d~tettion :oFpregt1ariey...r.elated->li~th: ,.,. StrategyPaper 200.3).
ptoblems, the first antenatal ch~kup -*'bQWd
QCCU.r "iii'tlle~fifSt trnnester'Qt~~ ~'ley~ More However,thepublic health .systemstillbastQ
t&an.l1atr~ror-wo-inei:l:w~mHa-a:arleasr<5ne .take '~c~counx.o-r ttre ra:~t thatpre-gtnm:cles-are
live birlh in the five yeara p~g the s-.uvey a
indeed,:ri~ky and that number of co~plic5tiotas
- adopted-this te!"Oli1inenda:tion. F'.or .thtee in ten . durhtg f;lclive:ry ~ not detectable _during .tl;le
w.o tnen, the ,fttst vi$it . was tttad:e wh~n ~ejr prenatal stage, tha:t tixnely referral duriJ)g an
. pregnancy wu in the fourth or-fifth month, while emergency is essential es.P--dally in rural .~
one ih ten .had.the fttst antenatal-checkup ~hen This bas .r esulted in a cute lack -of eme~cy
they were -sb.c to seven months :pregnant. Women obstettks care services {in terms ofboth racmties
in -ui~ [\Teas -~end to -have lheir:first cheekUp and Pets,onn1) or a .functionjng referral ~
earlier than rural women: while 62 peree.rit of and the continuedtolerance OfTBA-assist8lhome
urban women had their it&t AN.C visit in the first births.
trimester of pregnancy., the corresp.ol).dhi g
pr.ppprtion in rural areas is 44 percent. Half of Indee{l, WHOfWB estimates of the lifetitne risk
these women:who received ANChad had thdr:visit ohna.t emal death and the proportions of detimics
b y the time they were 3~8 rnonth!i pregtlant. this with skilled alte~dai}ts show that generalb', $killed
finding i~ similar .to that .recorded. in the 1998 attendance .at delivery is associated with l<>w risk
NDHS (3.9 mont)ls) for aU births :in the preceding of maternal death. Some coun~es including the
five .years (notjustthe most reeent) (NS.O, DOH, Philippine~ ,exh:ibit a xp.id~l~-to-high proportiOn of
.a nd Macro International Inc., . l999). deliveries With .skilled attendanc.e together with
high lifeti-m e risk of matern.a l .death
fligb-quality ANC inetud.es educating (www.unfpa:.org):-.although :this may be .explained
pregnant .w.o men .about .conditions _,d uring by high fertility rates w}:lich is part_-of:the lifewne
pregh-Qncy that they should recognize as risk C<!-lculatfon or the absence of obstetrics

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 CHAPTEF{1: OVERVIEW OF MATERNAL HEALTH JN THE PHIUP~NES 11
------------~~------~--------------------~----~,~

emergency equipJnent/ supplies if a skiHed THE BIRTH CERTlFICATE .

attendant was available.
The new strategy for delivering womeri~s health
programs calls fo:r s. shift from .the currently
practiced risk approaCh that identified hi~dsk
pregnancies.for .r~fertal d~g the prenatal period
to .a.n appr,ch tha:t ~nsid~ra .,ut pregnailt women
to be at-risk of <:omPli~tionJ at cbildbirtb.. This
im,pliestbat 1) atthemdiVidualletel, every mother
will .hav.e access tQ akilled ear:e jn pregnan-cy
includiilg skilled dellY.eJY by a nudWire, .nurse,
d~. e~ergen,cy ~txnent for all complicatibns
dllrl.'lg J;r;~gnaricy. d eii'very a:nd ane-r binh,
postpamnn family planning .~d be-sic neonatal
de~1e8, .2 j at the Se~ level, A tranSition to
mQre ~date ~$hibUtiQn of deli~..es. along
uie ~tln:Ulrnl of -~. }Jls;;lu~g more. nonnal
deliveries in baslc tae.iliiies, ;more ~ni:ergency
~~$to irite~ kvelfacilitieS. and feWer"
de~~t ho"tne and at biSb.er levels.
. ;.. . . ~~~t:j~ . .. .
. For..~e::stra:tegy t!> sueceed, the "'tbtee delays
ofd~g to seekc:iL.-:e, rea"hjngapp~priate ~.
and reeeiving cru:e of h~th tacillties,_mus.t be Past IJlt~rv~ntto ia th~ PhiUppt.ts .. ,;. :>-.
addreSs:::t,Qile. criteria. path"WQY according to th.e
In all 14 r.eg-l ons of the Pl\Uipp"ines, it is
requi.red.by the .CiviJ R~sLry Law Ad:lfo. 3753 to
report all v ital e vents to the local tivi1 regi:st:r'an
in cities .and municipalities where auch events
occur.
In the cities, the Cigr .Health Officers are the
civil registrars. Jn ,municipalitie, it isthe
municipal treasurer and m u~icipal district
~surets who are the civil re~strats. These .
reports are sent tc) t:be National Statistics Offi~
in Manila the firSt ten days ~f. the :a ucceeding
month.
It is very -e8$eiltial that registmlion of birth$
shoQ!d be co.xnpl~te and accurate since the .
certificate is nee~ed for ~"id~e of -:ag~.
citizenship, parentage, as well a s b' st.~stica!
studies by soci&l public h.e alth deln(Jgrapb,ie :aJ'ld
obstetrical ~genciea that d_eal;~,~th;~l!~W.{lh
prOduction. _;,;,:. .::, .:~-: ,<: :::~, . .

~ .
lffllCEF-j~WlJO and tJNFPA in 1997 i~i to~proVe
t he ;;;,;.......~ility. ut:iliZa.tion
. .. , and.quality
..

for<t1i"ct~1!r~at'nl"~nt ~ or eQtnplkation.s dur:ing

Ov~ the past .t O,yem, glo~..~~a,for.
. of$e~Vlces reduclng matern~l dea'th. e,nd;.i Unta."$,JiJl.ve
unde rgone a p~r:adi~ sliif~::(.._!t,.:~riitJAt,~
pregtiailci and -~~birth, based on mrlenee thz.t researchers a nd -~tibners thou&bt thilMugb-
at~~ :15 ~t;o.ftill .p~t women develop risk p~gnancies ~Wd - .b e dete,."'ted .aDd ,~
S~QQ~.-~mP.~~~Qp~ ~~- ~~!!~~ ljt~~!~OOg ~.~-- t4.~t..ru:ll~n~tii.~.~ . ~-<lllld. -~mt m~y
ac..cesa _to ~--.Q!m.~-g~...--..Thlls,:Jhe . matemal..de.a.thJJ.:_lb.e.J_:alsO._:calleclJi:Jtmining ...of
sirigle.Q:lost critical . intqVention is to ~nsfue the traditional birth attendants. (tBAs) itor-!du~ rlsb
pr.Cseilce of a heelth worker vtith midwifeey. skills of death .or illness dUring pregnaiiq. These two
at .every birth; ~d ~risportation to .m ore intei"Ventions were "Co~duc;:ted .in the Philippines
comprehensive le-Vel of ~4 h'our quality -ob$tetric over the past many years.
car:e in case -of an emergency.
However, these two inw rvehtion.sdid not.have
. A. ..new initiative Js .t he "Making -Pregnancy a gr: :at impact on the .r-ed.u tlon e>f m.a tetn.al
~er" Pr'Pgrain where skilled a.ttendartt~ must be mortru.ity in the PhiliPPine~. :J3road .agreement now
backed up by ~ftective health systems. This refers exists am.o ng health professionals and policy
the clevelopmen:t bf pOlicies and tnechanistns of makers that D'lost IPaternal deaths stem from
payment tp support their work, setting up problems tha t are hard to detect or screen for~
standards and protocols to defme it, and ensuring any woman can :lq)erien~ compli.cations during
esserttiat suppli~~ of medicines and equipment to pregnam;y, childl>irth and the post-partum
make it possible. It als'O means infrastructure, perlod~but.are almost alway$ treatable, provided
suitable buildings, . roads arid tran~p~rt. In quality eqlergencyobstettic. .care is a ccessible.
addition, -there has to be a refetral system, and Complications cannot be pt~d~cted: all .. m9thex:s
monitorin.g, supervision and training of must be a:~tendedbya ~killed :health~ssiQnal.
sWI'. Meanwhile~ records must be kept to provide Midwives and other professionals with :Qiidwifery
essential health informationand enable effective skills can avert.. CoQtain.or..solve many ~the life.:.
planning. threatening problems tha t may .a rise' .dllrirtg

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1[.:.

12 S.ECtlON 1: . BASIC CONCEPTS OF HUMAN -REP~ODUC110N.

..
. .
childbirth - but they need the back-up of.a midwiv~ can work in the delivery of :maternal.
hospit:sJ. health ~are, parti-cularly on basic emer&ency
obstetric serVices.
In the"I>hilippines, traditional biTth attendants
(TBAs} are usually neigb.bora or r~!ativee wno take . The Phjlippin.~ Leaguet;JfGovernment~
care of the needs of the partllri~t, especially in {PLGM} i~ -the b~"!St ptgaruzat:ion of~
the rur~ comm'-tnities. Local studieshaveshown midWives (over 1000.0 ) __in tne counti.Y;mo~tly
TB:A.~ to hae no 4U-p~ct. on the red1i9tion of . in~olv -in. -health se~..iC:e delivery. tb:rOugl::l the
maternal deaths. b;ed~hse they are unable _to goyertu:1~t sen:ice .de~my poin~.,..Th(:y:teC.eri.tlY
<;:omply with . -ba"Sk stiuitia'rds of <W~. . tr care ..mclu.ded
. . .. -m.idwives
. ~ . .g .m th'.e ..
. ra"b.cin
.P - . . .~.
ptiv'ate '. .
{Reci4oro 200~,. brut Stra~~ :P~Jler2oo8). They 'P:}:e -:other midwives , or:~iza~on~ include the
h:ave no life$av-ing 'ski~s to deal with life- In:~~ M.idwives A:ssociaiiott of the Ph.ili~
threa:tenfu_g problems_ such ~s h~~ort~age, (IMAPl and th~ M_id:wivea' FcJ!ndation ot'the .
~~ 'Qr"obs~ct~ 1-aWr. 4iCai attei.Q:pt~ in Ph:ilt~~ '~Qr t:Po'sewho.are m .the ~ih ~ . .
. the past to tnfu 'traditional birili.. attend3l;lts have- de]iveiy ~ror. many of thetit attend to .home
not:m ade a-s!gnUlc:ant 'r~1ucticn in tlie morbidities 4e.liv'~~~ itltboUgh .tnanY .are -~ to. ,- pr&r .
andlllOrt.aJ.itiMhicaSes.attend.ed by them t?ecaus.e to at;tend'w thdr -1i~ts ~ -the M~terni\f.Binhlng
of: .th-e ildriiih_e d -<:\Iff"l"C.ti:li;i~is in dC't~ctihg Hom~ whi9h:~,~~qilly ~~ th tb;.eRunil
c9mplication8 ~a_.-.t;he in:abiliq to :give. :early H~lJtiita ofnia;nytown.s.in:th~;prov:incs..ih!se
iJlterventiom:. -tiriov..ciVe8 .a~ -~~ly wH1 -rlistit1;m~. ~ =iilin<>St
- :-''.-- all ~es~g ~:sin the e<>u~tJ:Y.. ;Wd wo1-rl<i
~-,wNtrainingpa~a.).so;~.iqll1ld ~ i~V.e<iittk: appro~tc1y -eovet tlie:11latemicy li~ needs of
#n,pi1cf..p~: n:a~e~aJ::9~~ty~~~~!4beS!noi:- .. " -~;~~.,-to ~~-~-:~~.'faA. .,.::':=.. . _ .
sub.strul~te'r-'~h~beJ:ief~Sy,_s~- of..WAs..ar..d~., .. . . _ r..-;.....-,1;;. _, . ,. . ,, . , . ,_ .. , . . . . ... ; _
thua hli!t 'li#le !:' effect "on- practicu:c:.Flie:,:extFa::- . i. ~- -~~ _~. ~~ !~~2 -~~~-~: _k;n~
Ci?"!lfiden.~ :g$led fr-Om the :ttaining-~ence) -~}:1i4~e.?." --~~--,P~}~92, ~ ,f.o~~ - ~
may4n~t~aa~-r~a4~ ,t()<}~~-high~e:c,;-iij~~'d:ell.ee, .<'>L. .t!t~: :~~~~--~-~?~~ :.-Q.r._.-:rp.i~~y:es: . . .
. .~g~~s\~~u;t~;s~~~,~ei~Y.i.~~-:~~rc~~al:!-> ....- ... . . .= .: :: ..- - .. ., .. . __, .. :.. . .. :- _.__.;_ _.. ..:. ~- .. .
(R.ecld<>ro::2:~).~,Fuifl;lern;n~re,~~~l!no;tlilfulg!:;;:, , h ~~ ~~~'pcifon;n P or:_~"i'C):lder,.-<:fqr~ao:-f~'~'~ry: ,;0!\ __
:scit;ri!m:~~- e~~~ce~:tlfifi:.f:,s'o,!:ti~ ':ti~ft+~~n.o~edr.. - o~et-. ~-~ . 01"'. :.a~pensation...seivices
tts.4iti6tliU .i ntetvetitiOil$ ~Cl.i :as 'profuioD:s o'f- .. : r .e qu:i ting . a:n --~I:i.d1-~t~ii.{l~~g-. :cf." . -Ul~
haSic'':jt;iifeonlil'::are,&na~Tt3~ :,fnffiiifige'"are not. ptiffei.J?l~-- -~'d- e,'!Jpli<::;ati~fi.-1'f~ .. :-..P~
.eHec:ftve-<wtlli~ut -:r~a~~rwnir e;il:er.gTn:Cy iWd. ~~q~e~----~. ~t:p:e.....,su~u~-81i<i-
obstet."'ic:a:re-ser-ii:c~ {P.raft ~Strategy~aptt'2003). ~ :of -.wori:l:an dUring .:p~, l;ahor
arid p~~4~ rp.an~g,e~~):lt o.f n:ormal
:Tlie ROte.9flfidwiVes tn Maternal - ear~- in the delive~, -~clu~g .the 'tfor.ri:l.ance of .
'Phfifpptnea _. .. . mternill exs.ni~~tion .dl.llg ;l(:l~r . Pa.tient,
. . family
. . .arid eotntnu:nit-.
. , . ~JJ

Witli titne,_!J.t is a lQCa:l g<;iaJ. to' _pave .delivenes
att;;;nd: bY
sl$ed attendants -With -ip.i~~ves in. 2.. to~d~liv.~ p~ hea,lth .qrr.e servit6 ill
the frontline. Midvriv~s. in the ._Philippii1,~s are :the oc;>trunuf}i:ty,, -ihdud,iilg nutrition and
u sqaily. gl:a;dua:tes ._of.a two to :~e yea:r progtam family .planh1ng .carrying o-ut the Written
?-iter hlgh'sChoql;.and':iu-e certilied to practice via order ..ofp}lysician~, with !:'e gard to' $f.en.a,tal;
a l:icen~ur.e board examin~tiu~ gi~e'n 'by the intra.-na:W and poqtnatal ,careof the_ normal
n ational Professional :Regu~atotj CQmm'is_sio:1. pn~l1:a:n.t rootber in giving imm~pori,
Ther6 .are now more ana .- mo(e programs to inciudin:g o.r al .a nd pru:ente.r;al .dis.Peosing
iniprov.othe delivbr:y_ ~f:heal~-<:are in 'the r:~mote of oxytbxic . dnxg ~ter deU~ecy of pl..atX~ta,
areas,: by e-n -tout-aging the p.erc'en tage of S\;l,JU~g per:enni3J lacerations. to con~l
attehdance -of . the deliver-ies J~y . trained bleeding,
professional~.--usu.ally the -mi9.wife.s ._who ,are -.
u:iU~y COnside~ed. as-.the fir;st encO~Jlt~rJ;lealth .3 ~ to . _give intravenous :fl~d -during obstet:Dcal
prof~sfoiiirl,in.'the natiohal:};lalth syst~m:!fhere .eweq~ep__cieS:: provi9-ed.. they have,been=. tra,inep ..
ar('! other professionals such as the ,ob~tetridans for: that . putpose; and may . inject Vitamin .
~nd obstetric practitioners with w hom the K to the newbo.m.

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 .. . . . .
CHAPTER 1: OVERVIEW OF MATERNAL HEALTH IN THE PHIUPPINES
....------___.,..----------------,.----~------
The Role of .O bstetJ'lclans ln the Philippine
Heal~- ~
The .Philippine Obstetrical and Gynecological
Soci~ty (POG.S) is the nationally recognized .
pi'ofessional organization or .Cbstetricians ~d
gynecologists, the memb~rs of which are
accredi.ted before being allowed to pract;ice in many
hospitals and to I>e recognized by t..fle national
health inslliilnce system; Presently, there are over
2.000 members distributed ill altnoat all teii<ms
or the eonntty~ .however, most ue in the urba.n.ized
arelil to b~c::ome a.' member of. the Poas; a
physieta.n ~!Should l)avc com)>leted .a four~year
reside.n cy in obstetric.s Jllld zyn~ology in an
accredited mstif:l;tion; submitted case diSCU$Sipns
on prfo.~ed proeed,ures and passed written and
onil ~tions, given b.Y. the PhUippi.n~ , ~
of Obstetiic.~- and. Gyhecolt>~. The POGS is
invol~- in' cont.~~l,lmg ed.u<ititional modUles for
mj(hvives, e specially on maternity care arid
woD).~'s~tl,: iss~s.
::~ . ., .t.i~.. .
The POG$has. ~any outreacbprograms as .
part of the COuununity Service program of the
SocietY..~.~~ is the AdQpt-a~Barangay (Village)
proj&tur~fu:e..' provmces w.l\icb wa$ :suc.cessful
m =6 0nglng:$peeiaUststo ~erve in the depress.e d - intensive, :or ea:ta.s trophe); , Ihpe,tient peQeiits~
and~::re~~~areas of the country; This was
strengthenedby.the local and regi.onai chapters
oftb~ ~~.ty~ A~i<,\e. ~om th:C ca,sjonalclini~
.sen.i~s.in 1'tnedical Ulissicns,
.........,.... ............
:r-~,., -~_.., ~ -.--- .......... .. . .there
... .....,.,. . .....
~~!3mdy.p~gL~~r ....~e~g.:. sar..J.ta!i()n~ . .. _(D..QH)_J:U:~mioi~tra~..ru:der..in.20.02cprovides.~t.
propet nutrition and livelihood training projects.
Another program is the ABCC which is short -of
Anti-Abortion, Breastfeeding, Cancer Detection,
:and .Conc~ption Control. this was a lecture
.series ptogram in c.o ordination with the
Iutegrated .Midwi:ves' Association of the . hospi~.
Phili,ppines.tiMAP), . an.d rural nurses a~d
doctors. There are als:o demonstrations of
.medical and surgical procedures, and sharing
ofeducational materials.
Other recent capacity building programs include
the Reproductive Health workshop series
c oordin.a ted by the Asia-Oceania Federation of
Obstetrics and Gynecology, and the ALARM
project which ~tarted -w'ith the Canadian Society
of Obstetrics -and Gynecology,. the Blue Program,
Adolescent Health Information Program, Save the
Mothers: from Hemorrhage, Life Saving Skills
tralning courses are also educational modules on oorne 'by the OOH hospital.
Scanned 8y:
. . .
,.,,,
women's health, adolescent healtn; and
hemoglobin streening are partnership programs
of POGS With the pharmaceutical industry.
'T he Pht!ipplno Health Insurance Corporatlon
The. -Philippine Health Insurance .Cox:poration
'(PhilHealth) is the ilational health insura.pce
system taking care of the employed sector and the
de~ndent sector v ia partial bene&ts .for.health
care service.s. Crucial to .the .effectivc and
sustained .implemen:t{ltion of the maternal ~
servic~s is a sustainable and eqUitable sjStem tor
financing. This financing systelll 1nC'ludes
acceleration of PbilHealth accreditation and
requires action frOm the .1~ .:goverrii.n~t. units
to ' ni.M~ s\lte t h&.t !a.cilines and providers meet
accreditation 'Stii1.4~Cls. Program~ are being
encour.a ged to .actively advocate for meettng .
em()ilment targets in the PhllHealth-sponsored
prpgran:i. ~ .:-. .1 .~:.1.1 .~ .! .::~.; -'- i-"'~ i
. In ~rteral, inpatient ~tment,o.fH~ilY:itl~~
is PhilHealth compensable subject t() bene1tt
ce~gs::depe11ClL'1g on hospital category: (primacy:, .
seeondary,or:tertiary)!andtype,o:f..illtl~,:l~ .
in.clud~ . payments and ptofession$d..r.;f~~~t~4r:-e .
often than not, Pbilllealth meinberSI!-hav~:to:ipay
an exce3s bill especjaily for... confi.nel;:lents in
are
l~es
.,........-....: ... . ..PP'vatet~h
m . ,. . - . ... ....... i~ Alltpa..
- ~-
__........ . . .. tu
rtmtn~.o . e.attb
. .
indigent I sponsored members of PhilHealth
confined in DOH-~tained ho~pitals r.eed not pay
the- excess bill on top of the PJ::illHeelth coveiage.
'T he support value for these cases i$ in effeet 100
perce.n t, with the balance borne by the DOH
Phil'Health developed benefit packages that
make quality basic health care services accessible
to wo~en. In-patient benefits include payment
for room and board. laboratory examination,drugs
and medicines, operating room use, and
professional services. Thus, with the benefit
ceiling, PhilHealth members confinec;l in private
tertiary. hospitals pay an excess over the bill. On.
the other hand, as an added benefit, indigents who
are members of PhilHealth-SP confined in DOH
reta.ihe<;i ho.spitals do not pay the exces~i1Pill on
top .of ~e P:hilHealth. 'ceiling .AnY. exce.s~fbiU i;:;
:,.
C
 $ECTION 1:. BASIC CONCEPTS OFHUMAN REPRODUCTION

lv1aterruil care-t~:ses in an inpatif;nt setting are health units and am:pulatory surgical clinics are
covered .Qy 'PhilHeeltb as part ,<;~(the r~gular . also all0wed to provide the N:SD package without
inpati~t benefits. To qualify fo.r chiki:bfrth.c~s.. a~ditiona.l accreditation fee provided they ctnri'ply
an .individl:lal,ly payiilg m~mbr pays ,at ieast nine with .all r.eqUir-e_BJ.ents for NSD package pr9vision.
(9.) monili!y pte!niuci.~. Indigent Philftealth-SP The standards ..for acc'reditation of nonhospital
metnber pay.s three{:3) monthly pt:emipma . to facili~es mdude: .l) the capability t_o.~der .qu.alit
qt;lalifyfor~dbirtbcle.inl~. Nonnalspontaneous pr.enatal car~. "normal" nildbirt~ {N;SD)
childhirtb. . (NSlD) -ha~ .... ~{pe;cial .eov.e rttge assi~tanc~. . routine newbom ~e. -po&t;pa.tlliiil_. .
a.rr.a:ngem~nts . :N'S:P ~n~fi~ . c overg "n~~maf cat~. a:n:d f~miiy planning s~bices~ ~) ge:Q.etal
WleotnP.licatt4 ~ hildbit'th for. ~e fitat four infrastntc~e require;!rentS ~cl)l<lln,g::.S\l.pplles;
(4l Dlfth~. A1lotb.~-~ ofthiJ.dbirlh-al'e wvered and -;3) q}l~ty assutapce ..a.Ctivities. Many of -th~
r.~ ,fif ord~r {)f .b lrth. .. mid~manf;tged 'F anllly Weilnss.C~ Iro;m all
.. . . !: ov:er the country hav- 'been -~ccredited Jor
N$0i$.-q>m~~ble .1n ~~ -~-in notv i.t:i~w:anee cove~. .Health professio~s~u$ as
hospital f.ailitlesat ~a case. ~te .Of P4.. $00...00..For do.ctor:~ ami. rial.dwi.\re.-s .are:~$0 aci'e'dit~d to
huspi~~:.:_thl$ 'b ~ ~-er ~~Q.birth amooveNS_ proVide ~e NS:P pac!age subJect ~: .~uon .
~ ..1~....~ti0
h O~y~~ .. I;l.:~
.. ... .cfm
. .. sOOAJ.O:a..nd.p
.,. ' . , . . . l'OfesSit:>nal
,, . .T-N'IUireine
...,'i. ~Cti
. n.ts, whkh. i.n. clud.e:.. active.. r- . e for
f.ee ''Qf . :F~~ooo::O-q. For a-~~~-~os_p ttill'B, dO:Ctor.s ani! :parmership viit;h t:wo ~d~'w~.' '{an
rei~~p:t:l~~~~-m-~Q.<*l ~~ _:~ obstetri~""gY.neio~o.~ . ~pect~~;st '.o~ ~ i~
.pa~
. . 't. ~: r~ ~1:':1\ " " ' . .. . tal - NSD obstetrics "'
. " d. a ..,._t:.a
_ .ttii:' s.~.:,. _ .l;
s. Afl. .,....__......: . .
_ :. ~ v -.
:l'~oiJ~ ~~:,l$. _or .:pr.ena . . ~- , , C > M ~-- Y'-'-.-.u .., OVLJ.LUll'W..l '-...
and:~rti-~;-~~M~~t.ot-t>a$<:too . .
is f:or :poati,iat~ car~, .ti>.tti:it.Y. ;pla.p.ni.Iig<!1.:. . . 1'he p~di.gni .Shift for ;ne:w .4?.,tetV,etitiQP$ ..tO
=~.:.e~ss~-=:.:a:~~~t?~:s,
pro~d~ fue_~.s ..<:N~wb.'o,ro::-cm,.. wh;ic;h . in~n~v-e.s, .a~V<?C9:CY: and .c4~tii.;l~ 'The
io.Ctuae. ~~sere n1n,_i~
~~- 'fikd'.a'S~a-~rl>te
. '- - .. .: . . '7'~":- .;: ~iiieentives~and .Ra~
~ . ~:shall
- - , ... , . -.... . , ..

.
.. .. .. . o . . . . ' . ... . . . . . >... . .
datnl;,'.fdr '-lw~pit.al births tru.t . ' inthtded::t. . "the bepaqo f . veriill'BOO and~~ ~that .

NSOu::;::=:::~:::::: :.;r~1E:5~~:
rtri(1Wlf~ft"f3$age&:-~~b~h<?JP.es;-~dany guide-~emWwairlaa:-single~~etsahli~sage;fu.at
oU:ieNinit10:gou3 ~fu"'7faeilitie$::k~.ttd::r:ui'-ro. --em,bodies:-~~orpi()jectgoai: . . ..

'
' t r~t~. '.D a. 'li!' 4~~"1 s ..,~.-~s.,,~.~
rc. - -- ia.ie's ._
.
:~~ -~:~~ ...., .Jl A~_at ~~ :y~
,,,o:iHti-:~-11!:~.. o :c~ _, .o;,a -~Hy..o.~-t.--:4~
C !a~,C. witkJI '.K,S 'i t 0.1& ~ i.x. , ~. ... .
....:au i,{f...r a ll .-a'~.. , rs
- r s~...,..,,~~ t-xuJ.. ..1
,.~ r.,lf '-"~ :,. -~ ~ !. ..."' --:.-!. .. - . ' . 4
'Zttr.:. ~ltr>Ac .fr Jt.
F.~ cl{li J. ~l./y~;.,..,:. _-
P -te 1 a a n:t
W o ia.ca: W ~A'
"[.w.iil<h.')i-v.-r in
s h.th-h l r.. ~.rli tr .-
~ .;.tal'< Put21 cr
'"My l'.l' .. itt J.eJ/ver I-n 4
4 I 'I' IA h ~ .ftz c!l/t.y . "

.l .
c 1.. 1,~ N T' s l.ttit~&t.iO.n olS ~.P p.o;t
tni4n:t L oni .J 0 YCfll ill .n:ts' Maternal Care & Advocacy
Wo . :W. 'kA2 o B araoa Y St:r:ategyFi:.amewm-k
~~ W iJtttiYOT 'i a C) M u.n icl p 1 .Philosophy..: Client-.fl""'.
' sed,
ll IN 1a' s t.a:c:.ilit.y. . o Pro;vin.:lal """~
.. ).( "- " oct r . . . N otioR,, . . Client . ~oriented
~}.(.~ ./'.7 w1Ji ~4il-.6r ,IA 4 . . 1' .ollcl.u -& 8 "it,t " 1 o it .t: ,.u (Adt>pied.Jrom; ;DcH.:.WHSMP.2
.
A l~.tJt.~iit (tt _~~Jitv
.
L-A..,__
P-P';._u._'__'f..,....a-
c'l_~f,....ty_.__ _ _.,...__ _-""
. .BCC ait;i~dvocaeyStraftevy}
'AD V 0 C A C Y .

Scanned 8y: ~
r- <:HAPTER 1; OVERVIEW OF tMTERNAL H E&n-i IN THE PHIUPPINES .~ 15
------~~~--------------~~~--------------~------~--
1
!
~~ '~-

.POINTS TO REMEMBER

More than 113 of the global.burden of diseases for women-aged ~5-44 and over 1/5 for women
aged 4$-&9 are caused by tooditioos that affect women exclusively and. predqrnina~tly.

Poor matemal heatth and nutrition ~ntrib~te

to .l()W birth of abovt 20% w~igt)twho are Ofbabl~. .I
at .gre.ater risl< of lnfecticn, malnutriticl),. iong. term di~bHitle.s including visual.and hearing
. impairments, te<:!ming .c;tisabj~s and me~ retardation. and death. ""
I
: Reprod ueuve.f'iealth is a state Qf complete physieat, mer$1 and We'!!-Oeing and not merely OOdai
the absence of disease or Jnfirmity,ln all
~eri-relating tp the reprodu9{:ive ~tern and to its
functions and prooe$ses.

The Philippine government, .as part of the United NatiOD$1 h~ a:gr~ to follow ~ -~part Of the
Millennium DeVeJoprrient Goals (MOOs) :a policy to reduce maternal mortality fdtios by three-
quarters .and under.:.five mortality l?Y ~thir~S betwee~ 1990 a!XJ2015.

AI$Q incl~:amOOg ~e Millennium ~:eiopment :<:;-.qaisiS-~ ~v~. Priiveci>al.access.by 2015 :to

tlle wf,;1e$t passibJe . range Oi safe and .effective famity ptanni(lg.mel;hbQs ~~d to the fo119Wing
retate9 reproducti\'eheaith ~tvices: essef:itial- obStetric ear:e, prevention .and. management of
-.: i :_:- r~uef:!ve tract inf~ons inclUding sexually transmitted lnfectioos. ...: , ; . : ,i.>.,;
-. - . . . . -. . . - . .. . - . :; --~~... ,~-l-s~~~~ . -
. -;.:;::: The .materna~ mptta~ity ratio {MMR}, ot matemal~ths2-.per 1oo,:ooo live births, wa~repo~sto.i.
be.209 in1993a_qd 172 .In ti)98(NOHS 1993 and.1998').. :"' ". .- r~:~- .
-~-:~~1~r- BlM .isihe1:0mp}ete expuk>ion ore~~ ot::a.~fe~from:~e .rnot\ler, ~P{Wnethf~
. . .!'~~ -...,'l::r,"'"'
:..' . u~u ,;.,,1 t rd '~~ ~..:-..- """' .. or -~~ ~ta;;,. still ,a~...A'
. ffiuniCa :CO . ; tk'h> . ~ . -'-'9 . . -~=~.. .-~: ~ ~CU.

.

. .::~_,,,.-..

.'

.',,;J/;.: .
.,. ..,... ' '':"~::~::~- . - -. - : : . .:."' ..,.. .
. . -. . ,,,...J:.h ',.;4~ f : ' - . ' . . . >:.:1.:. . '( ~...1t~~:;--....
, .... ~-~~'\ . St~Wel9~-1lteweJghtofan~te ~ihed -lmmed~afterdeflveryor_as500n:fuer~et- '
a::; f~sibte. .It should be expr~ -to the ne;;1rest gram.

Birtf)-Rate-refer$ te the number of liVe births per 1000 population; l.iS!Jally :?15p reteT-red to as_ the
cruo-e-b"rrth-rate; .' ... - .. . .... - . .
' . .

. Womeirofr~prod~ctlve
. . . . . . a:ge.refer to all
.
women ag.~ 1H9 years.
. .. . .
Live Birth - Th:e complete. expulsion or e~action from the mQther of a produ.ct of human
conception, lrr~pectjve. ol the duration of ttH~ pregnancy, which, after such expul$ion ~extraction;
_ !)re<ithes ~ shPW$ any evtde~~ of .1ife, .such' as
beating of the heart, pt~lsatiori of the umbilical
cord, or definite movement" of voluntary muscles Whether Pr
nQt the umbnical cord has been cut
or the pla~n~ Js attached.

FetaL.Death -Rate -:refers to

the number of stHibjrths -or fetal deaths aft~r 20 weeks .gestation age
per1000 total births. It may be expressedbased on a-specific grcup of stillbirths and bir:tl"i bas~
.on age bf ge~~tion or weight upon delivery.

Neonatal Mortality Rate refers to the number of neonatal deaths per 1000 total Li\le births. It
be
may expressed based on a s~ficgroup of neonatal d~ths and live births :eased on age of
gestation or weight upon delivery.

! Perinatal Mo~llty Rate refers to ~he num~r of stillbirth's or fetal-deaths .o f ?O weeks' gestation
plus thenumber of .neonataldeaths qnder 1 week
. ' !
.per :tOOO.totat".birth.
' :
s
.
. .
Preterm refers to less than 37 completed weel<s {or 259 days) of gestation

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16 sgC110N 1: BASIC C()NCEP'TS Of HUMAN REPRObUCT~9N

~enn is Ji-om 37 weeks to 42.completed weeks (260 to 294 days)

. Posf-term r~fers to more th3it 42 weeks (o;295:days.ortr~~)

Maternal Death .;efers.t o tneiteath ofaWQman.whiie pregnant or within 42 daysafter termination
.of pi;egnancy.irrespeclive .ofthe duratib.n .arid :t he site of the pregnancy, from any cause r:etqted to
or. a~ravated :tty .~ prS9~ >pr.1ts 'JllamlgefolleOt bl,il :not fiOm acqden~l Or Jhcldental causes.

A basic essentiaU~m~rgency o~tetric ~re (B.EmOC) :facility 1? one tli~t performed :au 9f the
fo!lawing $ix ~ (knowtras sJgnal f\l~) .at least 9tce in the previous-three montl)s:
.- 'a<;!~i~tstrati~ ocf paren~antiblotics, :o~:and anticoovu~nts; . . . .
:"':
man.ual ternovaf oftne .placenta; .
. .
removal of r.t.ai0e.4J?r0d\.l~ :{e.g.. rt~nual Vacuoin asPl$tion }; ~n;::~-

' A eo~~~h&tl'GJV;e e~~U~ettJ~cy ph$~etric ar~ (C;Em( jC) ~c;l!ib'. ~ ,o:ne :fuat has
:~~~=:n:~,trnnsfu~n;.m'adqitiOOto:a~sbc.BEmOC?eMces.

..:,;:h6-~~or.~-r{D9ti~~s:~a)l.,_p_~fl9~ wo~n..h8ve.at.Jeast.~OU!'quati~
.~.pUi'posefill a~!~::.-~1~'~'P.f,~~~ .. : . . . , ;.. . . . .

The .~ot .~H :~tt&t.~ :~~~s-~~~s h~ P>9ra~ 'fils fr aslilit from the

.',.=~~~~q.~;;~Zn~~:~:

Atthe s~ Je..et. th~~ strategy:req~ .:a transition to moreappropriate.distribi.J:tion 6tde!Ner!ez

ajong the ~tibJ..iOtn ~f t?re. :~ing . more normal:deliveries ,i,n ~sic h~ lth rac.illtie:s. more
.emergency referrats :to iritemred~ leVei 'facilities, and f~wer deliverieS afhome ana at 'higher
leve~~ . .

The ..p~...pJ..;ipl~ety. ?s. ~:tr-~7392 o.t0ef.M$e kn~ ~s ..Mid'Mfel)' -law Of

. 1S9Z;. C9nsistS':Jn,-pe~\~tt:~{jg... pr-off.eon.gifO .perfqrm or ~f(der, fer -a ~f~. ,.saJa!)',
or other .reward or tom~.. ~fvices requirin.g an understanding . of .the pliilcipl~
and , appii.ation of . pr'oCedut~ al'i\1 techniqu.es in th~ supervision and care of w6man
auriog. .pregr.tancy, fabor:~no p.ueiperium mari?gementof normal derwenes, 1ncluding the
peffrma!1Ce of-Internal ~e((~futnation d~ring Jabpr patien~ farni!Y an<! community.

The Phillppin~ obstett~l and Gynecological Society {POGS) is the nation atty. recognized
profeSSional 'Of.gahizatiollOfOQStetiicians ~n~fgyneco'log!Sts, thememPets .of which are accredited
bef0re bein.!;l}.aUowed topract:tce ttHnany hospitals and to be recog niz~. by the.-national health
insurance system.

The .Philippine .H~altn:l~st,uan'ce Corporatloo (R hiiHealth):lsthe nation aI he~lth insurance system

taking:qjre .of the emp!qyetrs~.;an(Uhe dependent.se:ctor via. partia! ~nefits:for ttealth care
. ser.vices, includingmatetnity and. neWborn SerVlces, and worrien'shealth services. . (

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 CHAPTER 1: OVERVIEW OF MATERNAL HEALTH IN THE PHILIPPINES .
...,...---~~~...:...-~~------~----..,--------~-'-------- .,, 11
1. Maternal mortality in 2000; E.st:i.auites devdoped by
WHO, Im!CEF a.J;ld UNFPL /odd Health Organization,
Geneva, 2004.
2~ United Nations. Report of.th~ liltematiotl9.! Conferw1~
on Pop~ation and Development. New York, United
Natimu, 1994{<!QCUIDentA/ CONF.l71/13).
3. Report of the Ad Hoc CQ:mmittee of the Y,.'hole pf the
1'weilty-.fi..t"St >Special Session of.the ~n.eral AS$embly.
New Yolk, United .Nations, 1999 (document A/S~21/
5).
4 . World Health Orgar.ization. ,Reprodu~tive heeJth
indicatQt:S ; g\ijd:eHnes fo~ t:Q.eir generation,
ini:erpre~O::l e.nd analy::;!~ for global monitoring, 20<?6
5. Pr~;~portion of births .attended b . y skilled heslth
:personnel. Estimate3 by counfcy - .2007. Last update;
,, April 2007. WHO. Avallablefrcim:~ttp:f./www;Wh<>..int/
l-epio:ductive-health/global_m9bit<>rin_d data.ht:1
6. _J)efinilioi)s.:andtcnninol.Qgj.C$ {http:/ fh!s.ky' ..gov,IJ'W./'
'+1IonJy,r,e rs .fA 00 C'BA9 8- C 6At i- 4 A 58 -1314 C-
324E7Cg~/O /Vit:al$tats019~Jeneric.pdf)
7 . ~~~;P.~CJ" safr~ .~critical ;role of the skilled
.. atten~:,.a. joint statement by WHO.lCM and FIGO;
. .~ -!f.'Ger..e~.Wo'dd-'Heai!h:Or:g8nization,.:2004.
banned 8y:
8. IGD-10. lnternationru statistical clas&.ifiC!\tiOn of
&;;eases and related health problems; lOth ~
Geneva, World Health Organization. 1992.
9. Graham W, Filippi V, Ronsmans C. Demonstrating
.progra;nme lmpact using matemsl mori:ality. 'He.alt..h
Policy an~ ~g 1996; 11: 16-20.
10, WHO, ICM and FIGO. Making pregnancy safer: the
critical role ~f 'the skilled lU:teJ+dant. Geneva: World
Health Organization, 2004.
i'l. UNICEFJWHO/TJNF'P.A. Guidelines fur monito~the
aV&ilability .and 'Use of c;bstetrlc ~ NewYodc
Unit~ ttc.ti<ms Cbildren~ii .Fund, 1997.
""\
12. T~ddeus S, .Mairie D. Too far to waDe 1Iiaternal
mortality in ~ntext.. New Yor: C<>httnbiaUni'vctmy
Center for .Population and Family Health. 1990.
13 . Gu,idelin.;;os for sexually transmitted infections
survdllance.Gene:va. 'WorldF{eyJth ~ 1999
(doeumentWHO/CDS/CSR/Ebcj 99.S).
ls. Intematior;uu ..Statil!ltieal C~caoon: of Disease,lind
Rel;at~ H~th Problems . Tdith R~o~VoL :2 WHO
pp:129-l~. 199~ . ''-t: .
' f -~ :,.:-:~~-:~~ . :: ...... . -;:!'..-j..~ .- ..
16 . .Re::idoro zy, 'Dra.."tOOH St:rat~.gy' ?q>c.rf~u:W~s ',
Healfu and Sa;fe Moth~ood Pro~.;,r;;-~b"';.~Z'{.
' .2 004). . '~"' ~
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 2

UNDERSTANDING AND USING

THE MEDICAL LITERATURE
LORA GARCIA-TANSENGCO, MD,-MSc

What is evidence-based medicine?

Fwe reasons why v1e should p~actice evidence-based medicine
Steps in the p;actice of evide:~ce-based medicine

a. Frame the question .

i. Four fundamental types of cliniw! questions
1. Therapy
2. Harm
3. Diagi1osis
4. Prognosis

H. Study designs
1. Randomized, contrciUe<! trial .
2. Observational study to assess harm
3 .. Study design to assess a diagnostic test
4. Observationatstudyto ;asse-ss progn<:fsls

iii. Three basic components of a well-built clinical question

1. The patient
2. The interventio"n
3. The outcome

b. Search for eyidence

i. Sources of information
ii. How to do the search

c. Critically appraise the article .

i. How to use an article abo.ut therapy
ii. Hpw to u?e an article about a diagnostic test

d. Clinical application

e. Evaruation

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 SECTION I; BASIC CONCEPTS OF HUMAN REPRODUCTION
----------------------------------------~--------------~--------------~-

specific clinical problems ~t .aris~ ~their daily

1
: .WHAi' . EVIDENCE-BASED MEDICINE?
...IS .
practice. By ind:j.vidual cl.inlcal expertise we mean
: Many demands and chal1ertge~ cerifront tile the Slci.!ls ano.judgment.tliat individual clinicians
-d:.to.rs -of the 21st century. In ord:cr to keep acquire through cli..-..kal e:kperie'nce and clinical
. ~~~-~with th.e exponerttiaUy'.gtowmg amcunt of practice. -Experti~ ~s revealed in many ways, but .
~~ID!ortn.ation availa?le in the.medtqrllit~ture . particularly in tpore accurate diagnoSis, effective<'
eacrvrl:ay, it was found 'that the clinician should treatments, and in the mo:r e thoughtful and
. r.ea.d lfi) articles p~r d?y, 36:5 d~ys per y.ear compassionate use of individual patient$'
'Jb.ariqofi}'. The busy practicing din1dan has . predicaments, rights, and preferences in making
,pei:ha~ an 'h our a 'Yeek to read his j~mrnals, clinical decisions abottt their. care. ~y best
P.#fib.t qf(:~y.p~e.~ii~ o_.f.:the ~b.natiol:l . . a-v~ble ,exter.nal .cli,ni~al ..evi,denc,e, _we :xnean .
n~~- t~ }.teep.l~~iriself:up . to <4(t.~ ~Ui ;~ :~t , . dinie~Uy r*le~ant; .'pi~i~.nt-:cent'er.ed- diniC:al
.in .s fielfi.:.\Vh.hot:R'(;\@gi~ :;0Ati,p.1lo'ij~ ae~-. .. !"esearc}l..: Extorn;~l eltn:jcal ~t.i4en~e . both
. .~ ~& -clirii,~)\:re at nSk rif ~ m~~tes }?r~\oiCl;ls1j -~~t dilignos~c ~ts
d:lJ(geri>v..~J;Y c~t oC.date. ffoW. then. dbe:s: th:e ~d b~t:ments aitd repla~ them: with riewohes
ppy;='~i~~ t-oday surv'iv; these formidable that are mote powerful, .mo~e accur-ate. ;::riore'
.. .cfu.illetxg.es while kee ping up with appropriate . effective. and Safer. Patient v.alues ~hould ~ be
~~~ 'th:e f\llswer is ~ou-gh_a.n efficient. integrated ii;lto tllxili;al ,deeisip:r,ts by .~g into., ..
sl~:Ve, . ,p.a:1Jentd.r1ven se.ar.ch .of the best acc~c.nt -61,ti:: ~:tien~':s individual pref~rences,
.a~~"b~~ e}'ide.nce~ -its critical apprais~. an.d ii issues and ~ta.tions.
. .....~~~Wlen.g.ed t<> be vali-d and applic;able, its '-
. ~~tkitf;mtQ~.pracfk:e. , . . The :scienlliic.met:49Q..:E!f, BaM :per~p:s .dates.-:.
.. .., : . . : . baokto.. a. time,;o/heidnqlHstLve.phy..s.ician$ ~sed: ...
: ~t--i~;;E'vidence... Based.:,MediC:......~.e?:. virum .,we . to qccept pronouncements-o'fa~llioxiti~s:that ~d. i .
. :w..~edi&p..srude~ts. we J:Xl.S;>"'iVely aceept~ and .no. reasonal;ile rationale :ot. exp).anation. Take for
. m~S$ical,ly ..$elll.oriz~ 1e~tures. of reilC5w'ned example t4 pievi~-q.s ~UtO<:;rntic:pr.'onoun~t ...
.;.. :Prtf.~e~~or~ ~Ehb~t . ~~~~~<?~: Sih~.e. VIC ~l!re that-:veneseti9n'~as~~<;ficlalfor cholei<l.A,poSt- .,: _. .
. ~ ::$~ ii. we 'should .:acep't ;pi-evailiiit'practi:ce: .revoh.ition au .French! ~ician; 'Pierre.- Louis;:. _: ; .
. :.pr..~:~4th.ewer, _possioly,,more u~ful ilia,.guo~tic . . rep!.lciiab6d . this, prpP;o'U;ri~~ent.' and sciu;ght.the . -. ..
. i~.,Qt. more~effective-th~py7!'weit;lqu.ire(l,fi:om... ' .-t:rutP..in sy*Jliatic. oose~tion ofpatienta 'The .
:~~;~~~)it '~rtS or eonsUlted out 't~]is. fum.olis- $ly 2'o.tb ~cerrtuto/.ubstetrici.an's dogma .o f
:~(;)4i-.:.-p$.teS.sora.wt>uld.often~r.eply ~~dn.,o.ur ~ _a__~@f.!,..:..~Y-.~ .CJ. ~<Rf%1!1. . ..~. :~
~h~e-.-e.~ .We<tl<.'>d: our.. h~ds:. ~ccepting.. ev.er:y : :been, ques~ned.ancL.is..now. .Ilo.. longer...acceld '. .
~ :'f;l?.ey say without a. doubt. .itowe-Vr, .experts as ;:!. .doctrnle to be eon:sistently practiced.
.:are' :riot: without their biases an-d oft-en -h ave
. CQ~_fli~ ~~wers. Such was thedilei:fuoa .ofthe 'Perh~p$o.ne ,of~.e first prqponents ofEBMin
:: P~pQnen'41 of frwparad.~gm. shift from experience- current pni.ctice was the group of Gprdon Gu.yatt;
:~ ,m$cii1e to eviP,ente.;~sed rne.d:icine. The a t McM:as~~r :r:J:niversity in Can'~da, who, .
. .. :oi4 ~digm, the traditional; autoCratic manner in,corpo.r ate,d ffil<;{ ~OJl~o:liP:ated. th.is_principle mto - . .. .
: ~Q.f ~li<l.~g o\.trSelves fro~ e$ert opinion based practice in 19~2. 2 Siri~ then, EB his ~d; :.: .
on..U:ii>.ical experience and knowleClge of the and .grown ~~enti~y. There are J,lown umerous'
~~ophysiologyof c:lisease, revolutioniZed into the evidence-ba.s ed 01edical journals and resources
' ri.~~P.wadigm of evidence-based medicine (EBM). which can be availed and exercised by practicing:
clinicians.
EVidence pased .medicine I:s defined as the
copsCienHous, e~plicit, a'nd judicious use of FIVE REASONS WHY WE ~HOULD PRACTicE.
..cu.&r:eti.t best e'Vidence . to make decisions on .how EBM
. to.p~~de ap.t imal care to individual.patient~. 1 The
pra:ctke of EI?M involves integrating individual Sackett outnnes thefive reasons why EBM. . . . . .~
clii:ij~ expertise with the best avail'able external should be encourage9.. amon~ clinicians.
. clin,iP.aJ.eviden.ce-and patient values. The approach
'to l~g differs: from the -conventiomi.l in that First, n ew evidence is daily being generate4 . ::.
cHpiclans .are required t o make a _conspe.n tious whiCh may possibly change tli.eway we look after.. . . '.(
.d!ort -at a systematic syarch for n~w evidence -on' our p~tie nt s . It would certainly be m~ s t'<-: '.
..... . . ':' ;.

C
.. ., .;.,J .

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I;
..
CHAPTER 2: UNDERSTANDING AND USlNG THE MCOJCAl, UTERA11JRE
discoocerti.I).g if our patients know much mor.e
than we 'do abo:qt ~e lat~st e~dence, which~
readily be a~ssed . through wireless technology
ap.d thdnteniet.
Second, despite the acc~ssibility of-this
information t.l}ro}~gii the world~ide web, busy
:practi;tioners usuti!y 'fail t{l ~~ttll.e newpiiden~.
nttentimes1 the most ava:ilable source'$ .of
informil.tion io :c liti.icians Are the expetts
ffrequ~~tiy ineons~stbnt and
ipvanably'w:rong) 3,
te:rlb.ooks tusu-a11y obsole.te with l~psed
i~foflitation)~. didacti~ cqntinu.ing med.ieal
education {sometime~fu,effeciive :in i;lisseririnatin&
'infor:nation}-s, a nd .medical jourtfals {.6ver-
~elmic.g..ly large volume). 6
I .
Third~ becau.s.ofthefotegoing, our k'uowl.Clge
~tiles out&.ted!,ar..d:~urper.f~nnance d~es.
Fourth, studies hav~ diSt\irbmglj shown ~t a
-clirticfun's practice d<>e's n;ot improve with the
:triidih-'Ohhl eo~uing medical education. {CME)
'P~~~
Fi.fi:h, EBM :h as.heen .Shown to help c'llrocians
~;~t rif:-f ue ever-cliangir;~ in,fo::ttkticn .in
.fuglii:edicill"literature. We.need valid' i.nfo'n:M.tion
'-~~~t :is~Ues ~b6ilt:.~~o-sis, ~~osis, ([U'esiioii:
~~ori, aiid -~ernpy.o~ a :dailY basis: .I_t can
~ a~ often as up to five tim~s per in-:-patient9.'and
~ foi:'every.three outpatients.w
~t ciellelopm:tn.ts..h:av.e..mad::..-it..easi~. for
us to . acquire the sldlis tp clfectively inc:Orporate
evide~ce-based meP.lcitie into o~ Glinical pni.ctiCt:!.
S~trategies h ave been d.evelopcl. to e:asiiy .ijnd the
eVidence and .appraise .i t for its validity and
relevance.' Other new ci.evelopme~ts ate the
cre.aticn of eyste.m atic review~ and ~.on.c~se
s~1mmaries of .eiTectiveness o f in!:erv.entions- in
health car; (like the Cochnin~ Coll~bora:ticin and
The World Health Organiza,Hon Rep roductiye
Realth Libro.ry)_, the creation of daqJ.ba~s from
where we ,se~ch"for the evidence {like th.e Medline,
Pubmed, Ovid) a nd the creation of the vast
expanse of cyb.e rspace, now known .as the
inf0 nnation su~rhighway, wh;ch delivers the
needed information t-o us in seconds.
EBM, however, has .remaiiled a hot topic for
clinicians, public hea).th practitioners, hearth
policy makers. a nd th e public:. tvf:a ny_ a r e
ambivalent, even
having negative' feelings about
"it. criticisms have ranged from evidence based
~-
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..... 21
medicine ~ingold hat {everyon~ is alrtady doing
it).to. it -b eing a dartgero:U:s innova:tidn; perpetrated
by the bigheaded intellectuals to servd:ost cutters
(Hea lth Maintenance OrganiZations (HMOs).,
insurers) and suppress clinical freedom $ince we
are told what to .do based' on the evidence.
As w.e go through a constantly:e-,olving process
of fmding d_.efinitive answers to scientific questions,
' we discover n~w and better wajs to pLir'.ride om:
patients the best care .possible. .l!N1den~ based
medicine is a tooi doctors must learn in -order tc
pro0,d~ .i.are :and effective medicine.
STEP8'INTHE.P.R:A.:CTICEOFEVIDEliCE-B:ASEb
MEDIClNE .
:The practice of EBM .consis~ offive. steps; each
8
of which will 'be taken. up in e.ct-llal. clinical
e..~ples jD. thh t::P:apter.
. ~~ fi..T"St.s tep is to Convert the ln>$mft~~-Y~U .
n~d. whether it be.- o;t : di~osi~ ~~~4.ti.on,
treatm~.nt. or pr-ognosis, into. a;t"f-!>.9~~.ed;
.answeiable c'li!1ical .q~sti.on. .. :... ::. ~:,:J;fr:'.
The second..-step is to' search for thetb-est
evidnce. that will an$Wer' Yolil;" 'foeiised"t;lfpkal
. .
. -.
.. ~ -:.1~~;:~9!~.
The t1ll!.-q, .step is to .criti~y: ilFPili~~:the
evidence for its ~alidity relevance and.~bility
to Y.Q.Qi' J!..a..!i~~~ .. .. . ..
Tne fo~:ffeiHs"to appTyiflii:CTirucarprnctiee,
taking into account the critically :apprais ed
evidence, our clinical:.e:xpertise and o'ur patient's.
i.t:ldividual biology, preferences and clues.
The last step is to evaluate our performance
in EBM for further irppr.over:qent and excellence
in :lts. practice.
FI'l'.m~g the Question.
A patient ei!counter almost always -requires
n ew information about its diagnosis, treatment,
prognosis or some other aspect .of clinical care. 11
Sometimes, clinician s have the answers forthwith,
gat.p.ered .from.stock 1mowledge learned in medical
school or .i n co!tferen ces. But can you be so sure
that you h ave the right answer that wiW.~ltirnately
be most ben eficial for -your patient?. Eft. Sydney
Burwell, Dean of Harvard Medical .Scllool once
said1 " }{alf of what you a re taught .is' medi~l
s'tudents will in 10 rears have 'been :.shovtn to be
~
. .......
~. .
}~;:.
~~-
'

22 SECT!ON l : BAStC CONCEPTS OF HUMAN REPRODUCTION

wr<>ilg. 'rhe trouble is, n.one 9i your teachers : then foll<?wed up over ti,me_to dde~e whether
knows .w hich half. ".12 :Spmetnes t he ptacticin:g they develop the ou.tcom-es of interest {_Figure 2 .1 ).
cltniclan-has some uncertaintyregardingthe in.ost Questi.o,n s abo~t ~ can ~so be ans-Wered:
effcitive medicln~ that can l?e giv,en to treat $e by randomized, .controlled trials. Ho'\Vever, if the
..:tient, o~ per:ha.ps the m-Qst-aCCl,l:rtUe:diagnostic outcome is potentially harmful, it will'not Otlly be
test that ,can :be requested~ that first patient difficUlt but a lso Will be ~"'Ucally una~ptable :t:o
enooim.ter beComes a venue fo:r pci:fonni:n.g the fu-st rfl.ndomize the :eligible pa~ie~~ t-o .a. po:~~ibly
step.i n pracin,g .f:Vidence..based medicine. ha.rmful interve~:tion. For in~m-"1, you eannot
. .
random~ .a paJi~n.t to :r eeive eith!!I' ~n.iibg
~

CJltUqil qu~a~:ana ~ of fcur fun.dainental tad:i~tion .o r not, because we know that all
types~ They ~vo~e , . radiation .an l}a.n;tt a p.atie.nts :b Ody. :FQr this
-~.s~m,, ~ l iext be$1;. :bu:t wealcer st~qy ~
.1~ Therapy: .det~gthe ,o~tcoxneoi{illf~.ut that ~- ~w.er . questlqns about harm are the (
tr~tmenu-on :ita e!fiacy.;m.iiftpro~g::Patient :9hset:Yilwnru ;Stud!es...~ti~tl! With M<f.:~ut
~dit:io:n :'Qr.sa!ety :'pyd~.\Yok,ti:ri:g advet'$e events the . exposun: of i.Otere~t, w;hetherby .;hoke or
happenstance, ate followed U::P iii time to
2 . Rartn: detet;ltlitllP..g -t he ceftects of.poteo:tj.ally . detennirte whether th~y .deV.el<>p 'the ori:trome. of
iutn:nfui-A&ents on 'patiep:Uunction.wotbidity, i.ater~i (F~g~re -~~2J. ~~:r: fusta.hee, .a panent whp
. ana. rr;ro~ty wu~.'~s;al to Jot-.i#Q.g 'rt.~;ajation ,~te ,fql1owed
' up for the out:cq'fue .Of.~cer. . .
3. .Di-~gn(,}~i~s: d'eter,r!lining . 't:h~ .abW'ty "9f a . .. .
. diAgn.osac ;tst\.to t~..,r:enti8,~1);etVt'.een1t;lwse ,, : : ~l"~i:. q\.;.e.sti.Ons . <;X;~~~~ ):dia,gnp~.. ~'clitiPle
:.~ffi.>::~~ct.Wi't)io1,i~a~:tirl;g~t<:t;.C?Pdi'ti6Q::n:t!di.Sease~,.: ....pitients :wl,i:oFiuf!,y~:or.~.m-ay: :n9t!:~v.e.;ther4i~' ,
: : .. : : '.. .. . . . . . (targd, ~ol1:4lti9P:) ~e::t-e 't'O.Under.go : bQ~. file .
4. Frc>gnO~: ,.d~t~)'i):iixg.the:fti.tute CQut:se o{C~, ~di.ag:Qbstic ~i in cj).I~spozi an4 the:.~)~li:l ..
~t's disease~~ stimda...+tL"~1attei .~ thete$tihai =i.&.Cin.laideted.

. . ~~ord~ .to ~er c#~stions on: ~~~t-ot , :.::.::teiO:~~~~~~:;.:::~~~=

the:ta:p_y,,welhavc;,to~l6ok-iforrami9~.,~attolkd-. .....~; Ct?f~t;io~ ,~i;l.;U:d. ;;~stic, ~ 0!"
~ (R(;'JJ. Thl~ mvolv;~: the rturdO~~on of . refc#ncesb!.ri~~e~a~ostic:;~t;iq.:~~n
eligible p~:lients :to :':f:W:b::gr.bup.s_, :t:i~~.t .the and !}le goldstand~.~ th~ rom.~ {l?.gure
~~ent o(~~ c~P:~1 :~U.P. 'the pjtleii'tS :iiie 2'.3J. . : .

Eligible ..
fatients . - ~li9.~ation
. ..t

.___......_;;_,._.,J
---+--~~I .outc<?~e
E,ligihle Olo.keor
.P-atiet;t~ H,appenS.tan.ce
~ot ..
~x~sed
...
F-igure 2.2. O bserv<l;tl~mal stu.dy'to i!-ssess h arm.

Scanned 8y: C
 CHAPTER 2:'UNDERSTANDINGAND USING THE M~DICAL LITERATURE .t:). 23
----~----~...-....-'----~--~-~---';-'--------~--~-~-~......;'-'l
.~---

For questions on prognosis, the .study design ..
involv~s identifylng patients belonging to ~
particular group-with .or ~thout fa~tors that may.
affect their prognosis. The study subjects are then
follcw~\lp ih time in brder to det:erm.!ne if i:p.ey
Will 'develop the t arget m1t;.~e .{Figure ;2A}. For
instance, pregnant patients -~ foilow.ed up 'for
possible pirth defects.
.
~
.For clinicl3.ns who aspire to practice evidence
based medidp.e, it is .Criticalto :understand What
type of-studies.~ addresS y~:rur c linical qU.est?on.
Qtheiy;r}.ie, it woUld be 'Very diffiCult to tm.d the
the obstetric:"ian would have to make a d.e.cision
on .how and when to deliver .t};le baby .inbreech
presentation in fue . West poSsible manner. This
is , ' therefore, a, question on treatm ent or
interveritio;:t. It was mentioned earlier that
randomized controlled trials.(RC11 can.best an~rer
this trpe of clinical question.
W.ha,t .Pieces of in~o.rma:tion would .the
practicing obstetrician need .in order .t9 arrive at a
co.r rect decisio n on mode of clelivery? ~at
questiOns would P.rst come into mil;td wl;len. posed
with this ~enario? How will you fr.ame the - :-~

answer tli.atyou seek. . question in &uch. a way.l:hat will .facilitate #fid.ing

the best -ext~rnal evidence? .
An exai,n'ple: A .29 year o1d, p.rimigra;vid, who .
regularly goes to your Clinic :{!>r. pr~tar check- .Some .o f tbe iniHal -questions .might be the
~p. ~s a {~ms in :ft:ap,k~ .pr~tatio.n.at.. ;M) following:
SJ7-~eeks. age.o f::gcstati9n:- 'fh~ G.lini~ ~~
fetai -;vei~t is a!200 gtam:s~ W'Pich ~'co:rnpa~ble b., Will' an x-ray pelvimetry help me .make. a
w;th. :the oonologic .e-stlmlU:e. She comphtins of deeisiori on the mode of delivery? ....
~:ut~e .con;tracmi oCcurring evecy 2 2. ls itappropriate to,dellver 'the ba~~~~~~;.
to :S:::tl;i,mu-S.; The .c ervjx i slJ.oscii and -ui::ffa:c ed,. 3 .. lf the patient g0e$ ;ipto. labor, shoutd:~]alloY..r;...a
with'ti..-SdftC(lnSiirl.ent:y..At ~-ageof:gestat:ioJl.c::lo'~ . trial .d labOr o.r dcliver 'b y ou~t~.ee~
tO 37-weeks :a,nd With rom~ nt~~e Cot+tradions, . section.?. :: ... ~.,~~:
...
...
..,_.
.... ....., .
~
"'-rl--.

'
.. \~;:,) ~~;;..:.. ......
T~get
ron4hidn :' j :bt~.;r..:i.;i~~-\
.-: . . : ... \::;,. ,; .
present(+:)
p~~ .... ~ ~-

suspoated.9f , ~ D.~c . ;G nld

-tllrgd- . . . : - " . . . - .. - :rest .. ' . Standard. ~.
coil\lition
t~get .
.condition
abse.nt(-)

T.'!U:get
outcOine
present
Patients iH
risk.oftarget Prognostic
eve.nt Factor

Targ~
outcome
absent

Figure 2.4. Observational. study to assess prognosis.

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~.. .

24 SECTION 1: BASIC CONCEPTS OF HOMAN REPRODUCTION

~. '

.Many other questions might arise, but will . Now that the question has been properly frain.ed,
these question$ help you arrive at the best ~al the next step is to ~slate the question into an
evidence? These questions have to be structured effective search strategy. Since you elready have
in such a way that WUl. facilitate the use of the the -essential components of the .question, it will
best available medical literature. A well~built be easier to put together the search strategy.
question usually has three basic .Colnponents,l415 . .. ~

Searchin,g for the JWid~nce

1. The patient or the population. Who axe the
relevant patients? It has be,en stated earlier that new '!Vidence is
2. The ~tion or f!XI>bSuf'e:. This ~att -be in daily being generated whiCJ'l can. Change the way
the form of diagnostic tests, drugs; suqtical we ~e-our patients. One way :ofavC:>idi::pg the
inte..-vend.on, . etc. Think of the ~tnent riSk of~ing outof da~ with current best evidence .
strategies you want ..to comp~re~ or the is to practi~ "'problem-bastd leanling" or *teaming
p<>t~t:iaUy hattnflil expnsure that eoneetns byinquiry. 'thio is where the struc~ que'Sdon
you. For thO!>e is:sUC$ on the.r$-py ~r hann., you becom~. impottru)t.
will prob1;1bly be concerned with the
intetventlon:$nd it$cnltem.ative, or anexposure ))()you know wh~ to ,find the ~swer to your
and .its altetnati"\'e. clinical p"l'Ol,lletn? Will you find valid infonnatiou
3.' ~~You may want toas"k the patitnt- in your teitbook or .Otber library ~resource .
~levant <!O!lseQ.Ue~ce$ of the in.~rventi~n or matet:ials? llaw do you u~ -on-line tOOls tor ql;liclc
exposure. 8Ild~,search ~ttategies"IT~e ptoces~ _oJWl.<;ting
. '- ,. .. . . .. . ~:.answ~r .to .your,.clinical.q:q.s#Qi;l :CS;1'1. be
ffi~:J>ieri~l),S. -cunieat':~na."io; qm~stiO.J<"We~<' :e~!!pcrat4l:gr.an<hdul+pillt.~'P.~: inu:p:~4~A~"'@.d,, : .
aSked a"Pv~ttll'~ostie.tc:~t, .{X-,:Fa)'::P~et;t.'yl;. . . grati.fYW.g . d,epe~ding: ,on .liow -you .~pp~ ._,t he
the appropriate :titning of: "dellvety. (when}~atidthe probten:\.)l$irtl.tes<>.urce$ that s.te..a~ble w.:you. .
:~ppn.>prlaie: manner :Of deliverr (how). T';n~ lll$jGt Thia 1s .a: very .ctiticat: step in., th~ practj~ of
-l1icimtihn~ in~th~;.<J~~~J.l.s..:is. ~t ~they_~;~.:. to , ~enee~~s w,edici.p.e. A study has shown that .
atx::'cify:$e~on~e~;by;:wbieb.You:Will~dgc:the.. . the..,weakc$1-.lirik .in ~c " gen~rati9.n of. critical .
tar:getoffheiht~tio~ ;J-A;~s:~se.?:Y.9.U:~~ -, .. awraissJ.s.in...c!Wcal ,.pra~tice_. i$ :,the $eJection of
deliverthe Jetll$ usiilg, - '@QSt;:e1fecti~ mcxte Cf :. artictes. 16 Currently, tra;fuing.. in evidence-:based
d~JMty~~ ~!1'?~.-~~pro!lllse :the ~~tyot-b6th medi1ne Jocu~$ on the development of .erif:i:~
the.nu>Jh..~.:mlA~~ f.~!!t.~ -~e oitko~;s:yi>ij:~ma apptaisah~kms~~ However1 seleCtion,ofappropTiate
probably want . to avoid.are periila:tal @ortilttj, artiaea'!rotrr wl'Jicl1 ~lli:rlea.l deci.sions'"~ made
ne<>nalitY mortaJ.ity, ..serio'Js neonatal inorbidity, $hould alsn be ac:!dressed.
and matmw mortality.
&> what are the resources you i:night want to
l{ow identify these three basic components of -look at? Medical stUdents and resident;pby:Jiclans
a.well-~ttuctured questionirt the case cited earlier. often look at their textbQoks fltS"t. The clinical
top~.are gerum:dlywell organized. for medieil use
1. The patient. The primigravid with -a fetU$ arid -~ :easily aecessible without having to .g rab
p~sent:lng in Jr:arik breech. at a computer. However, unless your textbooks
2. The intervention .artd co-intervention. The two are revised on at least a yearly basis, o is heavily
~odes of delivery yoU want' to compare ar~ referenced so that readers can determine original
cesarean section am! vaginal.dellvery. cit,atj.ons and dates, there is no way of determining
3. The outcome. The consequences you want to whetp.er the information ga,thered "from it is still
avoid are pednatal mortality, neonatal valid, .o r has already fallen into disuse e~pedally
.mortality, serious neonatal morbidity, .and if new data have recently .
been discovered.
'
maternal mortality.
With the advent of the internet, paper sources
The structured question can thus- be posed as suCh as the textbook have been mostly replaced
follows: Will ce~ean delivery reduce the riskof , and supplanted. by electronic media that are.
pednatEtl/neortatal mortality and/or serious usually. periodically updated. The .internet was
neonatal morbidity a mong "singleton, live, term born inthe 1960s and its. applications were
breech? initially
.
l.i,mited
. by the military
. uses for which it

Seanned 8y: C
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CHAPTER ~ :UNDERSTANDING AND .USING THE MEDICAL Ul'ERATURE 'C . 25

----------~~------------~~~--~--------~

~.

"
.... .
was ori,g inally conc~iv~d.J7 It is a worldwide, Physicians {ACP) journal club, and Definitjve
publicly accessible series of .interconnected controlled trials. It contains .bibliographic data
computer networks th~t ~siillt data by packet with full text containing more than .360,000
switching using the standa,rd internet protocol (IP). recofds, with more thari 12,000 records added
The devc;:lopment of ~ protocol !or. information each year.~ With EBMR on Ovid, you can also get
distributiOn in 1990by TimBemers-Lee paved the general integration with the most basic and
way for the. emerg~n~e on the Internet of general database, MEDLINK
applications \Stith broacter p:ublic .appeal.u Today,
the internet is a.n 'indi$pensable t&l that must be By now.all clinicians must already be familiar
learned and used by every~ract;icing diniciah who with the world's first and Jargest gener-al
. wants io practice e-videnc:l>ased medicine~ biomedical re search literature databa$e,
MEDL!NE. What exactly is it and how do you find
Electronic text\>k$ m now e.ls(, Q.Vailabie for information in 'it? It stands for .Medical Utera:tu...-e.
Analysis and Rettie~ System Online, a huge
the 21"' .:entttry physiclail. Some can be. aceessed.
fb.r9ugh the in~rn"t for free Uke the e!tfedicine, or database with over 16 tnil:lion references to attiol~
9
!or a fee like VpToDate ot Dyr..atned. ' These ate published in more than 5,200 cut:rent.biom.edical
updated .more f~uently t,han on a yeatly basis, journals. publl:shed m the United Statts and 80
usuallY on a :q)ja.tterb':.b.a'$1$,. ~d arr: a\sP heavily other: Co\,lntrie:J. 21 M'EDLJ;N E is the large.s t
ret~~ .!?9I!l.e iA$tit:UtiQn$ $ubscribe to MD component of PU:bMed {ht;W:.f[pubmed.goy) Ute
a
Consult. .v irtual ll~ :of textbdoks. ~hich freely accessible online data'ba~ :o{ bioui:Cdlcal
includetht.latest Wllliam:S' Ob$tetrics. While web- jourhal citations a ndahstra.cts created by th:c U.S.
llriked.t~tb.ooks -are highly encouragiilg, the National Library of Medicine {NLM); It.{<>ve:r:a
readerS'I<Wbo want to pra~tice evidence~based citation-s' from:-:l949 ,to the .. presen~ ~~~ftven
mediciile"must learn to d(> the $earChlng himself older. Everyday since 2005~ fromiTU~:y..:to
together With its. criti~ appraiSal. So :4piess the Saturday; from 2,~000 to 4,000''compl;~.ted.
infotm~~n ypu want to retrieve i~ about the . .refeten~~ areadded.:ln 2007.alone,, ever ()70.; 000
pat~QJ)hi~l.oiogy .of.~ W$ease {for :whicb the w~re added to: tbis rapidly .growing:, c&.t>~~ of
tettboOlefo<avery :usefuN:obl)~ it is best to Jock -at medical in'formatiori.P. Sifting;~thr'o~~:lbis
oilier ~s wbteh may pffer. m,ore vruuable, prodigious wealth of data ean therefo~~'\lnnst
valid iDi6rmation. . challeng4tg_. CliniciaJ}S inust learn t:Q:,pen.orm
.s eareh $trategies tb narrow searches hl MEPUNE
hP..e~.1.ib ,!!J9~ .Qlu~eml in!otnlation.are to articles..With-iiigh.. relevance to your<particuiar
the Dlllllm>UB eJlli;l.f!nce.Jiatabases.$0me..o. these focused- GJ.inical- ~estiOn-; --- - ....
r-esollr'cC:s have alreaqy d.one' theseal'ching for you
so that thi! reader :ean hnmediately yield the Before starting the search,perhaps it is worth
curren,t best. evidence . af.t~r some.one else mentioning the most ~used search engine :n. the
perforn:tecl e:Jcplicit :evidence processing. Others worldwide web, Google. It has a 53~6% users
leave the. proeessi:::ig to lhe .u ser. These can be share, al)ead of Yahoof (19.9%) and Live Search
.acr-...essed from institutione that can invest onthese {12.9%). 23 It indexes billions Qf :web pages 80 that
databases .s ince th.e cost for access can be u~ets can search for the information they desire
prohibitive to a third.,.world doct6r~ particwarly a through the use of ke;rwcrds and operators. Itis
medical student or resident .physic'ian. simple to use; fast and became even more pop\ililr
because of its fea tured page ranking. To some, it
Perhaps one of the best js the Evidence-Based may bC appe.aling to just google the keywords in
Medicine Review from Ovid Technologies the internet, but this is to warn. you that Google
(www~ovid.com). 1 It is a definitive resou rce for will not give you the be.s t evidenee"'based answer
. electronic infor:m :ation .in the ~BM movement that to help you make important clinical decisions.
combines 1 .of the most trusted EBM resources
.into a single,.fullysearchable database: Cochrane Confronted with a clinical problem; proceed
database of systetpatic reviews, Cochrane from where we left off in the exatD.~of the
database of methpdology reviews, Database of primigravid with a fetus i n breech pres~ntation.
abstt:ads of rev:\ew of.effe.ctiveness (DARE); Health You have already framed the focuse~clinical .
technology assessment, NHS EconomiC evaluation . ques tion as the flrst step in theprocessi1Floolcing'
database (NHSEEP), American College of for the valid clini answer.

' /:.

Scanned 8y: ~
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..

~
> . .~

..
. , r, >-, .

~ ...
D.&:
. -~

26 SECTION .1: .BASIC CONCEPTS OF 1-lUMAN HEPR9DUCTIQN

the Clinical Problem: The pregnant w:oman With free; ~ext, you can write the keyword
?.rith terni, breech fet>~s. irnp:lediately into the se;rr~.h box, Then preSs the
entef key or click 9-o With MeSH, .:You will be
The cel.icical Question: Will cesarean .delivery . utilizing the Nation~l .' Lioraty of Medidne's
reduce the risk of perinatal/ neonatal mortality contr.olled vocabulary theSa.Uru.s. It consists 'Of Sets
.and{ or serious. neonatal mDrbidity .am0ng of te~s .n aui'.ag d~scriptor:s in .a hierarchical
singleton, live, t~rm breech, ..cotnpar:ed to stn.lcture tht;it.~ts ~hipg at va.rio"q.s lev,els
:va3inal delivery? of s.pe'Cificity. At the. mo.st ge~e:ral lev~l of tl:ie.
1.1-l~ve! .hi~rat~hy, ti,re v,ery l;lrcad :headings
Yo~ have ~~eady 1~ed '!"bout th~ vapous becollii.n:g .Illore :~peciic as jqu .go do'#tl :the :line.
:resaUrt:ci; ,~vailable. You can look at yom- text~k. Ea~h biblipgra,pP.ic..reference is .a,ssociated'with a
-al;ld .compare the .attsW-er to. oilier re$l,lrCes. .For set ot MeS'il term$ that di!sctt'b:e ,ftie cbn'tent.oi
tnls;pllipese1 we qtil ~b ,fur~~~ the .ni9.St the ,item. Simil3.r'ly, s~~h qu~des use MeS.l'i
baSiC and ;obvious:~tarting point .fur..~my :medical vcicabul~ to . .f4ld
.
!texD,.s '.on a. desired toP.i~,..
. . .
liter.at:ute search,. M'SDLINE in . Pnhlled
f--~bi.n1Ia,mhgb-v./Sit~slentrez{l. SinCe thi~ Go ~o the- :ho:me pa;g~..of f>ul?Med. Click ~n ,tiie.
Will J;)e .a:.ft-iq4eiit~a;ddt~s~.th?-t yo~ Vfill visit, it MeSH dat'a.:Pa.se o~ 'the left side of'1:he web page, .
'\..':t- .
wi;ll.bcwptthw~-f9,.~gd $.is to yo.ur boo~arks
> > > >~- ' >

bl!low the .P4~Meas~. 'i'y,pe::th~ nrst.keJW<>rd

>

i.'l ::Your w~'b bro~. b,reecli)r~ ~e ~Pox.:~~pre8septe,r.Ordick

'' Go. .TWP .i~~ ~e ~played whlili ~the MeSH .
Tfle:.keyword:.i;n. int~et- u~~ :or i:ifo.;iha:tiol). term$ )ls.C.d ~Y .the N ;itionaJ tJbl'C.liY of M~dne to
,;~~~~=~:~::.:,:~:~~~=~;:;> ~ti~~~cbn~~i.~n~\~~:
our searclidn:. 0r:dei:..:ta '{find,.Jh,e~ .!P,AAti:t;ci.gF#.j:i.~tl': . 1: .. Br~ech::pn:'$e.Il~tlo:O:. . ' .
':. : .. ::-

jOcli:nihl articles in' :$,:e data~as~,?:~he:~a:n:swer 2. 0l;>s~ l~bor ~m,plichlions. .' .

.:~~~~~==~;g~t~=.t::.!:!r~ ...;t~~:~,~.~o~4~~M~s~~. }~F#l:'~~p,ste.tn~ t.~cp~
fu.~ti' ' ..~co;~ t&v ti ...' d. Gut -p eo~~~ too~ .-..6-eecx~ri'
,~~
7 o~.:. m ~n ~;!,a~ :. come.-., o-... .w<>~~~ ~':t!i~:::~~~~PPro~~~t~~t~~~ u~.;.~iik:
> tb'e bOx next'to '"'b.reectx:.pJisentafib4. t~:~~~'.:jt~
. :FOwtati~n/:PJi.~~A.t.;.. .he _:p_~\'id w;i.th. a then sen.,d t9 th:~ ~ b<?.x :~y ~lect'iiig ~~
.fetus~p~tingJn ..ft.a.nk ~t!i~.~ . .. .... _ '80x~t:,Yt'.And'";"TlUs-:a~tort;t<;tti~r~4~~~t'he-teFin
Intervtnti9~ ~ secti~n .. to-~ffi~ ~-:-.Ch'?ile~~tch~PllbM&1!!.-Th.is- .:
~interventi~:m: Vaginal delivery. result$ in 2~03.$ .W~. ~:now," .~rthi~ :tbo0k
. :Outcome: Pe.r.ili,:aJal .;rncOrtality, n~onatal ~e:t~e.~.:edit~. j)..l~sned, ~~f'Q.:istrl~ilt~;:v:'hile
.~prta;lity, senOllS' !1:0Il3.~ ll).:6i>biP:ity, .a n:d . yo~ .r e.a d lnl~ eh:apt~r ~d repdi:t tl)is same
mateirial .in~cy process;. y.bu ~ghf get.d,i.ffete:nt.:r.e.s4Jts thai1. the
result . .~;hf).:wn ..~yc;: ~~~y if there ate new
.. ., Mter .idehtiPflng the key co.nc~pts jn y.o.t:~..r artic~es .add~ ir;1t0 t:he.~~se.
.re~c4 cquestl~n.; ~ ' tp.e,;:n..:a~t:d;itl.g. to :U1<:
InC>S:t to ~e.lea:st. signmcant..In thi~. case; the Repeat th.e ~~ pr.ocess:bygoJngha~k tbfue
~g .could ~ ~s .follows: MeSH databa~.e .'~d *ey, in y.our 'secon.d .seaich
term, ~areqn. Fiv~ item s are dis piayeci:
Most significant.: Br:e;ech
Fo1lowed by: .Ce.s are.an Section 1. .Cesarean :i;ection.:, repeat ....
Followc:d by: N~onatal morbidity{mortality, 2. vaginal birth :a iter cesarean .
other o utcomes 3. iarean.'.~G...Uon
4. .Tiial otiabor
You can now enter .th~.~mpst ~lgnifi~t term . .. 5. :~-~:p'~tory distres-s syndrorhe, newbOrn
... . .
. in the searCh bois.at.the top ofthe web ~~ It is
: suggested that ,you :do thls as you re~d ..it. There Yourillght want to~l~t.#3 ''Cesareansection.
." :are .tw9 ways of doing a .searc~. by U~;ng Jree: t~ Again. -se~~ itto ;the se~h box:: ~d click &arch
or hyusing-the.Medical ~ubject: Heading~ .(MeSfi:l Pu~M;eq.' .This:r~s;ults in 27,480 hits .. .
. . . . . ~ . t .

Scanned 8y: r-.

~
 CHAPTER 2: UNOERSTANDtNG AND USING rtH: ~OlCALLIT~MTURE . ,~:.., .27
--------------~----~~--------~----------~--------~----------

After having searched the two significant
keywords, you may now want to narrow doWn the
search by combining the results of the two
searehes. Previous s.ea.rches can.be ci>mbined or
used i n. subsequent searches usi?g the
sear~!}
statement-number from the~istoxy tab. Among
the taos bel.cw the .se~ box; select "History".
All ~1s are ...~.presented by syareh numbers.
CliCk on t:M Urtked .searr;h statement nwnber to
display .the ,b_ptlons -menu ~t it.~lu,des BP01ean
operators AND,. -OR. or NOt to 't he :~e~c~. box.
.Altetillitively'you cab. e:hter.il.ll.lirilb.er sign follbwed
by me.'Selll"Ch nuni~, e.g.;~-~ "in ;the se.a:rch bOx.
Jbese..BOOlean :opera,tors ~ :be -used to=.c otnbine
-or exclude 'Searcli terms. Theten:il "'AND'" retrieve$
results that.inclu<k all the $Cat'ch tetms. oR"
.retrieVes results that induqe..at least one of the
search tenns. ..~Qrexctudes;the f'etrie...~ of~s
Irom . Yi>ur:.search. . T~ G(;IIiblll.e sear..4~~. use
:Jf~A;.~.g,! .~2-. a:N:D ..f3.or,qi9kquecy t:::f~..m:?rce
opti9~:'>-. BY.:~$:bi.D:ing ~ :tw.Oj_ we get 1.; 0$9 hi~-
0f&l~,y&u
....~n. . :eXpect m;.9otrJhrt>U.g...h.
.:d on't ,
I,089~es; to.'f ind:the a..--iiGks yq~ ~eed. .That
is .~~.i1n~#'~b.1e to '~eB.rch :from.
Yo~.~ ~er -~ _yt>lU'. seai-cli.t>y f uli text
onAA;iu1J~ ~-.-~.:gro~.P. .~Il;der. hu~s or . <>f?~liv~J;""P . Not yet: .T:l;i.c -~e."" st~ ia. ;to : ~~.
anij;l~:l.~:,~fi:t~~~. l!ril&u~~) p\ihliqi;ijon type:>.
dal6;~ .'. Ei 'lm
,._~;:\ ,.,:: )f. ' .. .;YJ
o ther Mf'1:>rn
. . r-~ . . etds.. This
..
can.~wlilliit the .que!j io articles Witt the highest
l~cl # ~eneeJ .OIJ}y tand~roiied-controne<tttials .Crltle.al AP.p~ of the. EVidence
or~eta+~.'l~~-~.~~.~~~~ ~gw.!Pe .~
page. Often an acitdem1c institution's libraio/home
w ge will serveasa proXy- Server sothatits f~cUrty
and students can easily' access electroilicjoun:i,a!s
from their. homes or clink~ free of c~e.z ..
Among the 11 releva.n:t joumal:articles, .2
already provide f!'ee full-text access.. Notice that
most of 'the signifi.ca...tit artkles -are offshoots or
corollary studies .of a trlhl publish in 2000 by
Lancet, :entitled Planned C$arean section versU.s
planfted vaginal birth f or -breech p.resen:tatit;n at
term: .a randomized, multicentre triaJ.;.also known
popuh:trly as the Term .Breech 1Tia.f .by. the Term.
Breech Trial. CQl!a.bor:atiue. Group of Hann~h . and.
H~.~.Judging by its title, ihis_Tef~-seem.~ .
to be rig.lJ.~ .on target. Fur.the,r. reading of ,the
abst.ra.ct tells .us that pla.Iliied esatea+lSetti6n is .
~fu;:r than plari.p'ed :vaginal birth for the te!ID. fetus ,
in ~e breeeh presei;ltatlliii b ecausethe pe.r;iif~ai~!
m<t,tt~lityJ J?:eo~t~l: rp:.o:rt:ality, .or ~qus :~till.
m,o~pidi:ty. WlS signillpantly lo:wer; fo~ . the p~~
all those . c~,~eap s~ctiqn .gr:o~.P .t han :foJ,.~~~iP.J~~l~~~
va:gm~l _htrth . ..K:r._o;~p; .~f?r~ou~. 1 ~.~W..JI;h
complications are similar between ..th?~U..O~~-
Should you n~w- use .~s abstract. c-9%1~~ri~\V
.~g .a decision regarding youi patientYmoue
appraire.:t;he doCuinenf.fu .oider: to .d.~~fuin~-,itS" .
is~ we '"validi~ relevan'ce and appli~bfutJr ":::~-:-~~F~:.~~1:~ftr"
. . ,. - . . . . ~ , ,r< '- ~ \ ~~r;: :
... 7'"' .

box, se1~t "'Limits'". The~ t'Jck 'the 15o~ b eside l!!.PsY~[. w:.;P.:lake.:;ensLof~~~n~.;~~nre .
Rfmddtiii:lea~C<>nfffinea'tnar an-<r'i~reta-Analy_sis ~ter.J!.. compt:_clle~scruearch...:f9~:litem~~tc-.''
irctl:re .Piitili~qon"tYPCl)O'x:-.}3y -cliek!i:g 0:0. v:-;; a;daress you;r dirucal gu;esti.ons; one mustbe able .
get a more .manageable ntimber of~Cles to to c:rlticallyappiillse tills uternhi.re to' det.erlnine
choose . . from becau$e. ther-e' l;U'enow. pnly. 35hits. it~ u sefuJness and scientific validity. .
.
'T he ' sciuth pan -also be d<m.e u~g -~-text Critical appiaisal }:ta.s .been d.efi.D.ed as the
instead 'of..the MeSH btQws-ei, =but thi~ seru ch. process by which 9:he uses.Predetermined criteria
. srrategy t:an ;~e ii longer -tiple .coinpai:Cd tothe' to r-ationally evihi.ate a publisht!d aitlde. on .
MeSH. The s6irch can b:e modified after ~g therapy, .d iagnosis, p rognosis, etc. A-set of criteria
0
the yield for hlts and misses. If you :come up mth is identified that is appropriate for the .specific
very 'few hits, you can u~ MeSH .if you used fre'e . focus;. these are then .applied to .t he literatl;.re
teXt, .or use free text if you used MeSH'. You ean sur.ounding the topic, and logical coi:lclusicns ar~
also com.~irie both ypur MeSH and fr-ee text th~n derived.
searches to come up 'w ith more hits. If there are : ..
too .. map.y hits, you qm mtersect more coneepts f.. number o'f . u~ ers' guides and critical
or u~ moi'e rigorous methoQ's or filters. appraisal checklists h ave been develo~d. so that
. th~ cli,ni<;ian can develop and enhance his critical..
. Brow$ingthlough ,fu~ tit'lea, there are -ll out appraisal skills. 27 28 The pioneer .grq~p~Jrom
of the 36 articles that' can po~sibly. lead you to a ~cMa.ster Un~v:ersity of Haynes, Guyatt, ..~kett, .
deci;>ion,..Ori the .saf~st t;n.ode ~:if.,delivexy. Io,r. your Oxm~. ~d o~ers. pupli'!>hed the "~~s W.~e~". .
patient:with -~ t.e hn, .bree<;:h fe~s. Cnce Telev:ant . in the J ournal pf.the.A?J.er,ican Mep.ical Ass~tion :
.ci~qons:are found, tr1ost of'the fuil te.A-i: articles (J.A.MA} about critically appraising different types
can be obtairied by ac;:c-~ssing the journal's home of publis h ed articles on therapy,29.3 ~iagnbstic

Scanned By: C
 28 SE~TlON 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

-1
te~ts~31 32
and .systematic reviews. 33 In. many cancer, heart attack, or stroke} or an unanticipated
mCdiCal institutions abroad, critical appraisaJ. 011tcome?
skiil$ teaching has be~n . integrated .in to the
:underu.a duate and postgradl.late medical It was earlier mention~d that.wben_searchuig
curriculum.34 .Readers aie ad-..ised to t"efer t-o these answer$ for clinical questionson therapy, look for
journal articles for further studies. -tandomized, controlled trials. It should, howevei-,
also .bc mentioned that when several randomized
Througq9ut medical history, the cpm.m,unity ttjals of the ~e treat;ment for t4e same di.sase..
of doctors has made numerous mistake.s in ve been conducted, a systematic rev:ieW .which .
otnlssi~n ot'.collUl)iS$ion that :~ve re~t~ ln loss statistically combines all of t..'-le fitudiea woul4 .
of. eou1Jtle:J$ .lives O f patient$. Fbr .example~ . ptpvid~ .a more precise -estimate o f the ~~ent
in;teiT'Jsts have tnade heaps of preseriptiQn for effect, thus providing us with the besttvidem:e.
cws l .anti~arrhythlJUa dnlp-.-egents that they User1s guides for evaluating $J$tefilatic ~f
bdi~ .WOuld prev_ errt k :thal arrh~ w~. overViews can be obtained from.the.!,&..:MA.seriet
in fa.et,". they were causing th_ent.35 These mustbave: ofarticles by the eri.dence-ba~ :medieineworldng
$ten:u:tled ;from erroneo\is interpretation qf the group.~
li>teratu:re or wr.c ng inference-$ al;)out the
~nd~tlti)'lg tn.ttb. :F or eaeh of -'o ur -elinical Answers tp issue.s of harm can be ob~
que$tion,., there :is :an Ut}del'~Jing ~e :a'i'l$wer~ frotn observation:a l .s tu{\y designs, provi~g a:
W'hl;ili 'iS inferte.d fi'Qm the results Qbtained from lower 1ev.e~of e vidence co~pared tt>-.iand~
cliideal ~it~clles. We mu-s~.t:herefore; be able tO controlled trials. When patients are ibllowed
leam''"ri,&le's,,oft.'- e~denee;.;.tha<t:Arill::;help' us ,. -forwarditl-:tiuie- :to..:deie~e. w.he~et 1heywm
Qit(eJ:eptia~ -tai~:.claiip~~,~'m~:valid~_onesf~ ,;-._ ' develop~the out.me,of,_conce~(ta.rget,.()utcb~};: ..
.. it., is c.alJ.ed a ::oo1't.nt1 s tlidy;. Wheninves.tiga10n .
Jro~ io~ ~: arftt:le:~t ~g : conipare .those . who ~b:ead)' h~v.e: the taiget
,. ... .. out.c6~~ .rrotn t4~~ who _. ~o . llOt; :an~ d~
. , 5(ble::_Q{ $e m.c>st~~ . quest.i~n.$. fw,"1V~ch . th~ e#eflt to: w'hic,b, '.the.two'. ~tip~ ;l:l~\Pe been
-~~~t~~-~~q~~~wbwa~~ve<t9;.-:f.~~4t?.J;>!--.,-:.,~~;,tQ:. ~~~~f~~n4..it4~ ~e4 ,!f. :~. .
cllii.iciari~;.,mvolv.C$'til!at\m-en~~stta~~;fut.o.tllet:rrJ~ ..~:d;m,tr,Ol,$fti4y~U~s .~j4~si1Qr ~~\1~\~.' .
pati~ts~::f'or<e.~pte;:-wbae~a.rc:,~~t-Uenefib- of a'bo~t,han:n. qn -~~be oq~ed from the-~AMA .
. gi~g l'lonnone. ~lacement the~py {I_Jln) tor series - ol:e:rticl~$ b y :the eVidea.c:e,.baStd.il:l~gne
l>dS~~tto.patJs'IUOIVqm-en~.who--;l:lavc~~motor Woi:king~group;,)t
sym.-p~ui's?:W~--~ lld~tiot,w:l:bert~c;te . .
frop1:idl~tion,"Qfhotfiu~es?Aietbere.lcin~..~nn . Three 'steps .in the critical appral$al of ~
a dvetse .d i'ects iQ..giving llRT. even.i!itis giv.en .for - evidence .o n therapy
a $h6r* ~od ofW:ne? . . .
Thtee ba:sic questions ~re pertiilent in the
iss~es .wl\~n these
'rhere :11.re tw() .r -elated as~~stn.ent Qf th~ t.ntdical .litex:a~ fot thc;rap:y.
qu~tiOIDJ are :a~dz:e,s.se4. First is~e:.i$sue,ofha!Q, Thef~stqueseon isj ~Are the r~its Q/~study
W1iat:rl$ks ax:e involVed wh~n yon-.givey.Qurpati~nt wdfd? Pue t9 the eai?Y ~c~ssibility-.or "!;lploading
honnori~ rep~cement therapy?.Is the.rlskofbfeast -qtateria,l~ ii1 the i,nteinet, m a py publicatlQlls that
caneer/ heartatta.c'k. and s~ke real-and ttue for are viewed by .our patients are considered tr.ash.
all pati.entS? 'Thes~n~ :is the is.stieoftherapy. If The validity of an -article refers to its cre<Ubility or
you giveHR'l', what benefits will ensue, and will believability. Guide questions to asse.ss validity
these benefits outweigh any sedous are those tha t involve randomization, follow-up,
.. consequences? intention-to-treat analysis, b1inding, equal
treatment of two. . groups , and baseline
Both the issues of therapy and hlUDl also comparability of tv.ro groups. Each oflheSe will be
involve -the issue of causation~ From 'the example discussed in o~r..~linical scenario. These -questions
above, is there a Ca.usat relationship between.an win guideyou to determirieif the resUlts represent
expotur.e {h"ke obesity ;- hyperte~sion; diabetes an unbiased estimate.of the treatment effect odf
. tn.dlitus; s~oidnS) :or -intel"Ventton (like hori:none they . have been systematically. modified. which .
repW.cement therapy) b.l a postmehopausal woman would ~lead us t9 :a :fals.e eonclusion. 'Ifyou-'hav~ . .,
'O.nd .~ . particulat:. antldpated OUtcome (breast . ded4ed tliat the study is valid, _then you carl.now

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 CHAPTER 2: UNDERSTANDING AND USING THE
_ MEDICAl
_ _ _LITERATURE
_ __ _ _ _ __
__,.........--..,.-----~-"""""---o-__;,_.,._........,........_..-.....;_ ..""::', 29

look at the results. Otherwise, you can q~scard it. search. Finally you com~ up with an ..ar:ticle
The next question is! ~hat are the results?" This published in Lancet 2000; 356: 1375.-1383entitled
refers to the size and precision of t,he treatment Planned ces~ean section versus pian:ned vaginal .
effeet, which willtdways be -b etter in wgersti.tdies. birth for breech presentation at tenn: a nmdornized;o
Tne last step invoh:es asking, uow can I l;l pply multicentre trial by the Term Breet'Jl Trial
these reslilts to my patienrr If the study subjects Collaborative Group of Hannah and Hannah. You
who participated in tbe trial are very-d ifferent frorn now have the full-tex;t article for critical sppraisal.
ycur patient. then you might hesitate to institute It is suggested that you retrieve the full-text _a rticle
the interventicn because of the la.c k of before W!! proceed with the 'critical appraOOL
gene~bility of the study. However, if the study
subjects ate ~imilar to your patient, th next Are the results of the study valid?
question is whether o.r not the -evidence will cr~te
_.:: a cl.UUcelly itnpom.nt impact on your conclusion 1. Wasthe assi~ent of patients randomized?
about w~t to cffer or tell your patient.
ln page .13'16 under Methods {Plea;se refer to
The eluifccd scenario on an article about the fall text article), it was state.d that
therapg ra:t)domization was centrally :conti:~lkd at the .
Unive'tsity- of To~ont{) Maternal l~fa-nt, and
We can pr09eed from the elinical scenario Reproductive Hea!th Re search Unit with :a
,presented earlier.A 29 year old, piiitiigmvidwho computerized randomization p..Ogiam, .-accessible
reg\ltBtlf. goes: to your clinic for prenaud :cbeek- by means of a touch-tone telephone. Women w:ho
upf tia"sir.ietus in 'fnulk breech preser1tation at 36 ' . were eligible for the studywererando~~~ted
srewee.n age ofgettation. The clinical estimated to eith~r the planned cesarean ,sectjon1 gro~p&or
fetid wei'gh~ \~ ~200 grams, wPJ<::}l is c~mpatible the planned vaginal delivery group {Figure 2:5)'.
with the sonolqgic ~timate. She (:otnpl~s .of . ; .. . .{: '/ -!.
~~tar; uterL'le contractions occl.trrin.g-e very 2 . So t he answer to the (lJ'St question is yes.
to.. 3':hotttil~ -The cervi:lt i$ closed and uneffaced, ;.'.~.;., : . .: C.: I ,":" .

wiili~~ciJrisisteiicy, At an ~ge of ge$tationcloSe Randomit:ation invQlves :rando~~c>qlting ..

tO 37~~~ and 'with$0me :u terine contractions, experimental units across the treabneilt;gp;n~p~.
the' ohstebidati woUld have to make a decision Thus i! an e:xJ>c!ri.ment .eomparesH 4'~eW;;rltug
on 'h~ f,lrid Wh,en to 4~Uver #.1~. ~PY iA ~~ . {treatment} ag!Mst a standard d(ug l~~). 'the.
presentatioidri th~ safest poSsible tmuuu~r. The patients should be allocated to eith~r the
miiii.@'Cfii'Jaii qucSdon iS:"~ ce.i areaild'e!IVe - : . ~~~~~~p_9_flli~-~eon~:iiP.~~iJ.aii<1Q..iii .-
. ---------~------.. ---~----~
reduce the risk of perinatal/neonatal mortality Ptocess . . Some non"'algor:ithniic randomization
and/Or $etious neonatal mcrbidity a:ilong .methods include tossing a coin, thrtiwing dice, or
singleton, live, term breech?" shuffling cards: In most experimental designs,
computer-based systems for :r andom number
Ycu have ~y gone tc> Medline ~;trtd entered generation are widely uSed tb ens'\ll'e' that they do,
the most signfficant keywords . in the' searoh box not have any discema ble pattern.
u sing the MeSH Qr $edical .subject headings. The
terms breech" ~d cesarean sectiQn" were then Why is it so important to r andomize Pa,tients?
c<mibined and limits were se t tc only randomized, The reason why we shoUld always in:sist on
~on trolled tria ls in order to n arrow' d own the randomized trials is th~t this study d::sign will

Outcomes:
Cesare-an
Sing-leton~
. live, term .. Perina11lVneonatal
Randomization mortality
breech
Serious neonatal
morbidity
Vaginal
Maternal mortality

Fl~ re 2.5.

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 30 SECTION f: .BAStC CONCEPTS OF HUMAN REPRODUCTION

. ::
come closer than any other research -de.s ign to Som.etime.s patients a~d clinicians have
assUre us that the two --groups .a t the start ctthe hunches on whether or not .a certain tmrtment
trialm identical in :an aspect$, including the risk works effectively or not. This somehow iniluezx:ee.
for t he outcomes cbncrned. That i$, 'to make the the outcome in one-w~y or i:he .o ther.Blindil:eg ia a
two group, equal and therefore, comparable in tenn usect in interventions! resea,rch to ~t
tenn$ofprognosticfactors. If!:her.eisan:imbaJe~ outcomes from being influe nced by ei~ Ule
or .unequal distribution of prognostic .fa~na, .-t he placebo effect (healing effect of an Gth~~~:
treatment .effect rould ~- -exaggerated, .ancded ineffective trea tment}, ob$erver bi~ (error
or .even co\Ulteracted in one or the other :gt'O'i':P introduced ~nto meas\lrell,lent when obeenen
An .exaggeration of tr~tment effect migb:t ".!~ us overemphasize what they ~ to find t\JlC1.fail
to~nchide that thcinter.;ention ~ usefui. when to notice wh4t th~y do not. XpeCt- ~t ,.U,,
in .fact lt is not. A eane11ation or eounteractmnof e:~:petimenter.bia.s{the outcome ten(ia. ~be ~
the tteatinent~fl'ect mightleadus to conclude that toward~...a result e~pected by the -in~
the t retmentwunseless or-even h.am;ift4 wp-en conductiitg the ~riment). ln a double 1JbJd
in trutll, it oould be -~eficial to the pa~t. When experimenta,l trial, neitl)er the patientJ nor the
thedfect is -s ein as :ith~r btter or WC>l'$e t:ham ft investigatorS.know who belongs to t;be t:mi~
actl,laDy is, that i!J ta.Ued "'bias.: 'l'he twQ gtO~ps group or who belongs to .the CQntrol .g roup. it b
n~tP be equ8J.- ~ mtlke .stM:o tr..at tile di.ff~s. only after aU the da.ta ha~ been entered~ the
!n w~me, lf'.any, 9.Te due to the in~nuon/ in\'esUgatbts learn which -ind;ividtnU:; 'tftte
treatment.rather-fhan aome other :~ . as&sned w.llicli..'ll'.is.is a strategy in~
.::, ~seaic,b t.o le~~n the iJUlu~ces. Q{ the- ~ .
2. W.ere,pa.~ts.Etrt~',fu fhe.DQ.Upa #Wh~C.h:..- and .unintenti<>Jial"'PPYsieel-;cues:on, the .~ ..
,trwer-e~mndorniZCd:'ik , .,: ;'. ' -;,, .. .-: 4'lu~iahiev.in~laJ.Ugh~11:~ta.n~-d;Otir~cic.nJ;Jif,:...,..
. . . . lf!>llildingls,a~,:th.ereJs,no,~ntQ~ . ..
In:page 1379 of the.jcurri.Ell un4ef-Stattstie8J that.the~ was ~eq\l.~:~tn:ienU>~.t.ween,~.t;wo ..
~~ it was ,$"fated ~a:t- the ,r,eaulua w~r" . . grt>Up~. .
a~&:JY;J.ed aeeo.t:4i~g.,_..t.o t)le.:int~n.ti~n ,:t~ -tteQ.t:

p~~p}e.~~d:~!~'.-:WQ~end~:wtah~~!!!~~:, : ._: tl:_..-~

. ~.~A.~
~-.,.,.,.~, anU;-!Qt;:w~~Jil:. Jl . ::"~...:i~~t,n~~;:.~ ,
.pa


.t_, ..;auu.,.,.......,
~-~~;_s..:u"fs.h.~-s-~~-_oe..t/.1_:.1-~~~-.~...':...
.
-~ ~&<:J- -~ - l A
:rs.
..:_. :.
to.
'. .:
.

~ :fn~ctedf"in,the: analy.Sia....c: ..,. ~~;:!:e!;it'r!:!::U:;!~t::=:~

:IfrQ!'aer-~ pre~tnevruue ot~ornJZAltifri. b1Uicrea~cunicnms-eitllerasseasa1micar.~
~ -8lio.mrums~1::tne:-:pa,!JEn:tjl.~Iil or m~~: ;o\jjecuve ou~me JD.ea"j~mi;nti:
the BfC)upe to w)lib they ~'Y'/ere ~om;~. tlUs.
_ :is :calte:J an ...intet#ion:.t o .tr.~ or :ifltetlt :to~
{ITT..
. ,.,- :....:.-~ .. . . .,.~u ..: ~... .... . th" .;.,.~..:-...:1
~ys1s., an au-., <S .u.u.s.e....Qn . . .. e --~
treatm~t h)t~nt, not on th~ t:tea.tn:l!$t.:mat is Be(ore proc.eet\1ng to the results oft~. study,
ev~ntuiJU.y l'ldmii)ist~re4~~ - ~s is in~~nde.d to one fmaJ. c~e~.k ~~ to, :dete,r.min.e .:wl:letb:cr the
avbid '\larl.I)Us mlsleading~::~ift~~ti<)nal proce~ of mrtd.at:JUzaticnwas suC~ :fturt iS,
~-~ For en;mple, ifpati~n:ts -who ~Y '~ore th t;wo .~ups were '~in:illE\1' in Qil.piQ~
-setitnis;jllhe$Stel)t:;l to drop out from.:the 'research important ways;at. ihe start .of the trial. U'thcreis
at a higher rate, eve.~ a eoin:pl-ete~y . ")l~ile.ss inequality betw~n the -group, adjust;m~ts should
"treatment may ~P~ to provide bepeJ.iCW,.etr~ts then be made for pot~ntially important px:o.gnostic
if wc:.onl)' compared those who finished. the factors.
treatm~nt. Therefore, in. an ITT analy~is, each
patiertt rando~d at the. start of the tri!ll :~hall The very first t4ble. in an article . of an RCT
be included iil th~. ~aiysi~. whether she d.rops almost ~ways answ~rs this questf~n. In table 1 .
out trom the trial or ftnis}:les the trial. Once entitled Baseline characteristics (maternal-age,
randomized, always analyzed. parity, gestational age, type of b.reec~ in labor,
et~.fin page.1378, the factors whichmay possibly
3. Were patients and clinicians "'blinded to. affect the outcome are similar between the group
treatrpent? Aside frpm th~:: expe.r imental . assigned t.o the planned cesarean section and .t he
intervention, were tho gioupstr.eated equally? group a~igned to the planned vaginal delivety.

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 CHAPTER 2: :UNDERSTANDING AND USING THE MEOlCAL LITERATURE

What ~. Jhe results? group and the control group; it .is neither beneficial,
nor harmful. A relative risk less than 1 is
1. What is the magnitude of the treatment effect? bene.ficial. A relative risk greater than one (1) is
harmful. Thus, the risk of neonatal mortality/
The effe~ts of~ i:r).terventioil ca..'1 be expressed morbidity in the cesarea.'"l. section group (0.016)
in many different- ways. Usually in randomized, divided .by the risk Qf the .s ame outcome in the
controlle'd trials, investigators often monitor vaginal delivery group (0.05), or Y/X = 0 .015/0.05
whether patients. develop an adverse. event or = 0.32. This means that the risk of neonatal
outcome. These ar:e also called dicho.t omous. mortality fmorbidity is 0.32 with cesarean section
cum>mes because you answer .e ither yes or no, relative to vaginal delivery. Is this good or bad?
depend.iilg on whether the event .ha:ppened or .riot. It's way below 1 so it seems singleton, tenn breech .
Let us talde ane of the out(X).tnes in the T.e pn fetuses would benefit from a cesarean delivery
Breecll."Tri:al~ the cumulativ$outcome of perinatal/ compared to a vaginal delivery. But then -~~ it
neon.at&l mortallty~dserious ne()natal morbidity would depend on how you as the clinician and
(pa~ l380, Tables: PerirtataJo r neonatal mortality your patient will int~rpret this.
at 4: 28 "days of age and serious neonatal
morbidity}~ hi the vaginal delivezy .group, 52 :Of The complement of the relative risk is the
"1.039: (52}10_ 3'9 ..a S%) d -eve1oped p~r~natal/ relqti~ risk reduction- <RRm, which u -~sed
neomitsl mott:illty or rlous ne<>nata.l morbidity. as a percent: (1 - Y /X} .x 100 ~ l - 0~32 ~ .100 .,..,
In the of
cesarean delivery gro.:'-r>, 17 of 1039 (17/ 68%. A :relative. risk-reduction 68% meaAS that"
1039.: ' l~6%) developed perinatal/neonatal cesarean deli\ery reduced . the risk of neonatal
n:iort.81iif~:(~....rious'rieoriatat morbidity. How can mortality I morl;>idity- by 68% rel~ti~e :.l"Q ;;tliat
we n<*-:~ftss these-results? Refer to Table 2.1. . occurring runong the ,vagmaideUvei&TQ:4p:f!tlle
grea~er the relative risJc :red.u ctjqif;,:f be : J;iiare
bne tll.~sure ot the effect of therapy that you effecti~ the therapy. Is tllis g90d 6r':ba(11 'Tti~ls
can u~t: i.: the absplutc risk-,r eduction ('risk . no do ubta 68%. ~UctiOI;l Of neQnat~l tteath . ~d
diff~re~\;or Jib$olute differe~ce) between the . serlous niorbidicy_is definitely ~.::1.b.~ -~ .
pro~~~#~tal mortality/morbidity ih the in"ord.e r tor.ave a.68% ~u:ttio~p_fl)~'$l:<t~Ut ~
~gtq"iip!tx) .,and.theptopor.ti~n ofthe ~e and serious morbidity in the ' !Si*pe~b~;:;~r#t .
outcome'bi the cesarean delivery group {Y). or X- breech, the patient has to go thr(>u.gll:the~ri.s~~o"f
Y O.Os-Q~Ql6 .Q~034 {.034 :x 100% =3A%). This adverse effects and costs of ceW.~ ~n.

;~~~~~~~~Pe~~g~r~i~ Ult,im~~~!Y ~.e. g~ign ~J!t~ .QP .QYf..~lilmt:.:whQ .

3.4%.ls this gooq or bad? The answer depends
on how the clir~ a.."ld the papent will interJ)ret
it. WQuld ycu allow yourseH or your patient to go
through the usilru .r isks of cesare~ section in
order tO .pte\l'eiit the risk of neonatal mortalityI
mc;>rbidity lJy 3A%?
Another often-used measurement of treatment
effect is the relative risk the risk.of events among
p~tients.on L'le new treatm<mt under study (Y}
relative to the risk amqng patients iri the control
group (X). A relative risk of one ( l) means that the
risk or ~vents is .th,e. s:w1e -argqng the treatment
.~ give -con~nt..<m.~JIDlC~u::e..ptdelirei.y__Qn
the other hand,, ow patients Tely .on th~-d<>ctors
to translate . and interpret comple~. pftea-
conflicting information.
. Wh,en th~ .risk. oi adverse event~ in the
treatment group is the _S8..me as th,e risk in the
control.group (RR... l. RJm... o. ARR .O), then the
treatment has no effect. When the riskoftreatment
is greater than the risk ofcontrol (RR>.l, RRR= (~) .
A.."'m= H, then the treatment is .harmful. When the
risk of treatment is less th~ the ri~k or control
(R.R < 1, RRR= (+), ARR"' (+), then the treatment
could be beneficial (Table 2.2).

Table 2.1. Measun:s of the effects of-therapy

Risk in"vaginal delivery (ba.sefu:le risk) X 5~/1039 p.os- So/o
Risk in cesaiean delivery, Y . 17/1039 0.016. 1.6%
Absolute risk .reduction(risk difference), XY o.os o:o.16 - .034
Relative risk, YI X 0,016/0;0S- 0.33
x
Relative risk reduction, 1- Y/X 100 or {X-Y)/X x 100 1 (0.016/0.05) X 100 "'6B%
Number needed to treat, 1/ARR 1/0.034."'- 29.40 .

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~
32 SECTlON J: BASIC CONCEPTS OF HUMAN REPRODUCTION ..,

Table ~t2. Measures of the effect of.:therapy. the absolute risk redu-ction (ARR). That is why
pharmaceutical companies usually frame
RR ARR ~ discus:sion of drugs in terms of the RR .or RRR.
Rt-Rc 1 :0 :0 No effect
H~.rm For 1nstance, the press release for a cer:t.aiD drug
Rt>Rc >1 H H
Rt < rt.c <1 (+) (+) ~ncfit could dai.tn a 75% reduction .of a vertebral or hip
fracture mthout ::.tny n;:ference to the ARR or the
Rt.fG.sk of treatment; Rc"' Risk; of control NNT because the NNT is . as high :a s 300, ie. of no
benefitto.299 patients. Why? Because .even.those
who should know b:!tter, like you, Me alwa,ys
encouraged by big numbers. In 1991, when a
The inverse of t he absolute :dsk reduction is group of researchers present~d identical .
calle<i.the nump~needed :totreat{NNT),brljARR. m fonrtation about.adnl,gind;ifferentmeasures.of
The NNT k tn.enup:>.be.r-of patiet:rt3 "Who ;need to be ",treatment to the epidemiology ~cujty: a.nd
tre~tcd in btder to ptevent one 'a9diti~na:l bad stud<ents at.Harvard Meqical Schocl--:-a group.tha.t.
OUtcOtT1e {to ~Ute the txpecled number.
bf cases should .be knowledgeabl.e with medical statistics,
of a d.efuied. outcome by one).'39 You -can: tell a almost half had a "stronger inc.l inati.on to treat
,p atient th~t'q,n NWf o'f 10 ~eail$ .that the ~hance W.ti~nts J:t~r teading. the !{R or
RRR, as opp<>sed ,
she :will benefit .in this :!fe';attr:l.ent :b l .m 10. '.the to th~ NNT:~ 'For our <::ase scenario, you Iri{ght
sin~!' tP,e NN!', :the gtea~er the benefit. In :fhe want to review the .t able again and mW<:e
you~.. o~ .
,Ca.~ :~ec.ano, 1f0:034 ~29)t, rotmd ~ff to 30. '.:::1terpretation.
Th.i$ cnieans that for evezy '30 ~gleton.', term .
. bp~~$~}f.e~ '4~liY.e!i4i't?Y::~ ~9ri,,;w~. - 2~ How precise 'is: the es~ate of the treat:lil.ent.
, c~n :pr~.v~Iit 1_: ,.~~se: ot::~eb'l)li~at::;ffiPLtali't'f/.' .. eff~ct?.,: . . . . ,. . . . . . .
.n}pr:oi4itr- Is f.s: t~ or;1lad?,:Again-ii' d;epends .
on ,~~. illiifp~:~3ild::the:pittie#t ~illinterpiet .When a clini~ :trial i$ :~rf:orriled, the r esults.
. ~S;:9.eastir$-. :A .~~ .:~ti~n:"i:~l;ti.i;lcl;P.:Y<>l1r: -~e ~r.e~se<:l .m~:ways :tbat WilJ.ct~m?nstrate tt1(!
.. p,<:ttie;nt,;.o.r.Jt:~~:t:.
.. . r ..... , . . . .. .
~,. ~ 1 ., '
=n~.i,
t '
~:.~.~ot~nnat.ai'.
. . .
~r ~ :!;\.:., .. ... .,
. est:imate;'ofthe

,p:ue,:value
.
as.ol;:i~.I"Ved.\fP:>'111

.~.
' mc$lityjfuprl,fi'~w': is';.:~enfed;::-2:m~n:2Q~ofuef.. trj~J.:;; ~~ lpl~ and.i~ :~ Vc;J.U~ :will;~~~er - be: ... ,
ca~ ~ri:idt:get fi.lucli&ti~t.:bn:the 1o'ther,~d;-' ... kno-wn_ :.nie:~t'!ihea~u-re a~~.COp).p.uted:..f'rw:l).the
. ifJh~'dWh~~Q.9.us ;niort>id.ityef.ypurpatierifs ob;;e rva,dons of th~ sam,;J)le de'riv'e d from :a
chll.tb;J.~;~nsider~;t?~.~:xt..~P.~.':9..t!~ltt~ p<>~~l~~~~1is .C@ed tl;le poif e.stilnat'e. .u .-te'ils .1:1~
:thlt,t-:yo',ir~t~s:..vet:yc.appreli~nsi.v.e...~00.1JLth.~ . t,!ia~.:Qle .0ieva.tu.e-.rspiooob1y ~mewfieremfhin. _
pat.kn;t In:ighfwn~i~ergdmg tprougn t4etisks and the Viciriity of th~ -p:d'fiifestin':l,atewruclli's-ullliK:ely
~sts. of :ce~eai.l se<::ti<in :fu. ~V?id it. In ronfrast, to be precisely correct.
the:Nftrfor atrea.t:nlerit'can/oevecy- hign. artdthu~
t...'1.e.likdib.ood. of indlvidual benefit oftTe:atinent:i s Tpe -neighborhood within w.hich..$-e t;:rue effect
YerY towr-.-butifth~ intemn:tion.-is..heap, pa!nle~~. lik:ely lie's :is ~res~. by the :cor:tfi.d,ence interval.,.
and acce~tble;' tl;len ,th~re'i:s n:o hht:m .ip. adoptili.g a r .a nge of val-ues w ithin. -which on~< c~~ he ..
i~ 'rio. e_......~.mJ~l~~ .ar.e 'w~g_ a ~tbelt an~ eatihg cpn.fideil:t that-ap;:>pul.ation,parametet:is .estimated
a ht!altpy~~ii~t. n-NT'.'s a:_re IDU'ch eitsie~ to to lie;n .Th~:f h d ose but not identii,taltc~ymg
oompreh~nd than .Some statistical deSCriptions, that ilie true size -of t,he effect, which. is never
that is why e -Nm W:as he~de.d :as :a . ri~w :and .exactlY. known; has a 9 5% <:h ance of falling. witl).irt
objec tive fool ~o help. patients make .fuformed tl):e .cqn'fidence i-q.teryhl. !f the 95% confide~c~ o
.d-ecls'ii::ms . .It avoid:s the. conflisini 'distin~tion interval .for a rela.tive risk (RR) or. an odds ratio.
between~eiatiVe_. and ~abs0lute" re~uction oflisk. (OR) cros se8 1, .t hen.th.is .is taken .as no evidence
of an effect. If l he confidence interval does nof
: So which is the b est measure of the.effect of overlap zer:o, the effect is ..s aid to k sta:ti:sti.ca.zly .
tberapyc?t6iven allthemeasures .in Ta:ble.r2.:1, what signi.ji.oont. The practiCal adv:antage of a confidence
~ Y.ou;advise.Y,o~,r.pa:tiel}~ re~l.ng the 'best and. interval {tather than a .P ~alue) is that it presents
.~afest mode of delivery' :for the "Sfufil,~ton, term the range of likely :effect s. :. ..
bteech fet~s? Doctors are most likely tO .adopt the
treatment if they are.given .~ r:etative.fi.sk .(RR) The Pvahie, on the.other' hand, is a: pn:~bab~ty .
and the relative risk reduction (RRR). ftowever, .with ~ value ranging .fro in Zero to one. It is 'the
the re is a . .tendency to reje~t the frea:tment if givep. answer to .the .questicn: I{ the. p6'imlati:ons
. .
really
.

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 CHAPTER 2: UNDERSTANDING ANI:) USING THE MEDICAL LITERATURE <'l ., 33
----------------~--~--~--~--------------------------------~~ ...
have the sam e mean overall, what -is the to 0.81) art;i,serious neotl.atal morbid~ty;,{RR 0.36,
probability that random sampling w:oulq lead to a 95% confidence interv~ 0.19 to 0.65) both are
difference between sample means as large (or statisticaJ.ly significant because t4ey do not cross
larger:) than you otserved? lf the P vs.h.ie is 0.03, the line of no effeCt which is a relative risk 'bf 1.
that means th.at there "is a 3% chance of .o bsetvihg Take note also that' the . p-values for all t_he
a dlfrerence as lar~ as _you obServed even i% the outcomes are less than o.os consistent with a
two popu~ation ~~ ate identicaL ~ p value statistically significant result.
beiow ()-.05. Is a statistically sigliificant r:esult,
.. whereas a .value i:i.bov 0.05 'implies that there is 1f the confidence .ihtervais are. not reported in
no statistically significant Q:iffe.rence in the the article., the next approach is to exami.P-e the
t.hciapeutic::etrect: of two drugs. p-value. If'it l.s exactly 0.0.5, then the. u p per limit
of .the 95% confidence interval for th~ RR lies
Let:us now take the study we are appraiS.ing. exactly at the line of no effect or RR of 1, thus the
We h.avea.}Ieady, calcuhtt6.1 the rel.aHve dsk to be p<)ssibility that the treatment has no effect ca.Jillot .
0.33. Ii:qx~.ge 1380. Table"2;5 ofthejoumaJshews be excluded. As the p-value -de~ses .fa:i:her frQm
the relative .risks for the different outcomes of 0.05, the .upper limit o.f th~ c onfid.ence inte-rval
. perinatalor ~eonaW in<lrtality at <-28 days and goes farther from the line Of no".effect or RR of 1
$eD,ous n~na~mofuidity.The point estimate of and becomes. s4\,tistically signjficant.
.lli~ ie!.:itive #sk" for eotilomed petiriatal/ne~?nat?-1
-m~~D' -~d '~()~s 4~AAtal nior"bidizy ~s . 0.33 . Now that you have determi:?ed ~e ~agrutu<l:e
With a 95% corifidence futerval .of-0.];9 to 0.56. and precisiop. of the effecfof .c esarean section on
:.~~~e.~: ~~ than Q.O.Ql. 'what di)e$ this .the singleton, .terril. breech, you ~- nbw'tj.ll::n to
. , '~ea.U?~iWill .tp.is :help us mak~ a decision on . the final question of how to applY.;.fr.?e .'rt~Mlfs in
''whethe(-we will:d~\'er our p;:ttient vaginally or your ci..i.llic8l practice. . .. . :~, ..
. ..r; ~ i ~ ~. . ~ ; }~~.1: ..
abdqmhiany? This shows that the lowest poss~ble
">.v alile.i or the RR is {U9and the highest value is Cap.l_apply the results to Il1Y patieil:d
.-':Ot$6$"$he~l>Qintiestllria~ .inihis case~ o.33, .is the . . . ~l.1",a ~ L.. , -~~~\~:: } ..
.. ~ .~.-otiei~e.mosflikeiyto repr.eseri.t the .tru~ relative 1. ere .the s~dy. ~tkp.ts .sin?ilfl~J~q; 9I.~:f!,~H~nt ,
yr.
.:..ri&tbi~..<f:'pn.' the.-.obSciv'ations in the study. As m my practice? .. . ..:.
v;;e::;dMSider yal.ues more distant. from .t he point ' .;~.~H~ :: iJ)l(-.~!.i!
1

eStin:ui.te, they become less consistent with the
..,. .... ........ . ris'"k.
. obsef.V'e(:frdatiVe ...... Ifiliis:Were
.. .... . .... to"be
: .. Plofted
agraph:-witlr:a:-rel<~tive~risk""of-:t'r:eprese.p:ti..fi"g..rro
.t reatment'eifea;--the-95o/o-Cbn:fiaence.-mter:v:n-Will
' be to .i ts ieft {l~ 'Ul,an l); .shoWill,g the beneficial
'effeet .of cesarean section. in r:educing pei:in:atal/
~e-Ona:tal::nort.iility and serious ileo.natal :tnorbidity
-{Figur~ 2.6}. .
. .
This tesuJt is !;tatistically sigt}ificant beta~se
it :exCludes a t'elativ.e tisk 6f qrre. In fact, the
individual outcomes o.f perinatal/ n.eonatal
mortality (RR 0.23, 95% confidence interval 0.07
-~- 0.19 0:33 o.56
. . . . . t :: . ...}:-. : -;. .
This is where the mclusion and exclusion
... .. in
crit~rii:l. Dt fue
study ar~ a.Tl:aJ.yzed.. ~f you;;Pa:.tient
fU1fi:11santrre~eligip-rnty.ffitenaanCfG;oes not Vid.Iate
a.nj:'ofllieexcluston criteria 1,1ee<:rmiEe."stUay -~o
can therefore qualify. for. inclusion, then you can.
s:ay "l.vith confid-ence that you Ca.n apply this study
to your patie.nt. There may~ afew-attriqtites that
do not exactly match with 'tne eligibility crit~ria
used in the study~ for Ln.stance, your 'patie.nt .may
be older,. si9ker, -or. perhap~. suffer. from so~e
comorbid conditions. The .next question to ask is
whether there is. a compeiling rea~on why you
canno t apply the r esults of this study to the
p atient. Often the results can be. general~ble to
your patient;> because there w:i.Jl.be no .c ompelling
reason to .disregar.d the study. The st\ldy will be
all the . mor~.applicable to yqur pati(;!nts if t h e
results are rep}.icated in other trials.

2 . . Were all clinically important o.utcomes

RR ,:1 considered? ~:-
.,\~
Line. of no ~ffect
Sometimes
. the.
. choice of outcome.fi~easur~s
.. . .~
'Fig\ue 2 .6. Relative risk and 95% confidence inttrval. cc;.n limit the clinical applicability of. a . trial. The

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 I
I =.
34 SECTION 1: BASIC .CONCEPTS OF HUMAN REPRODUCTION

use of surrogate endpoints -in randomized, Mter h~ving answered that the results can be
controlled trials has beeome very popu1ar in applied to your patient and that clinieally
0 clinical trials.'Surrogate endpoints -are defined by important outcomes Were considered. w~ must
the National Instltute-s of Health (NtH) as now deterniif1e if the be.n eficial effect! of :lhe
"biomarkers intended to ~Ub$tttute f'or Clinical treatment-arc worth tlu! potential harm and c:osts.
endPoiilts. 1042 These are used when t~e primary Most treatments, :medical and especially surgical.
endPoint is either -unde s.ired or :veiy tare {like are not h~~~ in .t hat they.cany inherent side
&trolce, tnYoca:rdial infarction, pr .death), makin:g effetts, and oft~ catry a ptohibjtive~st. 1n ~er
it i~Dpraetical. to cond uct a tna'l that can to det~rniii;le the ~pact of a treatmdit .JOur
deinOtl.str.ate:statistitany $ignlfi.;:ant :diffetertce . patient and your practice, we can use ~~pt;
a
between two intertr.~nti:)n& .i n ~er~d: .sb()rtet of.the tu.tmberneededtotrectt. 'fhis.hasearlkt:~
~rial :peri.od. ~3 Howevt, the ~s~ of -s.utt:ogate defined .a s the n\Uilbet Qf patiet)ts whoneecl to be
,endPoints is ~pprppriate only if.thej' are valid ~atecl . in -order to pre-vent ,Qne additioCal 'bad
pro~es rt>r c!fui~:y. :b'npc>rt.a..'lt outc;:()me$. This outeome:{tb .teciUee ~ e~ted:tuim-bciroreoes
implieS, aceorritng to Prentice, that thC $Uo,pte of a defit)ed.o utcome by -one). ..
.must be boih a cortelat~ of tbe-ti'ue clinically - .
imp(>~t outoome :and ,taptWe 'a!l th~ -tff~s of .Th~ ~pact ()fa.ttea.ttnent d.e pends tl()t omj in
treatment on the clii'lipally "important .puttome.~!4 the JUeaslires of.:tteat:menfdfect lilt~ the '~
risk redtil:ti(>n, bl,lt tilso to. th~ .ri$k :of.:~
A .commonly ~ited, ~~pte :Ja ohole~terol, evC!}ts a.~g fi:otn the ~bfiC!rtt. A ~. ~t
whlCh if ele\'ated~. tnerea$H: ~e ri'$k for heart hi the detisioJ). to a~ifiister . thernpy 'i* .the
.~;~:It:ha~~~}'~~~~; ~e!ctw~ the Jlat:ient~$'d~'k'pf.theadverse.~~tifleftlll1~
reia&~ a ..shi
. p : bet'weericltoi~lAaiitttJ:eartdi~-se,;
. . .. . ...... . .. .:Tbls
. . .. meana:
. . . ..tba..h . "'~-.;..-
. . the: ~~~ .;.the~:nro~...,-,:..,.; tbat
. .. :r...,.'~~:t .... -
isnotlinear::Pl8Ily.with~n9f.Dl41 t:holeSt.et:"Ol4e\r~ldp , <. th~.p4tie.rit'Wil!~rience;an,a:~~eveiitlflft,
heart disease :aJi(! many .wttb ~elewt:ec:tcthtilestetol . untreat;e<l. th~ ~ore :likely :the pe;Uen~ will~
do:pot ha\I'C:h~ 4t~~'rh:e'liDleatly~pe~t . rro.m th~--~unent, :and:.the few.er':S\ltll:~b
o1.1tcome is .de~Ui,f~->iil~ heatt . di$~se; Wliile.. ~li~e,d ;t.o:P~t.<me..~nt. :J'i'.or:;~the .
..Cholesterol:is 'the<~te !:Ou~~e.:_ A clllrlc;:jil ., : reJa,uven$k:~:U~9n'~~;ta:se:we..~ .~ .
ttial iJul.y .. show, . fot ~ple;. :~l}~t ;Shnvam.tm 1s.'6$%::tf$R~.:.~}.:iVI~the :n\iyiber~;tc,
m
(Zo<ij is effective 1-ect(l~g 4oltsfl:rolwitholit ~t.:is3-o ~-y f!ll.:ao)~Wl:Ple:we.thfgbt:say ~29
;sb,~ ~ tl,u,.t it pnw~u.Aeath. Ftoo 6f o~~~b.~t !llQ~ .lJC.n~:fit -~~
'iot~~'e.fikiacy.fu,:red~J.~tiv~:'disease . aCE~.sCCtiQn,.,th~adY.e~~e&e.nt-tba~t.
. wiuso-on1;t:p't~sented..:nvec .ye.a.t:&-,aft.er--it--was to--avoid-~by--doifig-.:a-: cesarean:..;sc:dion "~-is
inttodl.lCed.ruidtbenoftlY'fOi'$eCOildaJ'yprevehti,on pel"i.J\ateljnonJital death Or SeflO\lS ~tal
fmeteasingqPJrtiuli&$topn;verttp~on) :'5 mothidity, atc . Jfiip,lUi~t enoU$h Jor 1n11f> .go
thrOU,gh tl)e riSk c;>f pot.e~tial CO~pijc~ o fmd
.oilier ~ptesof.8\m"Ogatem~ers.~! CD4 cos.ts of~.~$eCtlon. How6ter, if the .~ber
coun;Uor death fi"o~. mv inf~tio~. to~t ~fred neede<J to t:reat i$ high to avQid ~ 01,1~~ 1rtiich
. vdlln'lle Jot shb~~$$ of.b reath, .$ p hase duratit:ln is not ~s ~rious asdeath, through anfu~n
fot" b~st chlter~~~hone.niinefuld~nsity. .whieh .i~-f~ugb~ with complications.en(t~ you
for :mtidence .otfra.ctures. would :have setond thougll:ts . about usitlc the
treatment.
Jil the ~rt,ic)e that".we are evaluating., were
clliiit;:atly important outcomes co.r tsidered? lt is Fortunately in our case, a cost analysis study'
pretty obvi6'us .tha:t .perj-nat a:l ~nd neonalal c omparin-g the two approaches to bre~ch
monalities.are clinically inipottant outcomes that presentation at delivery was conduckd .to
weTc considered-:. Other Clil\ically important determine whether a policy of planned ~
outcomes conside.r ed .in this trial a tnong serious was more or less expensive the,n a policy of
neonatal mor)>idity ai".e: ,s eizures, birth trauma, planned vaginal birth. 46 Results showed that
need for intubation and ventilation, . hypotonia, although the pre-labor costs for cesarean section
and abnormal level of consciousness. were higher. wom,en in the planned vaginalbirth
group spent mor:e time in the labor and delivety
3. Are the likely treatment: benefits worth the room, and:their infants required more care in.the _ 't
potential: harm and costs? . neonatalOlntensive .c are. Unit. However, whil~ the

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 .CHAPTER 2: 'UNDERSTANDING AND USING THE MEDICAL UTERATURE. ..... 35
.. ~~

authors conclude that it is safe~ ~d less expensive
to undergo ce~ean section, th6y alsc wa.i-hed that
it is a misinterpretation of the results to conclude
that a-planned v~ birt? should no longer be
offered to patients. The immediate -adverse events
for the mother with a policy of planned cesarean
.are grte~7 and some 'Wbmen might still upt to
choose a planned v-c,&inal.birth_deZ:;pite the higher
risk:tofue infant. These
ft...-e short-tei-m outcomes.
Not mentioned were the 1oP.g'-terni .risks and 'co.sts
of a pOlicy of planned ~ section compared
with p~ed va~ birth over a lifetime .. For
mstance. it <lid not mblti6n the 'Tesout:ces and
C9St:! that Will be ~ in future pregnancies.
as possible. This s h ould take into
ca'nsideration the selection of patients how and
the test was compar{!d .~to an appropriate
reference or .gold standard.
2. Does this evidenc-e demonstrate an important
ability of this test tc accurately distinguish
patiems who do and do not .haye a specific
disorder? This is do'f:le by exai!liillng the test's
pr.opertie$ th:.rough a computation of its
likelihood ratio. .
3. Can .I apply this valid, important di.agnostic
test to a specific patient? thjs step Will belp
you make a decision on how;to use the test to
. yo~r patient.

. Tne exercise you haVe just dcn.e viill help you Some clinicians prefer .t,O .answer the second
assess and use the information 'from: ~des abbu t question involVing the results of
the test befure.
therepy..The .P~ may ha;e ~-a little too ta..ckfu1g the i;>sue on 'ValiditY bWivse ifthe ~rt
t.<xUou~ for your 4ls:te. but the tnith iS that. this is conCludes that the test does .n:ot prove an_'
a ~- ~~liniCiftns ilp.pliitjy e11~ge ;in _prior imp<Jrtant signillqm~e bli .the aecuracy -or" th~
to.~ treatmen.t-decisions.. By b:elpiAgyou go diagnostic :te~t,. then.who car:es about the va,lidity
tiliri\'lgb.'tlli~.processin@:expliclt.tn:anner-thrOugh of'the report. ,On the other hand, if the i.SsU.eon
gci.d~ ~~sj:rons will hopefully .make you a better validity. iB. answeyed fust and llie'&:~tf' is~i5Und
ciiiJckJi:! ~-~ . .. . . . . to ~ inv.ali4, th:m
who cans !h~~0tbe,~~s
an. rmportant 1:mpact .o n. dtagnnsrs" Wh:a~er
How
~
to _uSe an iziilc1e a1Y-!ut ~ dt.agnos-tlc test ..approach the clinician chooses, it '*m be cincial
.. .. t .... .
J...."'l.~;. '. .. . .. . _ . . .

... ; ...:" ::.:-' . . . . .... ' . . . . .. to do bofu stepsbefore-answ~g;,!}?.e- q~e~tkm

. - -.?M~~~Q:fi..evex: eueountered-.a dileinri:la when .... :on ,fue:applic~.bility;:toyour _pa.ti~~+ .: ... ;~,;_:;.{!:: .. .
ordenn"k~Yahd
~
interpreting diagnostic test;s? With . . ,: :.-:. : .;.~
"' ""hi,
1~'!/T~ ...
.:
~~ '"
Are the results ~f tb.e ar:ticl~.vali(t~< . /tJ
. . . '41'! - ... ' ' . - ' - '"'

the ta.Pidly evplving advances in scientific

technology and tlie increasingly high t~.ch
cawt>mfr'bfri:ew ~hmS m9W!W~g ilisea~.
itisevermoreun:porlant':forthe'd.iirlciah'to-ha:ve
~tre-aomty-to-:asse!i~nu:nffu'Cleal>Qutaoiagnos~c
test.. This section ade.tesses t...'1.e...application of-
a
. reSe:arch .on dia:gQ.os~e 'test within a clir~ica).
context.
The process sbl.rts W.itb a .focused clin ical .mightotherwiiebe.confu:;;ed. A tes t1s prasfically
. qu.est:io+l. This will guide you. in y our search for
. the evidence in the a):ipr!)priate article/ s. Once
you l1ave fotind ;a po5S~b1y u selu.i ~de about llie
diagnostic test in q_u~tion, the folloWing steps will
-h~lp you criticallyapprai~ the article.
Tfle gliide questions for _the critieal.!lppraisal
of a diagnost~c test inv.e>lve .t he same basic
questions &.s th~~py:r-egarCUngvalidity, result, and
applicaqility.
L Is this evidence a bout the accuracy of a
..diagnostic tes~ valid? In: oqiet to detennine if
ilie test is :believable; the -accuracy of the to . detect- disease lilld
diawostic test should k as dD"se to .the truth
.
1. Pid the cliriicians face diagnostic ~~tj?
'Dicttfiecf;ah'ennm.inplemau-q.e:-Wi'i;$:Pro'];iia:re.
- spearu:ni~Of'.pa.tleiifStO whonl"The <lla~c
t~f will be applied in cli...Lieal practice?
A dl!ignbstie test :will have _no pragou;~.tic value
if it pan,not differentiate between conditions that
u seless if it .a;n only. set ..apart 't:ho~ with' seV-ere
disease and those With mil& or no. disease. If the
test is_ e_onfine4 o nly .. to th~se who _a.ie
asymptomatic \}r to those with severe illriess.-they
are. not very- it)Iormative beCause if the 'diagnosis
is alrea,dy. obvlo_u.s, then tl:ie~ i.s no nee9. for a
diag~ostic test.- ln otb.er. words, a gobd. test should
be ~ble to distirlguish the .target Condition in all
spectrum of the di~se--mild, m~erate or severe.
How does disease spectrum affect_eP.tirnates
of the accutacy of.!l diagnostic test? If a.fs~bjects
in the study h ave severe dis~ase, theiiJf is easy
we
expect ,mor~~positive
results .. It all subjects have m ild or no'_.disease,

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. SECTlON 1: BASIC CONCEPTS OF HUMAN REPRODUCTION_ ! I

then .it is difficult to deteCt the disease and we biopsy. Can.you think of other diagriostic tests
expebi'mor'e hegative results. The 'perfect scenario and th~ir corresponding_ gold .standards?
is to peifonn the test on the entire ~ct:rurn .of
disease. If the referell;ce standard used is acceptable
inyou~critical'opinion, the next criterion that-has
An eMUilple 'of how the subject~ eomprising to he fulfilled is whether the tes:t results .(lnd
th~ stUdy are i:inportant in a.nalyzh-Lg articles of .a reference. stan~rd w:ere assessed independeritly
diitguostic test is the use :of eart:inoembryonic 'of each .otheL This means' ths.t th<?'Se wno are
antigen {CEA) 1 a tu...--npr rruir.ker used for -te$ting" mt~rpr~ting the reference 'standard .should not
colorecW cartcer. Initial studies showed that 35 know the re5Ults <;>ft..\).e diagnostic testw.question,
of:$ ~pl~ With advancetl cen~r of lhe colon or an import(_Ult criteria qilled *blinding." Pa.uents,'
re.:;-tum ~ve e~evate~ CEA, suggesting-its posSible clinicians, those monitonng ~:lliti;;oil):eS; :j\idicial
utility for C9lorecW eancer diagnosis a:n:d even as~rs of .outcomes, data -analysts~ au.l;l those
sqeenixxg. 13 Su~equerit studtes -oti a wider :writing.the p~pei. canall be blfuded or maslr;d.
$~ttum -pf pat'ients, however. showed that With. blipding, the investigators will.- a~id the .
pape.pl:S 'with 'less advan~ed.~ ste.ges -bf ca!orettal conscious and unconscious -inclination to favor-_a
can~~r, :o'~et cancers~ and-: >!V.en other benign partic_u:lar: dia__gno~is' tltat might oth-erWise tt~
ga~tf-6int~$~ bondit.ions~ also 'had elevated the 'gold sta,ndard to .be "'over-~tetp!e:~ wpen .
leV:e1J cf.CEA:: thus, due to the futiftedaccuracy the dfagnpstic t~st i$ pot;itiv~ a:.t;1d "lmtier-
of CEAM :a dia~stic and ,sCreeiri:nf,'-'tool:, its use in~~reted" when it is 11-egailire. feriiaps.your &wn
ha:~.'be~n abandoned and is ilovt limited to. cliriical experience ~a:.n; show 'yo,~ w~:y thU-is
._ ~pt~~~;~~~fu:~~?\yn,;:oloJ.:t~9~lr:~~:~9 iw~t._.V/hen,~ cfuPcian pa;lpaY.....s :~ -~~.
inrmeJefu.adn~-and ;;tr,oluntee-r~d;hi$ ibi~~n -
2. Wa!f.there a blind -cOm}>~ri$on-witP.an to th~ -~noiogist, ,the'httte'~'tii~}/dJi~:~i
, illdepen(l~_.gold_' smndarq' ;appfu!d' similarly patient to. ha'Ve an OV~ C}'St, eYen If.~- lS .
. ':.~.tlie
. ..
~tme:ht:gr{mp:and the-.contt:Olgrtmp?. none. U.t:J:e'.i lathol.o gistis aw~:~t ~.-P.aJ> ~
" ~-
. _ ._ . : . . . .. . . resu1-_ t.of_,a: patiel.lt
. ..
s4ows Q!r'vlcal' . ..
iri~thelial
- :Wli~n>assedai'itg-;J>u,blish;e'Ei'-~rticl.es-;l<?il _:a-.. -. n~pla_~.ia. ~:I~I;:.~t9m_.; ~~t).:, k;~ :4U~~~ .~f~ip~. }he
.dia.grioSti~.~~~~Ycrite~sh?ulru~tne~r~er,. : .~i'joici:al;P~QPft.Y;~J;:~~ $.~~~~ri;~#l.:~~ :~~:OOly .
to .d~teri!}itle:ifit'isValiC:Ifc;>t l;i&~: FlistiJhe~patient~ -.. CIN L ,In a :recent"Eyi~en~;,.BMe{l~M~'~
in: the .s~dy sho}ll<t have undergpp'e .bo~h the Fl~~&r~:P9.rts.f.A~th:e-.d~e.ofa~t~
li~--fio~t~J%.~'??ii&:ltafidT~e"refetenceor . and~abOve-chan~_.in.~g~Q(~~t..:-~~-!1-~:~
gold st~dard. :The. Tat;t er-shan--:s-e:rve ..as .biopsie~is-le$$-.tllan.-SO.'Yo-~ .. . .. , .. ...:._ ...
-C:O~tocy- eVid~nce ~at i:he_pa:tien.t bas qr does ..
notbaie the disease; Tli~ go).d .st:andardisiiefmed What is -the effect. qf. nop.-b :linding :on -'t he
.-as a inethod :)laying '8.:Il established or widely estiJ:I).ates .orac~uracy ofthe .@ .gnostict:ds:t?teSts
-a<ii:pt~ .aceuracy for d.etei:niin'llig-a :dlagnosi~~ will seem 0etter than they really are. nlis.t~ts
p~g :is~dar:d ~tO. whlh :a new SC;reeniflg.or in. hia:S, an -error that is :systematically dc:Viated
:.diagnostk tes! ~ 'be eollf'Pa7ed ''the a~cy . tGwards making the .test seem :~tter..
' i'cl:~ -'to the d,egrie .o(~grebtnent.-betw:eeri $:e . _
~e;uits 0f the 'in-dex test and .thbse frbm :the If there is a 4igii probabilityJhatkno-wlciigeof .
.r~ference stand~(L For e-x;ampl~, an . ~ticle the gold standa rd result coulq i!lllutil~ the
.~iri~s the' a 'c curat;y- of the urine analysis in interpreta tipn of tl!e diagq.ostic test in qUestion,
d:w.gn9~gurinarytraetirifection:The.investigatof the greater is the tinpor:ta nce ,o(theblin:ded
WiJl'have t~ 'Sl,lbject each. of the -patients to both interpretation. Also, thehigberthe probability that
the uik~ analysis and a reference standard like . the gold standard inter:pretatio_n could.ch3.rige due
. the urliie .cultUre. For th~ diagnpsis of. ovarian to -knowledge of th~ .result t>f the diagnOstic test,
malignancy, a screening method called the the greater the impor.tance of blinding the
:Sassone scoring syste m can be teste d against the interpreter of the reference standard.
.. _gold:sta.ndard:, wnich is:theactual hislopatbologic. . .. ! . ' . . . . ,.,., ._ ... .- .
,matn9sis'--on biopsy. The hi,nnap papillom $.viru.s . W~at :ar-e the results? . .....
~ :

.PNA {HPV-D:t;TA} tes tfordiagnosis- :o! c~-rvicat

mtraepithdial ti~plasia can be ~ornpa:red agail).st. L What likelihood -r atios were.assodate'd:with the
. a referer:tce stapdard llke a colposcopy-guided ra~ge. of possibl~- tesi:-res1-1lts.? .Are likelihood
-..

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 CHAPTER 2: UNDERSTANDING AND USING THE MEDICAL LITERATURE :, "37
------~--~~----~--------~----~------~~~--------~~- .
ratios for the test results presertted or data check-up. She is asymptomatic and g'Oes t~ugh
_nece_ssary for th.eir 'c.aJculation provi~ed? the wt~tine laboratory .tests. Her urine ima.lysis
s howed. 7 pus -cell~fhigh. pov.rer field. She says she
When yqu are confronted with a patient does not want .to ~e antibio.t ics unless you are
presenting with a s:rmpt:Om, there are two essential _ definite she has. urinary tract infection. You
steps before makin"g a diagn,osis. The f irst step therefore search the literature for the .accurn.cy of
inyolves identifying_ all the" possibilities or the urine analysis as a d iagnostic test for urinary
enumerating the differential diagno"sis and ma.k:L.'lg tract infection. An artide sh owed t.'le follo~g
an estimate ofit.S reiative probability. The second taole, which compares the results of urine analysis
step involVes incoq)orating ad,ditional in(ormation to its gold..standard; the "l.rrine culture (Tabl(! 2 ...3).
d~rived from further. testing the patient. Tbis .will.-
hopefull}; either rule out some of the differentials
or"rule "in .a _particular C ?ondition. FO.r .e ach 'I'a.ble 2.3. Comparison ofurine arialysis with u:rio.e cU1nrre.
. . .
dilignostic po~ibility, the additiorial incorporated.
information either_" increase~ or decre~ses -the Ur'ine.a.nalysis Urine Culture
'likelil1o0d ()"{disease. "Thus in making -a .diagnosis, . Wbc/hpf Positive{+) "Ne;ative H
you Will. mov~ :in~tincti7ely from one t>r many o
0 sss
pos~ibili:ties,_ calleq t'il.e _pf.etest prob.a.l;>iljty, to 1-4 3 .24Q
anQtb,er po~onhy, caJledthe p<>sttest prhbabilfty. S-8 12 -~7
. "The pretest proiJabiiity is the probability ofthe >a 39 '. i2
tai:.g~t. c:O.nditi'Qn :belrig p reser.:t before the
diti_ino~ticf: ~te sts ~te .available. The posttest . Total
prol:>i~!Y.i$ the probability ofi:l).etarget Condition :_.;.. . .-~.....~ ~ -
'

~mg p~~t 9.fter the .results of the diagnostic ~ .."~~.!-~.~~; :.

test ere avaiJ.abl~~ ' .:;-': ...
:.. ... .
. .
. .- .. '_,. . ... :
~ . . .. . .
.. The .. information value .of" a. t-:!st: result. _i$
eipresse(l .as likelihood r:atio~_-{LR) .~.T9-~-:~R 9;f~:
'

.:Apatiei).l:..e omes -to your clinic with right low~r

-G.Uadrtl.ti~. a.inen:otrheie for 8 weeks but with . positive test"is:how more ~ftena.posi~etestreswc::.
"'~' ~~~ spottmg.
.. .. .;va,lWUU
s ome: . . . y o.u 1"1st d.own a. ll t h. e occurs in .
~e>:sons~ with the tatif.~~JUsii4~f, .. .,...
.pos"sible diitei_-ent]:al. diagnoses in your mind. Your compared toUlose with.outt:h:etarget<disorde:tJ:I:b.~
hjghest ton$id~'O.tiQns are a~ute appendicitis and ~R -c f a neg~tive test is -h~w l~ ..~ely a-~ve
ee~?.P~:~~cy. J.ll.i~t. ~~-Y.~ p.rt!.!~~~.P:t:.QP.<~J?Y.itr .t~~tJ:e:~JJ.lt,_Q~).lr.s.iii..thosemi.th~fue.'~.d1SOi-4ei:
for each of tho s e _cogilltiQn.s? . .X.~YX ~P-hY.sic.al .c.om~to:...Ul;ose...wi.t:bout-:the...:tar-gcl.-di~eF>
:e~ti~i;";h~wed slight t~ndemess on the right . Siri~ the likdi.'LOQd --r:apo;J -~~re pot p~~. b
lower q~ad.rtmt. Does this change your: pretest the paper; you will have to ccalcp.latethe,likelihood
probability? Has it .moved . hi_gher for ect opic ratio .for each level offu~H:liagnostic te:;;tftsult~.
pregnancy and "19wer for acute appendicitis? Or The calculation invqlves ~ering two question~:
has .it remained th~ same? Then you subject the First, how).ikely is .it.to;obta,in-a given test- ~U.lt
patient to ultra~und, ~hlch showed. a complex (for instance, 7 pU~ceils./hpt on
minalYsisJ .amo;g
ID.as-s in the right adnexa. with ~orne fhiid. in the people . with the tar-get. disotder (positive i.lrine
cul-de-sac. Did your pretest probability move culture)? Second, ];low :likely is it to obtain the
fur..her .toward ectopic pregnancy and less toward same test .result (fqr- instance. 7 p lis cellsfb,pf o~
acute appendicitis? Later we will s how how you u-r-inalysis) p.~n:ong peqple without. the target
~use fue properties.of each piece of information . disorder (negative urine cUlture)? ;ForT pus ~Us{
gathered from diagnostic tests -.;vill "h elp you move hpf on urina lysis. these likelihoods. ~e 12/54
quantita~vely Jrom the pre~est probabilicy to the (0.22} and 27./834 (0.03), respectiv~ly.;l;Ul"d th.eir
posttest probability. Later you will also learn. that ratio (the likelihood .ratio for 7 pus cellsfhpf on
. "diagnost;ic tests that will make big movements urinalysis) -is 6.86 ..'fable .2.4 ~hows the ~sults
from prdest to postt.est prob abilities are for the calculation of. the,
. likelihood ratio..,of
.. .other
si~ificant and .likely ~o ~ ,u~ef1}1 J.n...our elinical test results, . . -::~
p~-a~ticb. . . . . --:$;
What do the likelihood ratios indicate? The
Consider the ca,se 6f a pregnant woman in her likelihood ratios give u s an idea ho~.much
firs t trimeste.- that cons ulted you for prenatal movement V(ili occur with either an increa,se. or a

Scanned 8y: r-..

~
38
.._.:,

Table ~1.4. Calculated likelihoo<lratio-s (LR). noxnogram l>Y Fagan5 1 (Figure 2.7J was constructed
to allow us to bypass the tediou~ caJ.culB.tions'il,nd
U.~e Anteysis .Urine Culture :l..ik.elihoo.d
Wbc/hpf Positive(+) Negative(-) Ratio
get an innnedi9.te resuit. The left-hand eolumn
.repr-es~nts the pretest probability, t,he middle
0 0 555 0.01 cohunn .represents the likelihOQd ratio, and the
1-4 3 240. 019 right,.hand col~mn rep.resents the posttest
S..8 1~ 27 6.86 probabill-ty. ~itn_ply draw a straight li~,e by
>.8. 39 12 .$0.19 an@Otiilg . a ruler ~~- the pretest probability 'then
ToW 54 l}34 1'9tatnig it to pa~ thro.u gh the_!Utellliood ratio.
.-
The J>o.i!lt where it ends mark.~ the J>Q&ttest
:p robability. .

. . . . .Going back to our cliuieat:seen~, u~ .the

decrease o fihe p~test _probability. A U:k4ibood data you ()~t3ined ttom the -~alc::ulatiO.n of.-
or
ratiQ one ,{1) rneans there is no moveme1;1t from l:ikellhood Pltios (Table 2.4) ~d s~ -from.a:pri:te$t
the pretest probability.. 'Likelihood ratios > 1 probability -of 6%. Not~ l .h at .the _}inf; p~ssing
in~ . t..lle probabilitY that .the target di$0rdet thTOP:~ a li}telihood ratio ,o f 0.19 (pU.s ce!lsfhpf .
is pi'e~n~. Likelihood ratio$ < 1 de~e~se- the ol 1 ~4l U).t>ved tlle p:rete~t probability to a ~itt~t
prbb.a:bility :Uutt the tar,get diso::der is p~t. p11>hitbllity o1 L~s. TheU-n:e passin~ tb,n)up the .
~ID,lood -ratio ti~6.86 (fur ._.p us.ce~sfbpf Ol:S--8)' ~,
. ali_t .how.:~ we usc the likelihOQ.d .m.tio to .gt> ended ii). ~- .~sttes~ p robapillty ~( ~o :uu~t a,s ~
frQ$.. pfite~t-. p~bahiUt,Y:.:. ~tQ,,~stte$t,~>P:rtiba:bill.tY-, -_......comw~) : 'rb.~ lfue pa$Sll).g t!U.nu~\ ihe Jik..lihoO<t
wbiaf'l$. m\jie'-4nrtpl1t~'tQr'US:::~lll.li-@;n:i?;~.~,:. ,.mti6!1>t4~l!P\l~[~ll~-fbp(~~~)~Qd..e4,~j\-~st:, ,
~.tnv~g'the p~test:.protab$li~;to_odds,- : .pft>'b;a:J;rilitjH )f'B:$% . . :.
mUJtiplt~'tht tettilt by ~e:likdffiOod'i'alioi and-
co'*~g ::tl1e .c9n$tqu~nt . pp~tt~st o(t~. - ~o
_ po:.B~ .ptPj:,a~~~~ '.l~:l;ri~w,:tlli~-,~~'d:s"jlike;;a., . . . . . ,1.,...,~
- ..-. -- ......,_,--.-., . . .
~-~~~~1is;~t~~t~~go;tll~ugti;,buUet:~:- . .-. . , .t ...
u.a j\Wtm~tnttetam~plef.ttsmg::O\ll"_!prmou$',;,. , .. . . , , .. . !1 . .

~~~r-th~.,~:PtbJ.P:a-tt.- pt;e,~t;,.~~-
wh' 0 /hai:-7.
, ,. ~ai~.'~Wibgt
pu$.J '" . .... ... ;:b
. . . - th.~~~+,;.
. -~X.~~.'<!. ~'fJ.
.
ofJbat)c;l--th-.-t -:ihia..._pa~~t ..h~%L~aty..J:ta~t . t
irit~on?TheiUl~ t<> : ~s crutbe Pfu.~ froJU
-preuous dini:l .-~r.,i~nt:e, put .:tese~e~,
~;(?r.M.tion:al -P~~nce $tatist.j~, practice
:da~sea.,. tl:le :c~tuU ~port. uscl! :for -deid.Jn.g
on ih ~C)' mtd ~pp'ttan -():(the ~~ art-a
~tudica .devo~ . specm~y :t9 de~_g :pr.e~
te$~ prob.iibilitie-aJ .11; 'is ~nly. ~ :$Unmte~

~t-~s :~ssIle yout '~retest probabiUtyJor this II

patierlt'with 7 pus cellsfll;pfis .6% (Oi06). Cqnvert '5
'thi ~o - -od.-ds, thus-: Odds =
.pro'b~bility.,/
(l-pr(>-bability}~ :o51{1- ~00}:i!= 0.064. Multiply Uiis
:b y the likelihOod tatio: 0.06.4 x 6,~6 OA4. Th,en.
ro.nver uhe :pQsttest-<x!ds back to probability, -thus:
Po$~St probability Odd~/{1 + Odds) ~ 0.44./
(1 + 0 ;44) -0.3 or ;30%. Sa :the pretest propability
bas j~~d from6% to a posttest .proba'bility ~f .l . ,_ ~ ....
30%. Is th.at-shift -significiifit- ~nough, 'f!)r-, yl)u.-~to:.... -- .- H. t
start antibiotic treatment? frt.Tnt lldilood PostTest
~ ' Rlo Prcbabily
Notice 'that the calculation --can b.e -v.e ry

laborlous and .time-consuming. Fortunately, a Figure 2.,7; Nomogram

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 CHAPTER 2:UNDE~STAND1NG AND USING rHE MEDICAL UT~RATURE

So far we have been focusing on the property be u~eful in clinical decision-making by. just
-of the diagncsti~ test by determining ti}e reme~bering the nmemonic: SpPin and SnNout..
:magnitude of tl}e tlW,lge -from what we thoUght Ifa test has a very high .$pecificlty, a positive result
before the test to what we think. after we obtain effectively nlles in the diagnosis. Note :t hat specific
the resUlt of the test. Tests that 'produce b ig tests have ve-,;-J few false positives. If you get .a
.changes are 'those fuat can b~ useful in ou:r dinieal positive test. you can
almost be sure that it is a
practice. While t}le like~oQci. ratios arc more . true positive. If a tes.t has very high sensitivitY. a
p~:rtyer.fuT tocls in distinguishing p:1tients a.n~tive result effectively rules out the diagnosis.
througho:ut _a wide :spectruJ:n of :disease. we m~--st Note that sensitive tests have very :few false
still~ Cognizant oftht .more da~ and less_ useful. neg~tives: If you. ~eta negative test, you .c an count
concept of ~:nlrltivity and specificity, wnJch.is .still on it being a-tr.ue negative.
widely -used in current literatute. Tllese concepts
eonsider only tWo r.esul~: normal aild. a:bnonD.al How can I apply the results to patient care?
(pos,itiv'e.or.n~at:J.ve}. Thus;i~~es.sey be 6dined
ru;td u;nder$tood J;J 1,1smg -a 2 x 2 .table (fable 2..5). 1. Will the repnx,!.ucibilit:y of the test results and
its interpretation be satisfactoryin.JD.Y clicital
settfug?

. Wl:).en applied to stable patients, the test

Gold Standard shouk~ 'be :ell)le to :p rOduce the Scurie -results. 1f :the
~ ~ ' ""!'
(+) H tes t. is .. not; repro.d ucible. th~~ .t~e;r.e ~Y ,~
;~l*-l ' 1., .~>':~ . a. b ~:rent ~~blell,ls with the test'it~lff~.~,l;>l~~. .
:~4~) .... ,, ........ c d ansmg.. wnenever a test .requires r~!#.WTI:~B&~.=
. . . ..
~

This.is especially true if expertiSe fu.~e'd.'Jii

the inter.:Pr-etation.. of th~ 'test For'in's~q;:.;Y~
. . :and.Yo~r.co~~e -~Y.have ~A, ~~gr:eements...
~ .~.. :~l)~tiv.l,ty ..h defui~ ~ the .p.t:obab'Jlty o! a y;rith .the. dia-gil.osis .of. cernal .d ila.tation .o[!a '
. .. - . . : r- - .. . . , A:.l"'"> .. .: >1.:,...4.T
~-

: .. J><>.~J)iy.e:o.t.e~t. ~o.Iig those .wbc .triily have :the patien4 even :.u..yo~:.ar.e. both ~~)I:.th.~~:
dis1;tse (itj a +.e):.. ..Specificity l"Sc ,defined as the probletns ~th. reproduciqllity~ th~~~~~r; . .
pxpbability,of a ~egative test. among those who do must address tt. by using meas~;that c:or00:
not bnye the disease {d/b+'d). F~itive predictive agreement by -chance. .-~~,.
vahte 1~ 'the pro."*r>wtr of ~s.e ,aDi6D.g iliose
wb:o ..tested-po~itive;.{tf/R:~b1:-:N~afiVe~:preq:i:oove 2. Aie :ffie:r:eswtsa""iieable. ....,_to ..___
... ------------~~----
the tknts
__ ~ in
-~---""- .. .
-vg-Iu-e-iW:Uf'e-proQabllizy oi nQ .disease :amoiig"':Ui'ose my .praCtice?
who test~d negative J~r tbe .di~ease {9-/ c+d).
Likelilioo4 ratio .is the probability -9f a positiv~test Dia gnostic tests tenq. t o behave differently
.resul~_.amemg :tho~ who h ave the qisease divided arn~ng :different
patients in a wide ~~trum '-o( .a
by tlie..probability oh~ :neJ~apv.e :test ~.,SUlt among disease, lfthe p.opulqticin sampled consists mostly:
those.who do not have the disease (+ LR == {a/ of severe <ii!'>ea~. the likelihood .r atio will move ..
.a+c}({bfb+d);.H 1,.-R- (c/-atc)/(l!fb+.d)). usmg~Q~ awa:y Jro~ a -v.alue of 1 and, the sensitivity
clinical ~natio .of pus cellsjhpfon urine an.ai.Ysis increases. When the w.tients mcluded.in the study
where positive and negath:e test results are not mostly have Diild disease, the likelihood ratios will
shown, yo1,1. can -m e assumptl.ons and make you1 move clqser to 1 anQ.. the sensitivit y decreases .
.OWn 2 x 2 .taple by <;;ombining 2.or rp.ore rows~ For When 'the:fe are many CD!llP,etin:gcondifions that
instance, zero (0) pus cellsfhpf can be considered resemble the test beha vior..of the target disorder,.
negativ~ while the. combine9, l-3, 5-8, >B can be the Iik~liho..od ratio.s m9ve clpser to 1, therefore
consid~red p<Y.sitive. Or perhaps n egative would appearing.lessuseful with a decreased s~city.
include rows of Q an.d 1..:3 pus .cellsfhpf; while In contrast, if the behavior of the test among .a
:~'li~ y:ould ip.clude rows of 5._8 .- and >8 .pus inajorj.ty of the ~ple studied is very different
ceil~'fhJ?f. - .fn:5m: :fu~ .tget .diS;Order, then th~ ability_:pf the
testto dillerehtiate ~ose. with disease tind.:yl:i'thout
fUgh va,lu~ o( sens.itiyity .:S.;ng ~~cilis:i~ty ~re . ren4er.s the likeJ.ihood. ratio to:move away:r'~ml, .
useful (or rul.iffg in or.ruling out di$eas e .. This can maldng it m or:e usef).ll in .our clinica1.5e!#nz:

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 40 SECTION 1: BASlC CONCEPTS OF HUMAN RtPROOUCTibN

If llle. incl)lsion criterja in the pa:per you are Fo.r a disorder with a pretest probability below the
appraising is similar 'to your own patient diagnostic threshold, another test tha:twill aclnde
~pulat.Wn, then tl)eie is no reason to assume that the diagnosis by lowering the probability .furth~
'it is not applicable to yoUr- patient. If no~ you have will be u seless. Similarly, for a di$0rder -c:ith a
.to m.ake a j;udgment 'if )"tu7re going to U$e this pret est probability above the . the:r-apeu:~i:c
pa,pert<> ma:ke clinical decisicns on your patient. threshold, further testing to C;9i;tfirm the ~s
Si~t,..to papers qcf therapy, there must be a by increasing the probability wm be or n o
cpmpelling reason for you not tc acr;ept the study's diagnostic value. 'tests woUld be of value if it Will
:applicabiUty ~speda'lly if there are :mahy . move a pretest probability bereeen the diagnostic
co~peting tondit;ions or if the severity of disease and therapeutic threshold ~to eros~ '.either
in :'the study-is so differe~t frotn fu~t.:of:yourpat;ient threshcld~ ..
po,pulatioiL The issue of generalizability can l;>e
r~lVeif~by looking .fQr o~rvi~s thM pool the . Now consider. th~ p3:tie:r\t in our- clin.ical
re:5\Uts of many differnt studie$~ 52 seenario: a$ymptb.matic~ pregnant ~man ip. ber
f irst trimester thB,.t. <m urine aruilysis, Wlis''foi!:msi
3 :; ..W~ll th~ re: ;ults e4ang-? ~Y management to .have 7 puscells /hpf. Some \\;oUld :ccnsidet this
strategy? result equivt;>eal in the sense tha:t ~le.patienbnay
or may not.ha:ve utinary tract .~~on:.:Aie.}'OU
... CbrtS:~!;ler.a. hypertettsiv~. p;r.-egnant .p atient going to iinm~q.iately giv~ antibiotics t 9 t$is
pr~:ting Wl:th.gene'l"-'ili.ed jxu;iic; clqtiic ~fu.lres; patient?. Let us review. the llke~obll rnclo ()[pus
Al:zyo~~presen~with.-such .acasewould cells of 5-8/hpf on ur.ine a.n~ysis:~Jld the.
iP*n~~b' ;riuik-e-:ai~o~,<.of" eeJ3m,psiar.~d> . mov-ement fr:~m. pretest to posttest prob.abllit;Y
w0ukNUteaa)r.,fristitu~tfien~$iallJ\i::tctttm:ent, .. {'f'ab1e '2:4}.: The- likeli~opcct .r~do, is <U~{>.:The:
Wi~out ~hii$gJ.c,> ~.d.Q~,furth~::testin.g to ,confinn,.. probability. of disease .p rior to .testing ilie :u::::ne
th~~iagnb.sis>iri 'b:the:t wQro$'; :tbe.'Prowh.ility.:,pf was '& %.After the. 'urine analysis -~sult:.was .
,e:cirun~.f~r::Sohi:gb :~t :ti i~~;~~~ ~old obt.$1~. the posttest. probability ~s . ~ ro
wh~;!lo~e:r. tes~g ~s.'r.eqi.fu:~: Tb:i$ ;~s, . ~k WoUldyou; J?,ow:givelari1ili~~tic?)~ jpu .
.iiit"th.e.:pie~-1>~hilt>lliey;w.o:bC0ID.e ~so.Ju~. ~clled..-llie;~rapeU:tic ibreshold:o~~J'OU.mn,
th9>t:.we:\vo~tifo~aditiontdc.testfug~::beeii.utef:~\ ,; .. s~ed;'tietw~ni.We::diagtiOs&;indo.~;-.
.defiill~e ~~s ca;n,~~Y.be llllli:le:.'ln'such thre~~O.~d '~~:you :~ou!(:l ~~~~~ ~:P~ .~
'a t.~1l:e .YQU Will m o-ve
to choose .the pJost ini;tial diagn:osis,and:.petf.Otm fiffthet.~~The ..
:a:ppt~pria:re-..tt:ea1.'Di1iL we -pronaorrreya150ve answer~'Woula're'"ap,yaepeilct- tne"'iUiUClin;s
~Wlllc'IUfie'dl,agiidsts:ts ,SUffi:"'~~elY' to-wariruit juifgmenC-:-()..ne-:ca,n. argue :that antihlptks are
~tteat::ment defin.e.s fu.e :Q:pper t}lle.shold called the rea<lily aVallable; telative)y. a.ffordab~. With very
:~ vr tr-eatment titrt;.Shol4 few sid:e. effec ts . 'Those whc :,~ill be pv!ng
anti:bioti8 have $et a low the;raj:>eutic -:threShold
In :tb;e.ex;;un:ple we 'cit~ ~er; let u:s :a~~ine for these reasons. ~reis may tont~ that~-aQ% .
t:p:e: aeyroptotilatic~ -p:t~gnant .patient'in tier firSt pos.t test p;o'b~a-bility 'has ri<;)t cro~lsed their
trlr:r.):e..=1:er was 'found ~0 have l~ pus celb.fhpf. tlierapeutiC: th~shold ;.becau;se ~~ aysfili :~
:B:etneintjertha;t\ve:~ve.,settb:e'pr.eie.st'pr'p~bi,fity tr.~athig the pati:ent .~nn~2es~ari1y. the!!e
or the. p tobab:i lity before penotniing'the ur:{rre clinicians would fuerefot e x'ecourse to do further
.:2\n:alysis, tQ 'be 6%. T he 1ik~libood . r.a:tlo was testing.
ca~thlf,ited ~o he 0.19: {Table 2-:4) .. Apprj.ing .the
nompgram :ey connecting the .p retest pta'!;>ability Who determine.s what the dia.'guost!c ind
of 6% to the likeliho,o d ratio of :0.19, we get a therapeut ic thresholds are? lt is actually' the
Pb~ttest proO:babilit'.f of L ~%. Notice that the clinician who sets .these thresholds. 'There is n6
P\'Ob~b;lity :of disease .has deo:eased fmni-6% to absolute answentiith o nly dinic,ian intUition and
1.2%. Are, you no~ .going to discard the diagnosis individual expertise to guide the .setting, ofthese
of 'u.riniuy tra<::t.infectien? Yo'!J, m'Ost certai~ Will, thresholds. The greater: the .advetse'effects", .tlie
The probability below which tl:le clinic,i.an-.qecides .. more invasive, and.the more costly the treatment,
a dia:gnQ.sls warrants .no 'further consideration the more we will be in'c lined to choos~a high:
d~fllles the :lower- threshold. 'This '.is kno"Wn as the trea:.t:m~nt threshold: Th e more~ serious: a .missed:
qiagnps#.c or'.~thre$hold. dia~nosis, the l'oV(er will be the .diagitostic

Scanned By: C
 CH~PTER 2: UNDERSTANDING AND usiNG THEMEDlCAL UTERATURE ,, . 41
~------.,...:..,_------------~----:----------.:.----.,";;.
.,..
~.

threshold. This also t~nds to be "lower if the the risk of the. test is acceptable, and effective
treatment is medical (;_~n-invasive), cheap, and treatment exists. 31
low ris1c of adverse effects.
This exercise will lead you to use and assess
4 . Will ~tients be better off as a r esult of the test? artiGle .on the accuracy of diagnostic tests. You
now h~ve the profiCiency to make decisions on
A diagnostic test will be of valu~ if it fu:lfUJs whether the article is valid and a pplicable to .YO\.\r -
the ultimate criterion of whether _it acl.ds patientfs. You al:so have the understanding snd
information beyond that t?therwis e av-ailable and skills to use th e p.rb!>~t"ties of the test by.
whether this additional f..11..f0rmation will change calculating f<>r measur $ of acc:u raGy (like
.you.r m_anagemel:,lt strategy that will -be ultimately likelihood ratio-s, sensitiVity, . specificity, positive .
favorable-and beneficial to the patient.53 the ~ue and negative p.redic-tive values. pr etest and
of a test that is.. accurate wW be unmistak.ably posttes t pro'bllbilitie:s_) .a nd using them in.
.defmite if the follow:ii):g ceinditions for the target determining t 4e ap_propnat~ -strategy that will
di~rder are met: if left undiagnosed is danger.ou,s, ul!i:ma-ttly benefit your patient.

POINTS TO REMEMBER
_,.,. "/ :. _ :,..;.-j;~. . . ... ' . . . ' ~- ;
.:. -.~E~_~e-b.a~ mecticineis d~n~ as the conscienticus, explidt, andj~;~dicious use qf-t..~er.t ~t.~
':' '":- ~y_\9.1';~ te make deci~ons .e n how to provide ~ptitnatcare.to individual paueots: :r~i' ~: .. . -. ;.~.;~.

1
_
1-__ - . T~--practice H~M of involves integrating individual clini~l eXpertise ~~~ tpe best ava~~~e~~f
. -. ~;.SC.1.il.!i~lvldence and palkat v.aiL>es. _.-
- ':.
00

~-
. . .
0

O O oo 0 ~.::.t.:t . .
... O ~. 0 H. ~f'
0

; I:Leifjye:reasbns why we shouldpraetice EBM are as follows:-

.;;_ -. ;:?T ;.-!ih- ~:""~,:,.-..
:._1,ip_3r,J~ew evld~~ -is daity .:being ~ted wh~- l'fl~y - pos5ibly change the way we -~;.ptrer oot:l;':,:
-.-patients. _ - - . -~. : .--::
o Busy clinicians us~allJ. fc;!fl ~o ~the n.~w evidenca . . :;--
.o Because of.ttle ~t6regoi~; our know1ed.9~ be_Com_e~ otM?-~%1 9!:l.<!.:9;.!r J?ITQ.IT!':@n.ce.dedioei.
--programs:------ - - ----- ---
.
-o -sruaies l)$"vesnown1nat.aarnE3n's:riraci:~.~ DOt.-!mrx{)_y_.~_w.ith _continu!n9-me<1ital.sdUC;3tion
. -
o Evidence-based medicine has been shown to help clinicians ~eep abreast of the ever-changing
- in~ormatlon iil the m~ical litet<rture. . - .

Steps in the ,p~ of :evidence-based medicine

o Conve ct the information you ~d
into..-a_focu sed, -answerab1e elinical .q uestion. 1
o Search for the best evic!en~ th~t will answer your fpcused din~! qlle$tion,
o C ritically apprai se the evidence for its vafldity; relevanc e :and applicability to yowr patients.
o Apply if in cliniq:~t practice, taking into account the critically appraised evidence, our clinical
expertise, 2nd our patient's individu~l.biolo,gy, prefer-ence, and-values.
o Evaluate your perfonnan-e.

There are four fundamental types of ques_tions:

o Therapy: determining the outcome of different treatments on Its -efficacy in imprvviilg patient
condition or safety by avoidif!g _
adverse events
.o Harm: determining the effects of potentially harmful a gents on patient funQtipn, rnoc-bfdity. and
mortality . <'t;-
o Diag-nosis: determining the ability of a diagnoSlic testto differentiat~ between :t!)ose with and wanout
.a target ~ndin or.dh>ease ..:t..
o Prognosis: .dete-rmining the future course of a patient's disease fi-t

Scanned 8y: ~
 SECTION 1: .:BASIC"CONCEPTS OF HUMAN REPRODUCTION-

Questions on treatment or therapy are ans~red by randomized, controlled trials (RCT).

Questions ~boutharm can be answer~ t;;y RCT'.s and observational studies. .

Qu~stlons about diagnosis .a re .ansv.iered :Py $tudies ~t ~mpare the r-esults of a dl;3gnostic test in
question and:the aceepted go!dstandar.d ~n.d <letermining ltVhether the P?tients 'nave-the disease (target
I:
condition} or no.t

QuestiOns:ohprognbSis invOlve a stlJ.dy:~esign thatldentifiep patientsbelongfng.to a ~ftjCtilsrgrQUJ} ;_vlth

(}( withol!t fact<)r:S :affectln~ th~lt pftlgn6sis.

The ~ree basi.:cqil)ponents ot.a w~structured question are:

a The patient
o The interven~n ~nd C!Hnt~rvehlion
o The outc:ome

P~!haps-one o f.the'best sources ofE$M info-rmation is .the Evidence-Bas-ed Medid.ne Re.view frotn .Ovid
Technologies('N'NW.oVi(tcom).
. ~

- Medllne stands for Medical -Literature An~lysis al)d Retrievat'System Online. -1t iS a nlJ:9 ~ :dat'abase with
_.: .~ :.ov~r 't6:.mnr~n:r,ererenees~to;~~es:P$ilstH~<t:m niorethan '5;200 currentp~tl)ed~joumaiS;pci~>tiSt~~ .
' i;. iri"tt.e t!fiited St;at~~aril:f:Bo~.Otli~r:~s:' ... ... . ,. .. . . ;
"' to .. ,.. ~ ~ ..

MEDWNE' ~-the targe.st: coriiponent 'of. :f>UbM~ (hftp"tlpul?m~:govh tne freely.' ~ibJe.. online
d~ta:~ oft:iio:rrredical Joumaf$tion~and abStraCts created. by the lL$. Nationatbbrary-Of:.Medidne .
(NLM):,.. - : ': .
. . .. . ~ . .. .. ... . .. . .. .
' Th?:k~im'mtemet:usageQf~infotmatibn:tet:Hevalis;a:terr:rr:,i:bat.~ptu~s;lhe.~nce;ofca'~~t ..
in
The.k:eyxvords .medieall'nfPirnatJCspre ~e compon.ents in yourfiPmed que5tion, which :goes .tfi the
mn~il!C :P!Gb; ?op~latibri/patient, Jnterv.er'ltion; Co4rltei'Vention; :arid "'uteeme- ,
.. . ..., _ .. .......... .
MesH :arns~~;ot~:o.t tern1snaniffilffJescnprors 1name-ra:fehrcat:tructure tharf:)ertnitS:seafthiA9 :at
van.ous {ev~ls .C)f &.pe~frcity_

Criticai :?Pt:>rai~.has peen.fi.ned.as:,tneprocess.bywhich.oneus:espredetennine9 ritena'totationally

evai\;Jate a publi~hed. aiticte oo'the~py, diC!gnbsis, prognosis, etc.

The 'three bi;!sic qve$tl6.n~:inthe c.rltieaf ~pprais-a! :bf theev}dence on both :therapy and d,iagneSis ar.e:
o P..re.the..r.e's.u:ttS;:ot~the .~9y ~alid:?.- . : . .
o 'Nhat ate 'the.Je51.flts?
o How can.i aP.plytrrese results .t6.1'f1Y pattent?

Intention to tteat (ITT) anal%, is is one that is b?sed on .the initi.al treatment intent;.not on the treatment
that is eventually $ d:ninistered.

Thedifferent.r'rreasures ,of 'the effectof treatment are

o Absolute risk-reduction
o Relative risk
o Relative nsk reduction .
o Number needed tO treat .
.j

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 ; /.

CHAPTER .2: UNDERSTANDING AND USING. THE MEOlCAl

. LITERATURE
.

rhe reference standard (or gotcf standard} is defined as a method having an established ~ ..;dely
accepted accuracy for detennlning a diagnosis, providing a standard to wnlcti .a new screeolng or
diagnostic test can be compared.

The pretest probability is the probability of the t-arget condition being present before the diagnostic tests
are .avanabie.

. The postt.est probability ls the'ptobability of the target condition being present after the results of tb ,._
diagnostic test are. avaiiable.

Measures of d1agnostic accuracy include

o ,.:4Jkefthood ratio
O SSJ"lSitlvity
o Specfficity

I o
o
POsitive predictive valu~
Negative pr-edictivE value

Ukelihood ratios > 1 increase. tJ:ye probabillty that the target disorder is present Ukelihood rmics -< !
d~~~e the probability that the target disorder is present ,

... . ~ ::.<'S~~in:ar;d SnNout. if a test h~ a vary high ~peciftcity, a .positive result. effectively.rules int.l1e..P[<.Joo$is.'~ .. ..
.. '~ ...lf-8-~thas .a very high .sctJsi~vity, anegative result-effectively n.lles out the .Qi;:~gno:s1s. ":-";-~~: . . '. ~~-~- .
,., . . ~- .w \'! ' '':' ~1~:... '

. ...
-:~

~: t....._.:.v~' ~ !" ...~ .

.. ,..
...~<::ES
~ l:;~;~ck~jp~~~~us SE, Richard~n WS, Rosenberg W,
Haynes RB. ~dence Based Medi.c1ne: How to Pntctice
and Teach EBM 2nd e<!, Churchill Livingstone 2000.
:.~.
2. EVi.aciice BaSCO. M'eaH:me Wol::Eng :c roup.
. "'bas~1t'mc'd:lcln.e: Jt new approa,iili t9~leaclif:iigtlii
practice ofmedic~e:.JAM:A 1992; 268:2420, 2425.
3. Oxman A. Guyatt GH. The scien~e of reviewing
researi:h. Arin NY Acad Science 1993; 703:12S 1'34.
, .
8. SackettDL, Haynes RB; Taylor DW, Gi.bspn..ES; .l>~..s
RS, Johnson At C:licicai detenn'irrenis;<>tt:he~
to treat prl!nary hypertension..Clin Reri!D7.
. .... .. 2. ~-~-:
4-:~- ..,.....;...,_ .
9. OsheroffJA. forsythe PE, ~<;:ll~-l}G,-~
RA, Blumenfeid BH. Mill(:J' RA.. Physicia:l~ ini~n
~V:dence n'eeds:a.nruy!#:S "ofqq'~s~s p:Qse<i"aiin:Iig'.tSi Clinical
tea-chi.trg:-~-liitern'Me<r:r?9l;rr<i:-57o:.ssc " -....
10.. Covell D G. Uman GC,.~anningPR. Infotm.at.ion.needs
in offic;e p~ctice; -are they being meG .Ann Intern .l,{ed
I : 1985; .103: 596-599.

4. :\nt!llan EM. Lau J, Kupelnick B, Mosteller F, Chalmers
' T.C. A com parison. 9f results of metariV\aiysis qf
rando~d control trials -and r;ecommepd'ations qf
cl.i:nical experts. JAMA 1992; 2.68: 240-248.
5. Davis DA, Thomson M.A., -Oxman AD, Haynes RB .
Changing ::>!:lysici.an perfon:nancc: a syst~matic review
of the effet of continuing medicru edu cation strat~gies.
JAMA 1997;274:700-705. . 13. Guyatt G and Drummond R for the~Eviden'ce~Based
. 6. Haynes RB. 'wq~re:'s the n:iea't in Clinical jo~rnals?
{<:di.t~riai): ACP Journal Club 1993; 119: A-22-A-23.
11. Ely JW, Osheroff JA. Ebell M,H, Chambliss ML, V'UlSOn
DC, Stcv~er~, e~ al.Obstacles to ~doct.crs
questions about p atient care with evidence: qualitative
study. BMJ 2002; 324(7339): 710-716. .
12. Quote in Pickering GW. BMJ 1956; .2: 1l3-U6.
Medic~c Woz:king Group. 1Jsers guide:~ to the.medical
liternture. E;sSentials u'f eviden<;e-ba:sed clirUcal practict:;
American Medica). Association Press 2002~

7. Evans CE, Haynes RB, Birkett' NH, etal..Does a mailed ~4. 9Jqllan AD,Sackett DL, Guyatt GHfor the Evidence-
c.o ntinuing. educatio n program i..mpr-ove clinician base~ Medid.r~e Working Group. USeni~ guides to the
_perf-on;nance? Results .of a randomized tri~l in medical literature I: How to get -started. J.AMA 1.993;
ant.fu.ypertensive care. .JAMA 19.86; 255: 5~1-51<( 270; 2093-2095. . .

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15, Richardson WS, Wilspn MC, Nis.hikawa.J, Haywani'RSA,
The well,builtclihical qt:.estion: a keyto evidence-based
!lecisions...ACPJoumal Club. Nov~Dec 1995;i23:A-12.
16. Coomarasamy 14 La.tthe P; Papaioannu S, Publicover
M., Gee H. Khan l(. Critical!:!.pp.raisal incl.iniCal practice:
sometimes irrclev911t, occasionaJly invalid. J R Soc'Med
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17. PauLJ, Seil:: R, ~~tt 1'. 'I'll<! in~et lul:d ~
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7(!}.
18. f{owe W. A brief his tory .()f the Internet. 2004 I2oo4-
~ A~t \(\j. n~tp"-//wvtw . wahhov:e.coru/navnet/
'h istmy.h1ml
19. i-a~ss:e M...La.i<:rtu'n.e V, Ba:l-t:k tt L. Guimo~d J.
Answerin.g qini9Sl que~tions: what is the be;>t way to
~the web?CaniUUAn FameyPhysician'2007;-53:
1.s3S:.J:536.
2Q. bttp:ftWWV10:vid;j::OID/ site/ catalogjbataBa.&e/90~.
~.
..
. .22;.' http:/jww:W-:.nlin. n ih.goqv.f pub~ /fact s hed'fl-/
. jn~e...html~~; . SChuster 1.995.
23. Se&ch :abatefor.otop to -~- engi.nesftoin Nellsen/
.. : -~et~ .().t..26,.20.07.. .. : . .
21. htti>:l/WWW~..nih-&ov.fpubsffactspemflJ'esh.html
2008 .
; .... ~ . --
2S~ -~CM~1-& pnr.erstfY ~O.i'aii.es; ~~utliurs-; Electroruc
r e.aourc.es, 20.0~2' 12.0.02 May 4t. http://
.WWW.m~er"ca/honizyit~/resear:cb.htn.
26 H.8.nnah MS Hiumah WJ He.ws:on::s~ Hodnett ED
Saigal~. ~AR. Plru:in~d-&ie~~tio~~ertu;
planne~fv~b1rtb. fot;" bre~h .p~set).t:f!.ti9n. at t~~:
... a . r~do~!le.d m\llticen~ t..rial. _-il'e(!n .Breech ;rruu
. COUahoriltiVe ~f'9up. 'lAncet fl~; 356{9239):1375-
. 1'383.
27. OXID.an AD, ,Sackett DL, Guy~tt QH. For .the_EVidence
Baud Mcilicine .wo~ng Group: :u sers gui4e to the
med.ical.lite~ture: I How to get -started. JAMA l 99l;
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13~ Grecl;l,halgh. T.. l:tovj to read a paper:. Getting your
bearin~ (de?ding whs.t the paper is about): BMJ 1998;
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29-. Ouyli.tt GH. Sackdt DL,;Cook QJ. For the ':Evidence-
Based MediCine Working -Group. Users' guides to the
.medical .iitciature. Ii. How to use. an arti~le a bout
therapy .:or prhention. A. Ate;..e ics ulti'or t he study
valid? J~ 199.3; 270(2 ~) : 2598-260 L
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medical liter~ture. II. How to use an article' al>Qut
therapy or prevention. B. What were :the resul~ anc!
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271(1): 59-63.
31. Jaeschke R, Guya tt GH, SackettDL. For:theE viddlce-
Based Medicine Working Group. User~ _guld~ to the
medical literature. Ill. !Iow to use an article ebout a
diagnostic t-est. B. wha! are the r~p.lts end ~-they
pelp me in caringfor m y patients? JAMA 1994;.2'11-t9):
703-707. .
32. Jaeschke R, Gu;;tatt 'G, Sacketd~L. Forthe Evidentt-:
Based Med.idne Working Group. ,Useis ~ .to the
medical literature. ilL How t.O u~e ~.article bout a
diagnostic test. A "f'ue. the. I"e:JUltis_-cif'the t!Udy valid?
JAMA 19 .94-; 271(5):, 389-391. . .
3 3 . O~an AD, Cook bJ, .Guyai t GH. F.or the EV$1enee
Based Medicine vi.ork'ing.G~.P.- Users' ~cil.to t he
medicru .l ltelilt\lre. VI. HQw to p.se an av~. jAMA
1.994; 272(17).: 1367-131 i.
35. Moore T.J. Deadly Medicine. New Y~rk, NY: Sim.:on .&
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.21~'(17)~ '1~$7~1'37!'.. . . . ..
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V .tor. the };::vidence~b~dJ&.eclii:ipe W9rlcinf Group.
U sets' -guii:kstothe m.ed!.c alliteratur,e . iY: H<>Wio use
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trcatprinciple.. Cpntrohed Clinical-TzWs .2l(3):1~7-189.
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3 9 . Latipacls 14'Sacket D!-, 'Roberts R~. 'Ali asse.S!Illlent of'
cliniCally tise~l m easures .qf the co nsequences of
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C
 CHAPTE:R 2: UNDERSTANDING AND USING THE MEDICAL LITERATURE 45 .

43. McAlister F, StrausS, Sackett D. Randomized controlled
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._, .
~- .-> . L ~

.. _....... ..:
~

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~

........ . - .: --
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Seanned lly: C
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Scanned 8y: ~
 3

ANATOMY OF THE FEMALE

REPRODUCTIVE TRL\CT
RAUL 1\-L QUILLAMOR, MD....
ESPERANZAN. CARAGUE'- LANSANG, l\1D

Em~ryology

E:x1empl Genitalia
V~lva
Perineum

hitemal Genitalia
Vt;igina
Uterus :a nd Fallopian Tubes
Ovaries

_Bfood _Su-pply and Venous Drainage

Seanned 8y: ~
 . 48 SEClJON 1: BASIC CONCEPTS OF HUMAN REPRODUCTION
..,.

'El.tBRYOLOGY oviducts .(fallopian tubes)., with their ftmbnatecl .

. . . G ends, orQstia, openin:gin.to the celoinic~tontal)
. nuring the first s ix weeks of development, the cavity. The f~sed.:caudallongitudinal segmentsof .
geriitaf system in both male and fem~e embryos the paramesonephric ducts form the uterovaginal
.3te:shnilar and are potentially bisexual due to L"l~ canal, whiCh tater deVelops into the epitheliUm
px:e:sence c:if two pairs of genital ducts: the and .g lands of the uterus and the upper V!t.gina. :
: m~sonephdc (W olffiail) and paramest>nephric
. (MUiierianj ducts (Figure 3.1). This indifferent Tpe lower portion of the vagina is derived i'ro,n
. -s~$~ persists until the :;eventh week of ~e urogenltal sinus. The .solid eaudal tip .:n f.U)e
. deVclopm~nt. pataineSc>nephric ducts Teaches the posteri<>r\v.:'_a
oftljc :urogenital sinus :ahibout the.n..intb ~k Of' . .
<ievel~pi.lient. Fr9~i,he\ir'O~~i4~l smua-~'tbe
pail:e~(:$iilo"v11&in~butb~tJj~t,fli~.lVi~.~,~ ' ~-~
(
conL't.bi~'lj4~):iiofm~mxoo$4~
:
. p o" " " " ' " _ . . . . . ,. . . . . ._ . . . _ . . , _ . . . , . . . .. . . . ._ _. . . . . . . . . . . . . . . . . . .

. :.. :
. .. ,..
.
cdis:(orihs the ~ plate, -w:~clt c:nwd.s tJ;Je
~
: . . .

solid end of the utero$ a:nd.develoj>s a lumen.ttile .

cau~al end. I.n the . me~ntime, prolilet~~()~
continues at the cranial end of the. plate~ ~t
increasing the dis~ce -between th.e lu:rnen #!1h.oe
" . '..
end the uterus .and that of the urogenital :~~ .: ..
By the twentieth week. the Vl;l_gLllM out~' ..
becomes.entirely ~. "J;'he eXpansionltQf:tbe , .
. plate:aroundthetndof:the,'lotems.forin.lru:~,.:~. ::
fomices.-Theiumenotthev~ttrentairisse~ :
from tha~.of 'the vagil).al sit:tus by a. thin - ~ '
pl~, the h jri)en. . . ' .. .: .: .
. ' .:: .
In . the abs~nce of testostbrone,.. the.ri~ .,. .
me.$()~ep}?.rlcA ~y~m:\d~gcme~ ,_ in...the .:~ : ..
embryo. The functionless :tetnilants 9f the -~: .
.. , ni~.-pre~nce -o f the !estis deterttlinblg factor, group of' tubules - th.e e;Wcil)hof'()n,_a:nd the ~Y!!N'
. ~uce.d~b nie somatic sexc ora celis:a.na:encOded group .;. tlre parooptlor6tt, are locatechvitbfu1k:
"on the y.~iiiosofiie~ resiif&-In Uie.di!ferentiliuon. mesosalpinX: Vestigesoflfrcn:au<:b1tpt;rtm'ni:>~-
~f;e, .~e embryo .a nd""the development o.f the mesonephric duet tOann--s duet) may~ rol.Uld
.: ~nephric ducts into the male -genital tr.act, any-Where between the epoqphoronandthe~
wJ~h .s ubsequent degenerat~on 6f the and may deve lop later in life a$ a cyst (Ga.i:tn~
. ,~e~nephrie d~cts. The sem.it)iferous cords cy.$1':) in the wills of the vagina o r the utero~.
Jotm ibran<:hes ., with .their ends ~astomosing to . ....
. ;f:~~ the .rete. testis. The CQmmunicati9n of thf! purin-g the hidifferent $tage of genttat., .
-p;l~;Jlep'h..~c tubules with the tnes<>nephric dl,lc:ts development, at about the fourth week, there :~ !
'ft).rih-s the effere nt dl,\ctules, whereas the active proliferation of me-~ ertrtal cells ~U.n~f
me-sOnephric ducts ~orne the epididymis a nd the cloaca! m embrane. This produ ces the genital
~ ;:de!erens. Th~ mesenchyma l 'Cells give rise t o tubercle cranially, and the labiosc rotal .SWdly;t,&S .. .
tl: :int,erstiiliU cells oi Leydig. and urogenital folds laterally (Figure 3.2t.. the .
phallus d.e velop s ~s .the gen ital tubercle elong~.t.~
in the absence of a Y chromosome, the testes, Fusion o f the cloa cal membra ne and ;the
.an4the anti mullerianhormone (AMH), the embryo rectouterine septum occurs a t the end of.t he -siXlli . .
:.dUferentiates into a female .~ nd the week. Rupture of this membrane forms the anus .
: : ~esonephrlc duc~s develop into the f~male and the urogenital opening.
",gei iital tract. Prolifen;).tion of the cells in the middle
t nms.verse portion of the para mesonephric ducts The external female g~nitalia develop abOut. at
as .they .fuse . in the midline res'l,llts .i n the the njnth .to the twelfth week. The phallus deV-~lOps :, .
peyelopmeilt -of the uterus. The unfused cr anial into the clitoris with its glans and p repu<;e. The
portions of these duc ts eventua lly . b ecome the urogenital folcls . become the labia minora and . .

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 CHAPTER 3: ANATOMY Of THE FEMALE REPRODUCTIVE TRACT ,,,., ; 49
--------------~~----~--~--~-----------------------------------------:=
~:u

remain unfused except anterior to the anus. The The labia majora are two elongated -swdlings
laterallabioscrotal folds form the labia majora and that are lateral boundaries of the vulva. !hda:bia
remain unfused except anteriorly and posteriorly, rp.ajora converge anteriorly at the mons p.bis to
to form the mons pubis and the 'posterior labial unite at the lower border of the symphysis pubis
commissure, respectively. as the anterior com111issure. Posteriorly, tbdabia
majora do not unite. However, the forward
The ovaries, like the testes, deve:lo.p in the projection ofthe perineal body gives the appearance .
v.rogenital ridges (Figure 3 . 1). The ~artiest sign of of a posterior commissure which .lies bet.Wetn the
a .gonad appears at about t he r ourth week of vagina and the anus. The lateral sudace ftl the
development on the anterior :s urface of the labia facing the thighs is hairy, Their smooda and
embryonic kidney between the e ighth thoracic medjal surlacesare studded with sebaceous~ds
and fourth lumbar segments. The two gonad~ are and enclose the pudendal cleft. The round.lijanent
indistinguishable during the initial phase of of the uterus enc;is in the adipose tissue' tuid Skin ;"~
-d~ve.lopmen,t. Female . se~al differentiation ofthe of the front of the labium. The labia ~ are
.,e'Iilbryo results in the prolif~r~t.ion and thickening homologous to the two halves of the scr01al10ac
ofthe coelomic mesothelium (germinal epithelium) and the subcutaneous s.mooth musclddn.~.
and me~eu~hymal cells. of the intermediate are homologues of the dartos. The ~ .or fat
m esoderm, forming theovari;:m ccrtexand :medulla, beneath the skin is supplied wli:h a plrurusti'veins
respectively. Primordial gen;n cells, deti'Ved from which inay rupture .as a result of extemali;jury.
the yolk sac, invade the c:ortex wnere t.~y undergo
Jllito~s .Gnd. even~aJ.ly develop into oogoilia and The labia minora ar:e two thin folds till :skin
oocyteS:. .;.: devoid of hair and .subcu.taneo~s :Ja.t,.J~~~ly
supplied with blood .vessels and neyve;~.
THE FMAL~ EXTERNAL GEN!TALIA They flarikthe vaginal orifice andd.iveig~~P.Y
to blend with the labia inaiora. A transv.ersie~ 'Of
The female external genitalia is collectively the skin, the fourchett~, passes betw~ .i he
referred tg as the vulva or pudendum. This incll.id,es posterior tetminations Qf the labj~ . oi-a .
_the.mont'PUbis,labia majora.anc;l nii.n,ora, Clitoris,' Anteriorly; each. labiurnniinus diViaiS, .,U.W.~two
bulb or= tiie vestibule, and the vestibule of the
small folds that e.'ttend above and below~~.~tal
vagina 'iilto which open the ,o rifices of vagina, . extremity of the clitoris. These folds1 u.nile--i<with
urethra~ and ducts of the paraurethra,l (Skene's) similar folds ofthe opposit.e skte to f'olll!~1Jy
and vestibU1ar g!ands (Figure 3.2,, the prepuce, and ventrally the fttnuhim. the
clitorrs.- -- ... --. .... -- ..."- ----. - .. - ~o.-
a
__..___....
' , ~ ., - - Ro o - - - ;,,_ , __ ..., .

The clitoris, an erectile organ co~g.

anatomicallyto the. male I>nis; is COJll.poli!ld .of..a
body, two crura and a glans. The body, f~ by
the union ofthe crura, is entirely eml,>eddeiin the
tissues oi the vulva and suspended from tbepubic.
symphysis by the suspensory ligament; Tbea:Ura
of the clitoris .are attached to the perineal.-d'ace
o f the ischiopubic rami and -to the ~eriorlayerof
the urogenital diaphragm. They .are.coveredby. the;
ischiocavernosus muscles. The glans is. a small,
rounded elevation at the free e nd ofthe bocb':- Like
Figure 3.2. The un<:lifferentiated.external genitalia: Genital
the crur a, it is composed 9f .erectile ~ and
. tubercle. contains abundant sens()ry nerve ending;s. It is
extremely sensitive to touch.

Paired elongated m~;~.Sses of erec~ tissue

The mons pubis (mons veneris) is the forming the bulbs of the vestibule are ~ at
subcutaneous fat anterior to the pubis symphysis the si<l.es of the vaginal orifice and are .a,~ed to
formi.t'lg.a rounded me4iah eminence. It is covered the s~perficiallayer .o f the Urogenitai .di~gm.
by pubic hair and is largely absent in the m ale . . They are c.overed by the bulbocavernosus muscle.

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 50 SECTION. 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

. ' !-t
Each. 'b ulb -is a homologue of half of the bulb .o f the tuberosities,_ postetolaterally by the sacrotuberous
pen'is an~ the posterior part of the. c.o rpus ligament, and posteriorly by tP,e tip .of the coccpi
sponosum {F~gure 3.3). An arbitrary line dr.a,wn between the ischial
tuberosities diVides the perineum into an anterior
~ogeni.W triangle and. a posterior anal triangle
(Figure 3.4). The urogenital triangle is occupied .b y
the vulva, the .telfllinal.portions ofth<! urethra and
vagi~a. and the urog eriitcl diaphragm; whe~ea'S
the ana! triangle .P:rincipa.ily contains the paired
ischjorectal fbsS8.e and the centrally lotated ~al
canal.

~
\
.. :
\ .....
' '
r----~~\,__.+-f lf.c!<t:.l""'-- .I
:Tll~sr*~'P.9r9-er~:l:>y-!:tbe". Iaoia.nlin.Qra.1,;>;fue.~ ... . ~ ~r-~~~
V!!stibii1~;;6f~the'" ~'gi-nai-:.'Fn:e~apte~tJ.~oft,~e::< ..: , . . . ~!-..~ ~ 5
.:C:~o=!:.:f:J:t~~~~;,::-~ .
.:()t;l-~'skle:~>f~ oiifi~~ -e fuly-~gsof.
.thej~~~~glaha~t~~~e}.A~~ , . .... ..
.P?~F?~~-ih~,~~;6~:~.th.~:~~-~'fue; .~ . ... . .:..:. '-:-~'-'a""'.-.4""':Th..,..:~.e-.-~.."""_,.cin"'
- """ehl-'"7i-nan--,
~"". .......i1-es
-.. .; . .,:-: .~..:........._,.;-:.--'-....:,;-;.~
~ ~Jcti~~a,s:the-..m~$1~4l'(I1S"~::<;.~ , .... .:., .... ........ , .. .
. iri'-':the ~,.~-:.a~cresd:mt.-:~ha:p<;d~:tmro~:, ..
merit~ tile ' bJm,~p:. ~Jill$ -~8 riluen ' ~
's1~a!>eana-coiisisteD"cy.-:1fiti~dm~rfomt;:it-Jnust 'The su-~rlicial fascia ,of . the. .p ecln~um''.1s
oitiaSed att'liefiliie ofput5ettyTo'PrtNi:4e-eiltfor.- somewhatsimilar i.J:): arrangem:ent-tot he4oubie:-
the ~~~trual :flow. After the . hyn;ren~ ~ been layered superficial abdomin:ru .fasc-ia, having a
r\lp~ .' by coihiS or:
.by Other means, .it lS superficial fattystx:atumand,a deef>er mem.b.ran.o us
rC9~1 .oru.:J .as ~mall tags ~of the m~cus layer. Aqterlt;>.r ly, the superfiGWlayer 'is.continuous
:nie;nibrane; the -~eula.e: myrtifotnles'.- ~r~tet above .with' the ~uperfidal fa~ty la_y er (Camper's
-ve$tt~~e:r .gtaJ?-ds- {of :B'artho~} Io.c:ate<l .are
fasci,a)~fthe. }owerportion offu.eanteriotabdominal
bil.ateri$r ~t'the.postrior :p ole:c:>f tlie bulbs 0J.fue wall. The de~p'i~yer.(COlles' fascia) is cont;inuous
v~stibtil~."DU:ring .coi~s, lhey are-?>m:pre~s- :to above w.ith the de~p layer .of the superficial..
tele:8.se a mucus-1ike ~crdion to lubricate the abdominal fascia (SCa.rpa' s fasCia)' and is restricted
kiw~t end-ofthe;vagma but t his does notcoritribute 'to the urogenital triangle. .
tO the nortn:al v.a:girtal 'lub.Qcation. ~ey at:e . the
h,om,;;lo~es'ofthe bulb0urethriU glands. The ducts Two potential spaces can be identified within
rn~y harbor bact~ria ~.g. gonococci arid cau .s e a. the UrQgenital triangle: the superficial f?,ll.d de(!p
Bartholih :gland ~bscess. . perineal pouch es . The superficial pou ch lies
. betweel'). the Colies' fascia inferiorly and tb,ep erineal
'

membrane superiorly. Jt contains the crura ofth.e

The perineum is a diamond-shaped areaoat the
lowa end of
the. trunk ~tween the thighs .a nd
bU:Uod:a..Jt.-is .t he outlet o f the pelvis.and includes
-all ~chir:es inferior t0 the pelVic :diap~go,l~ It
Is oounded.anteriorly by the p~bic' symphysis ,and.
the .a rcuate pubic ligament ) ariterolaterill,ly by the'
ischiopupic rami, 'laterally by the ischial
clitoris, the greater vestibular glands, three pairs
of the superlicial perineal muscles (superficial
transvers-e . perineal. bulbocaverno.s us, .and
ischi.6ca~ernosus),. and the s)J.~:l;'ficial perii:{eal
v~ssels arid nerves. The deep perineru pou~h is
essentially the .ur.~genital diaphragm with its

Scanned 8y: r-.

~
 ---~--~___:,:.......:___:.::__ _ _ _ _,e____
_FEMALE
CHAPTER 3: ANA10MY OF THE_;,_ REPRODUCTIVE TRACT
_ _ _ _ _ _ _ _~---..,..-~---__,.....
.: '53
_ .')<:

The ratio bet\veen the length of the uterine consists tnainly -of longitudinal muscle fibd-s; but
body and the cerviX varies appreciably with a,ge. may also contain some circular ~d .oblique
Before. the
on:set {)f me_p_struation {premenarehe) bundle~. During,pregnancy, myometrial :tlndcness
the ute~ body is -o nly -half the len~- of the increases '6igni:ficantly _due to two major d!ange~
eervix {1:2j, but i.-1. nulliparous adult women, they ffi the m'l,l.~le fibe.S: hypertrophy, wi.fu,in;ettase in .
are about equal in lertgth {1:1). In m:u ltiparous size and inte~locking of :musCle .fibers. and
women, uterine lep.gth is .about thri~e that of the hyperplasia; 'With increase in nunibe'r ofmuscle
cervix (3:1) :a nd .after cessation o f menstrUation .cells. Th<fhyPrtr{)phy a.n.Q. mterlt>eking:-of.muscle
{postmen~qpause.} ~ uteri_ne size decp~ases cells are ofgreat obstetrlcai=impo$J1Ce :bbcause
considerably due to atrophy of the rnyometrh.i'm they pro.mot~ ff~tive uterine contraction and
and end~etrium. . . : contr.<?l. hemorrhage. The 1lt.t!rine serosa-is-derived
from the peritoneum and posteriorly . ~ the
The uterus is- eotn_ppsed of three layers: the entire ~iestillal.surfa...-e <>fthe u~rus. Antr:riorly,
inn'er. mucou~ -meml:mine {-endometrlurn:), 'the it in~estli tl).e v,esical surface ofthe n:terusorily as
~ muscular layer. -{myon1etrium), ' and the far as the isthmus. .
e:xten:Ud ser6$3:. r-Ile e:O:dbll1etrim#, :a.soft, spongy
layer .that l ines 'the uterine .6 vity; .i s 1ihed by The cerviX is a barrel-shaped stmcture-
CQ~~pithelitun 'l:rildcontitins tnanY tli.bula.t- measuring a.bout 3 em long. It extends:JtUn. the
,giahd~ thafUet'te -a :fliirialkiiline fiuta to' keep isthmus cf the ut..;rus to the upper po~Qfthe
th~ '**-4,vicy 'mpiSt. Tq gllind~ ~d.. sti:Qiri.3. v:agina into which it pretrudes, forming an iU'igle ,_ '
m
..are . -~ ""9.Q.M'!.li9:us pwcess of alteration as YaJYing .fr'Qm 45 to 90 -degrees.. It is thus divided
inll~teff<:by est:iO:gen and prdgesterone: .B~fot:e jato a s'upravaginalpot:tiQn and a, 'v~]SGdioii
ptiberty.. \the ~lls '- ~e cilisted~ but due t-0. its (p.ars -'V:8.girialis): :At tb,e ;teiminatiQni{Of:\~~pars>:- .
pe.dOdk '(lestiuc'tin Q.lliing ~(!ll'S.truatiqri anf). vagL~)si:heopeoh.lgintO thevagina}we~: ;'~.
-~~cy, it is J~ely_ n~-dli3.te9: iO fue ~dult OS . -The -ceriix is Ce'VQ}d _Of se_ro'~ except:~e~
utei:us ..the .e'ndo'zn.t;riu,m u -.ndergoes cyclic -$Upravaginal -portidn-tx>stcnorly; -~ !t,fri'tm:s ~
~tes~g eaCh.J:nen$t:i:ual cycle. 'i t is-:a.nts :~~ a:ri~~-r ;-_a;n.o f~erecto
..~t~'tl-~ -:-. _ _. t~t.?P~.i--~.~-~~
.
_u .-. -./'~y
'.,:___
.- ~~~--~_~_.:_:_._._'
~f 'foliO#.ii:g -riin~ati.on, but . _
,fu~'to as much as 7-1 o mm just ptiorto-the Th<; certi.Cal-cru)a:lis'liri.edby: ciliat:ed:\fnhtm'harJ
next menstruation_ In the early phase of the cellsin:itSuppe:rtwo-t:rosorSUprit~pO.tfori:'
menstrual cycle. the ,~ds are -straigh~. the but ~l~.o/ ~~~ i.~,-a.'P.nl:PtlY- ~ -~ ::~~
- ~p_ffl.ie:P.'lW Jow cliboi<4ll,- and the str:0m:11 dense. . ...~uamous epithdi\tni
=.:b .... ~-~----~ ..........- ...-,close
-.-..--~ to the- ~ -M:i-lhl-0~. _ .
- Bet~.. fu'~-nren.:srrtrar=.pn:ase; Ui~ gl'anas -:Decome - .J:!ll~ ~ition wintis-l~.the_~.
-~i:tuO:Us and; CQnvolut~--Hie eellsa.re--:eoluwar .
junction and is -c linically important !>ttaus~ .
.andruglily'SeC:tetOcy.- and thestroma is ab:undant -squamous.cen carqnoma ofthe -Cervix. ~M:ommon
:and !o9s;e nr t:P.e. superficial -layer~ The ~upetficial geriiW tract $!leer, is most _mce;ly :to.dadop in:
functionf;\.1 layei' '(:z.:on~ functionalis) of the this region. N~l:IDel'OUS .d~ glanQ.ulai':'iiliCle"s .
endotD.ettirun.'i~ :Slied--off viifu variable quantity_ of which 'secrete a, clear, -viscid, alkaline-mucus; are
bloOd, c6nsti.h1t!ng the inensi::rual flow at the end scattered :in -the mucous membrane of the upper.
of~;::b. cycle: The ba_sallayer Of t;he endomet_fiuni two t.hii.ds -'o f the -ce~ Occlusion ..a,nd distmtioh'
(zona basalis) is not shed and re:p::~ains intact, with retained s-ec.retio:n 'Of these follicles 'result-in
proViding new ce:Us for the regeneration of the the formation -'o f Nabothian cysts.
-functional-layer.
. .
' .
The ute rus is supported and ..hld in p lace by
The myometrium consists of interlacing several ligaments, namely: one -anterior, one-
b undles ':of smooth muscle fibers that forni the 0 . posterior., two .b road, two -transverse,ceiVical, two
due{bulk-ofthe uterine :structure. It is thick and round, and two uterosacraL 'rheanteriorligament.
is .~ntiliuo~s with the muscular. layers. of the is the vesi~outerine fdld .of peritoneum 'that :i!:;
oviduct~ and vagina. It has U.tree indistinct layers: reflected on to the bladder from the front of the
e-Xternal, mJdaie, and internal. The thin external uterine isthmus. 'The.posterior ligament.isiktived
htyer is tMde up 'Of transverse muscle fiqers that from 't he rectovaginal fold of the ~ritonedfu. The
run a,cr~s the Jund-ps. :The tni4dleJay'er--is the. broad lig~ents~ derived.froni -the peiiton~ fold,
most vascuiai and is 'made up :of thlck musCle are made up of.~terior .and post~rior la%& and
fibers that are ~cularly .a rranged. The- itmer layer are -<;:ontinuous late rally. with the su$pensor:y

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 Si;:CTION 1: .BASIC CONCEPTS OF HUMAN REPRODUCTION

. ~

ligaJnents (inf\mdibulopelvic) of the ovary. The uterine tube, giving rise to an ectopic pregnancy.
denee connectiVe tissue below the base of the broad Ruptu.-e of a .tubal pregnancy is accompanied by
ligament located oneither side of the cervix is .the heQlorrhage and requires i.Inmediate opemtive
tn;msverse cervical ligament, also kriown as .the intervention.
cardir.al ligament .of Macken.-odt; 1t extends from
the cervix to the panetal pdvic fascia and coiltains The oviducts consist of three layer-a; ~
the Uteru,e artery, veins, and nerve pl~se~. Tl1e mucosa, the muscularis, and the. .s erosa The
round ligaments are long, fibroJnU$CWar ban,~s. narrow lumen of each tube i~ tilled ~y n\ltlie!ou~
derived from the genitoinguinal ligam~t .a.."ld ~ folcts ofits ciliated mucosa. The mucous merri.brane
Situated between the layers of the b.-oad ligament . consist~ o{ a!) .epitheliutn and underlying
anteroinferior to the oviducts. They are ~e onty cor..ne.tive tissue containing blood an4, lymph
uterine ligaments t.'lat leave the pelvis via the vessel$ ila"ld nerve fibers. The .epithelium ia made
a~omlna! mg-.fuiru .ciWU to temlln.ate in the Ja.l;>ia up. mainly of ciliated, cc;>lumnar ~pitheUutn.
Jnajora, . irt which they becom~ ~blit~ra..ted. Tb~ . afthou~ .~~ceUs<are ,~fo.ry arul not c:maied. .
uterosacral ligaments, derived frQm.tbe.lvicfasc;i$.. lt is critinuous with the mucous linin$ f)f e
ext~nd. from the posterolateral surface <>f the eervix uterus and at the abdominal ostium Of the tube
to the -anterior.surfa-ce of the sacrum. with the P-ritanewn. The musc\rlatis consi~ .c)f
an :.bmer citcular.and bU~.er l~tudinal P'04P of
OVIDUCTS fibe-rs; howevr., an. innerlon.gitue!inru. ~oup. Q.f
fi~r-~:~ may ~pe$" in ~me ~s -of .t ljc tU~.
'llle oviduts {uterine .~bes. Rallopi~ tubes) Previous .stuclle.s h~ve showu tl;tat :ilie
tubttl
are'triUSC\tlotubular~~trt.tctureS!;,ll1easw;m,&ab().ut. D1U.SCUlature. :cQn~tahtly. ulet:g.()e ..Jty:thtnic.
lOt6~1~~long-and\l~ted'betWeen~tbe:~ym;ot.v <'oontraction~h~illC::f:a\: ; o~.:'WWcll;;~~'~, ;ib.e .
the up~r, 'oomer of:the; bro&.~i.)igament;~Th.ey. ph~$C~ of .,the.:,mens~ai . -cycl .. the ..~te$.t,:.
extend fro.Dl the .sup.."""'ior 'artgles !>ftru!.:il~r..;.!'J :to . .~uen;;:y and,intensity,.ofUl.C#.tOtt~$~ ;
the side.cfthe-pe}vi$lind thdrat\ti~Q..f:Onn~.tAe a.t;th:etime when t he o va ~~e~i1Jg \be tube.._
utefus mththe perit:oneal:qtvitf!of;fhe,abdoat~n, artd ithe, slowest...a.nd.weak.est.i 9~t.ractiomp).<':.cu~..
{l<"igriie:3.7.): Eacir tube tourses:;la:terailY.trom: the: .. . dUring f;p~gnancY~ l)lc... ,~ernat :, ~. :~et ~ .
uteros:to'theutcrine :poletof<theo~t().arcliover- " . . ino)ud~ .fh~.'~~riwn~w:p.:.~d;.~ubj~t.~~
an.dtt;~te-close,(tj the. upper<poteofthe~- ti~ue.
u is h~it(fJti:P~ce~ the.riie:So'M!pfrt*. -whiCh i$ ~tb~
p:an orme-uroa.augam~tit~tW~- m~r'tJtt>:e ~d. ovA:RlEs
ilie -base:Oftlie :me5ova.."9Utif~-- --- : --- - -- - - :
Theo~es ~paired. alinon<hshapeq bPcue~;
Four parts are rec<>gnizable on ~<:h ~~ the. :e ach mtasurJll:g abou.t ~ em hi length, ~ em
in.
inter.rtitium, -the isthn)~s. the runpuila.t and the .b readth. anc:l. 1 ~ m Ullckness. 'J'heit po~tion.
infundioul1..1m. 'l':he l~terstitia1 or intramural varies, hut they usually are
located on the la:t:Cial
portion,. the most:m edial part~ .'i s ,e~be4ded in the wall of the pehis.betw~en the.'!lret~r and~.
uterine :;v.an ~&opens .i nto the
.'Uterlne:cavicy:'The mac ~ein, in~ ~light depression - the ov3l-i~ll"f~ .
istiunua, .th~ canstricted portit>~ 'is . thin-walled (of W;:dd~yer): .
and is conti.iluous with the .s uperior ~gte of the
ut~rus. This anatomic ..ch~ct~ristic predisposes. Each ovary~ two surlaces,later.aland tnedWl;
i:he. isllimus to rupture . early durit..g an ectopic two borders, anterior (mesovarian) a...'1d..PO$trtiQr
pregnancy. The :~;UD.pulla, the .:intermediate <mated (free); . ~md two pol~l). upper (~ubal) and lbwer .
and longest pqrtion, i:; provided with a much (uterine). :It is su~pended frotn i:he posteriQr Janrlna
thicker mucosa but less develbped musc ular layer. of the broad ligament by its own inesentct)'. lhe
lts outer extremity terminates into the me.s ovarium. The lateral border is in contact with
infundi~ulunt, a funnel-shaped expansion of the .the parietal peritoneu~; the medial surface, which
.tube with .~ .n umber" of irregul~ pro<;esses, the . is partly overhung by the fiinl;>riated end of .the
fimbriae, projecting from itsm~gins. ~ertil~ti~n . uterine tube is. in contact with the epils of .the
. is believed. t~ take place i.p the ampulla; and .th~ ileum. Th~ : posterior or. free border prQj~ into
fei'I:.ili2;ed.ovum normally d~scends jnto the uterine the pelVic;: cavityandi s.iikewise in close re~tiot\ship :
:ca.vityforimplantation;ln s9me instances, however, with the.coils ofthe inte~tines. Theuppe~:pr tu:baf .
the fertilized ovum may imp_!ant and develop in the pole i~ att~ched to the lateral pelvic wall by a

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 CHAPTER 3: ANATOMY OF THE FEMALE REPRODUCTIVE TRACT
periton..~al fold. the suspensory (infundibula-
pelvic) ligament of the :ovary, which is a lateral
continuation of the broad ligament that contains
the ov~~ artery, and veins, lymphatic; vessels,
and a pbus Of autonomic nerves. The iower .or
uterine J>Qle is attached to the infl!rior angle of the
uterotubal junction .on .the lateral margin of the
uterus by ~ fibromuscular band, the ovarian
ligat:nent (derived from the &enitoinguinal
ll,gament). which lies within the broad ligament
(Figure_.a.7). O.n the_ri,ght side, the rig.l].t:o vary may
come ill contaCt ~th the tip of the appendix, and
tbeircl()se ro-lationship often gives rise to probiems
in thedifferetttiat -diagnosis -or acute alxlominal
disorders.
.T ae ovaries ~ppear :Pink With a _.smooth surface
bd'ot"C.~ o~lati<>n begins. th:ereaf~er, they
,are gre.y.e.,n.d sbr.unken with their surfa(:e -distprted
by ib.e d~~Jion dt..~ to t:..'le deg(meration of
~ -.C()rpora lutea:. ,The outer surface of
:eah<O\Truy~is devoid ~f peqtoneum and is coveted
With-cut}Q~ oi-'lawt:cluln.nar cells, the germinal
~pi~ilm:~ ' Beneath the genr.i.'rlal epithelium . is
or
the b.mica-lllbuginea, a dense layer connective
-1iS$ue: ~:hicb surroimds the cortex. The cortex,
. '~~cbJi'$~tli;e outer 1,8.yer o:f the ovary, varies in
fbi~e~~With age and becomes progressively
-tbiiiriet~t)le wo~an ages.- It contaim~ primordial
and graafian follicles in various stages of
dev~pment. Thereleaseofamatur:eoocyteresults
L,, the ;~~elopmertt of a yellow bOdy, the corpus
lutelmi..-1'lliS-..-aegenemt.es mto a: wru(e fiorosed
1>00-J,Uie oorp\{sa1'6i'Caiis;&Toretlie nexiovu1a:fion.
if no _p regnancy ensues or at around the twelfth
week of pregnancy. the inner or- central .p ortion of
the ovaiy, the med'qlla, contains a large number of
arteries and veins and is made up of a loose
connective tissue t:..'lat is continuous wiL~ that of
'the me.s ovariutri. FUndamental phases of the
ovarian cycle, in associ<'l.tion.with the endoq1etrial
cycle, are discuss~d in the subsequent chapters.
) ;loo'd S~pply and Ven9~!i Dralnage
The perineum and the pelvic organs a re mainly
. supplied by-the internal iliac (hypogastric) art~ries,
with contributions d~rived from the ovarian and
inferior mesenteric arteries.
~ch internal iliac artery arises from the
common iliac artery as one of its two main
branches, the other being the external iliac artery.
It supplies blooq to the pelvic walls and viscera,
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55
external genitalia, gluteal muscles, and -adductor
muscles of the thigh. It divides into an anterior
and posterior divisions at the upper margin of the
sciatic foramen. The posterior division has purely
parietal branches (lateral sacral, superior .g !uteal)
whereas the anterior division has both parietal
a nd visceral branches (obturator, internal
pudendal, inferior gluteal, umbilical, infc!rior
vesical, uterine, and middle hemorrhoidal).
The internal pudendal artery is both parietal
and visceral in its distribution, and gives. off the
following branches: small inuscuiar rami in the
gluteal region, inferior hemoirhoidal(rect81) artery,
perineal .artery, and artery of fue clitoris. lt is
therefore responsible for the blood supp1y of the
anal canal and orifice, external anai sphincter,
levator ani, skin . and !at of the anal r.:gion,
urogenital diaphragm, clitoris, and low~r part of
the. vagina.
The uterine artery provides ij)~~~ ~ .
supply to the uterus, Froni the U,.~~i1:3c~,
it courses downward andmediaLJy.~~e~#~~or
bctder of the broad ligament toWal:'d'the cetviX.v.It
crosses the ureter rtear the ~rtiix, a~ a;bout l.S.:em
from the . la,terai fornix. KnowJ.~ge ~f~\:tpi~. ' '
re~ationship is cliniCally impn~t ~n.se
damping the uterine vesseis Iar:~Jh~:~
isthmus during hyst<rrectomy mayrjnj~ -QJ::~.er
t:..~e ureter (F~gure 3.7). ~c~ 'A~4l~ ~ ~s
numerous branches. that pass into the uterine
wall, W.Viilliigmlo' a.nten~rari(f -.~-ierlOr' arcuate.
........-.._..._.. _, .... _...._,__ _..__ "-------.. ----~------~--~..
.
arteries. These _penetrate the myometrium
circumferentially and their terminal branclJes
anastomose across the micUine With s~vess1-s
of the Qpposite side. From the arcuate. arteries
arise the radial arteries, With their termi.haf
branches- the straight and spirala.rt.eries reachmg
the endometrium (Figure 3.8). The spiral, .or roil
arteries supply the functional layer of the
endometrium. Their: morphology ~e affected
considerably by the endometrial cycle, being less
promin ent dunng the . proliferative phase and
becoming more tortuous in the secretoiy phase.
The s traight arteries, which supply the basal layer
. of the endometrium, are not responsive tohonnonal
changes. Other branches of the uterine artery
include vaginal, cervical, tubal, and ovarian
.branches. The qpper part of the vaginaoi~upplied
by the cemcal and vaginal branches, atthough in
some instances; the vaginal .arteries -j~y arise
d irectly from the internal iliac arteiy. :f-ile tu.bal
and ovarian branches p a ss through the
~
 ::-.

56 . SECTION 1: . BASIC CONCEPTS OF HUMAN REPRODUCTION

' ~

meSO'.salpi.nx and the mesovarium. r~spectively, of the internal iliac artery. These vessels ~seftom
and anastomose with the corresponding br.a nches a very extensive, thin-walled basketwork of veins
of the ovarian a rtery. th~t surround the vagina, utenis, urinaiy bladder,
and rectum. They are easily tom during surgical
manipulation, and the resulting bleeding be may
difficult to control. Of particul~ importance is the
anastomoses of the 'l.lterine a.,d va,gir1al veins,
formirig a dense mass ofut~rovaginal plexus dong
the latera! border of the uterus. It is closely ~ted
to the uterine artery andtermination ofthe ureter
arid communicates with the ovarian veins within
thebroadligamenttoformthepanipn:m~tmp16clts.
i: .
The' u.tercvaginal plexus' ats o make~ ~Unically
important anastomoses Wi'th the superiof and .
. ' . . .
inferior rectal ve;ins, and the lateral Si:\Cl'al veins..
~~~
ltsana~tomosis With the superior rectal vein allows
~ 3.$. The CJldOJl1Ct:rial bl()()d supply. cormection ' .betweeil the systeinic ruid ~rtal
circulations With.the ven()U~ blOOd {rom :fue ~
. . . . entepng .t he p<>rtat cltc'Ula:tion Viii the irife;ior
The .lJliddle hemonhoidal artery, anothet: mesen:tericvein. Tbis,expla.iftS.l;J;ltas~SisC>f-cancer
~Wanch'ofth~.inteJirialiUa.~ry. ~suppUes . . in the .
pelvic .orgE\ris t9.' the: U.~er: :Theu~'al
tbe.:~':an~han~sti>irio~.~:vJithf,i.UieA~U:~dt:lf: ..pl~sJUtewi~m~~~.ap~s~~mo.~.'\Yit,Jith~J4t~- .
bem~ithoidal!(~:..W.enq~.':Dl~iiterlc).~:and.:::the,: : sata1 ~c:iDs ...which .'then ;.atu\ttonio~:.With the
. fuferiorh~citirh,.Oidat(fronrtheimtert).alpudeiidal);, . penvertep~. pl~st a :valvele$s . ~.ste:ql. ofydns .
at~At~;giVes .eon;1ep ra:nclles to tli!' vagina.. that e1ct.end ..-uu-~~gh;o.:Ut $~.. v~~b~. ~ end
th~ ~:.atterieS aiii~~frorox tli~,!rQnt;.,of..tbe: . . ~c;ntuaJlycbtm~With tbe.venO:u~ :~iti~~~ori.'le
,at;~::;l~h~eeti~,t)le::.rentU:t~<J;c:iafenor;:m~tenc .:. br~hl~ ; ,Thi~ . cpm.mun.i.c~tion. m.ake.~: : ~Urect
a~ertee~.;! t-tei~ets!'>.the:~:ov:ary ;; l /ti).rring~, .tho:c,, . metastasis.~'tc.-Ui~:'limiri ..p:Ossible~, . ~ptlring~ oili.et: .
~d.ib\1lo1Vic: ligtlillent;;r;gi~es off>branchesto .. areas o( the.body. . .
lhe~"W.ll.l~Jl ~d.- outer part 9f.1:he ov.iduct
.andJina:ll.].:~tomo~&.:-with;Uie.uterine: ~cy.in .In..~e"lu.t:pbar r.egi.onrthe.:ovari8n.Y.Ciris.:di\F.erge
tJl~.. sub$tanee-ot.the.-brt:lad--ligainen~ . -- .. (tom.the-ovaritm.artePy..a.rt(i.ha-vedilr~n:nteo\li'Ses ..
The right veirt drains directly into the inlerior vena
There .is . a rich an~stomoses . between the cava while the left cvarlan vein :dr.ain$.jnto the lett
..
iti~. illac .artery and the :other v:ssel~ m the renal vein.
pel~~.~th .fonilation oi~lhltel)ll -circilatioli with
th.~.aorlati.fi~i'!emotal.artery.-inc1udingthe.turnbat, L~phatic Drainage
'lliolu.ln;bat~iniddte,and J.ateriu ~cral; tiuperiorand
. n:Udd!c l;.emorihoid31, andgtuteiii arteries; In ca$.es Like ,in other r:egi,ous t>.f the body, the :lymphatic
.of une(Snt.t:oiled pos tpartum or intraqperaU.ve V~S$ClS of the perineum and pelvis generallY
il~mori'hage, one of the most effective and ra;pid follow the course of the v eins. Lym.p h from these
J'neUlQds to CQntrol bleeding is by ligat:itm of the areas are drained lnlo'the pelvic, abdominal, and
tmterlor division :of both mter:nal .iliac arteries. inguinallytp.l>~ nodes. Pelvic lY-Jllph. nod.e s within
' fh.is prOCedurereduces the pulse pres~ure on the the pelvic cavitj are the internal iliac, vesi~,
ble~d.ing artery, thereby perniitting thrombosis of rectal, iatei'al sacral, me<l.i an sacral, and perirectal
!.h~~ bleedln.g vessel to occur. nodes; while those located in the pelvic brim
includ,e the external iliac and
common iliac nodes,
The veins pf the perineum and tb.e pelvis for and a group of nOdes just superior to the ~cral
the:most part follows the course of the arterie~ but promontory. 'the abdominal group of nodes is
in the . opp<>site dir'e~tion. 'The interna.l. ~Hac associated with. the abdominal .a orta, and thos.e
(hypogastric) ..:vein is the principal vein of the that r:ec~iye)ymph from the .pelvic st4~ctilres are
in.t erior ofthe.pelvis and is formed by .a: confluence the inferior mesenteric, and the lateral and
of veins that generally correspond to the branches . preaortic nodes that lie between the renal ~d

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 CHAPTER 3:ANATOMY OF tHE FEMALE_REPRODUCTIVE TRACT

common iliac arteries. Th~ inguinal nodes consist

of the deep inguinal nodes alo.rig "the femoral
vessels in the femoral canal, ahd the superficial
iriguinal nodes. that lie inferlor and parallel to the
inguinal (Pouparl's) ligament.

Knowledge of this hierarchy ofnodes is Clinically

important because of the difference -i n the
distilbution of the lymphatics of the get:tital tract.
The inferiorportion of the vagina; vulva, perineum.,
and anus colleetiv:ely drain into the superficial
bigulnal ~d t):oe adjacentsuperficialfetnoral n~es
which eventually drait) into the deep femo.talnodes.
Thtis, infbmlDlatocy or neoplastic proceS$CS of the
lower V$~ v\tlva. perineum and anus m ay .
nuuiliesiby ~:using:tendeme~ or enlargement of
th~ ~uperfiGiat - .ingWrull- lymph nod~s whlch are
eaSily .e;pprecltlte4 by palpation. On the .other
hand~ . the Figu..-e 3.9. The lytnph.!ltic drainage of the female intanal
pelvic vi~ .orgaris dr!Un chietly to genitalie..
the hypogastric and the ilia(: nodes, wlth . feW
~!Jilinaili.J~: in the c;tortic and in&Uinal nodes.
. .. . .~ .....~:; .
;.::t.:;-;,...,,'
. ;'the U:t~tus has two- sets .of lymph vessels: origin of the piriformis muscle and1'iS!;7formedZ:ey
su~l}neatb tb.~ peritoneUIIl, and deep in the anterior primary ra.ml of IA, LS;'~.artd. Sl,:~~S4.
the .substr.triee of the u~rinewall. The\resselsfrom All the roots of Ute pleXus receive~' gray..,nifiii
tbe' U.tenn~:t
. ~ ..;,;~!t i ubes, fundus,
,~ :;.lo . .and lower part of.t.lte com..n1unicantes from tl:J.e sacral syl'npathetic trunk.
t

uterme:.~_. ~ to the lateral aotfjc and the

. . '

Some .brancpes c<>m.ing.from this, ~plexus,.,a:u'e'

. "pr:eaorti~'fh~s,
....~1:}-.,T"
f
tPgethe.r With . those . from the
ovary. 11ie'- region .near the point of entx;y /o f the
uteiittet~~ is dlmneq by vessels that accompany
the m~~ ljgru:ne~t. a..'1~ ~ ~CA file ~.~rti.W
in~ 'nbdes . .The three ._groups or<:QUeting . ~-~-~~~!-~~~1!~~~-P.!.~:.2Y!.:2f.~m_-t.a fb.~
v.eiE!s;snrffiec:eiViXilriUlimiOUre eiteniaTiliic-
iit>tJe-,.- la{eniity. ititernal - ma-c----nOdes-
posterol&tetruly. ~c! sacral nodes J>Qsteriorly
.{Fi~ 3,9). The blad<f,er dmiils mairrly to the
petvi~ node~. both. the external and intetnai.iliac.
Lyn;tph "fron;t the rectum drait)s toward the aorlic
nod.e , and tho~ from the anat canal drain to .t he
hypogastric. n6des. Thus, pathology of .the pelVic
Visceral organs is not aCcompanied by palpable
enlargement of the inguinal nodes becau se.
d,rainage is into the pelvici}md abdomjnal groups
of nodes.
Nerve S~pply
The pelvis derives its nerve. supply from the
lumbar. sacral, and coccygeal plexuses. From the
anterior primary rami ofiA and L5 of the lumbar
pleri~ arise fibers. that form th~ lumbosacral
trunk that descends .o ver the ala -of the sacrum to
join Sl. The sacral plexus is located on the
posterplateral wall of the pelvis minor h ear the
distribute<\ to the pelv.icr liluscles;~;and :-visc:ral , .
organs: Sf and S2 to the piriforinis and'f$3 at).d~ "
to the levator ani and eoccygeus~ ,.,1be.i>eJYic
splan,c,~ n.e;r--1e$ ~ d~rived.(r:QPJ.:S~, -~~~(! ~.
-~~~.~.:-~sciatic foramel!.J.9 iJmrora,~ the - ~_
region, the perineum, -and t he lower extreJ::;lities~
or particular important::e are th~.pelvic s phincluuc ..
and the pti.dendai n~rves becauSe they innervate
the j>el'Vis and perineum. The pudendal nerve (S2.
S3 and S4} is the tilajor so'Ui'te of m uscular and
cutane<>us "innerva tions of the perineum. A:J it
leaves thepelvis via the greater sciatic foramen. it
lies medial to the sciatic nerve, crosses the back of
the isc hial spin e and hooks a round the
sacrospinous ligament. It passes forward through
the less er sciatic foramen and eventUally enter the
puden(iia l (Alcock's) canal to innervate the
perineum (Figure 3.10). Before performing an
episiotomy d:urirtg parturition; this nerve.can be
blocked by injecting an anesthetic, on both sides,
in the area of the sacrospinous Ugament where the
perineal nerves course ar-ound. This is done by
. in travaginally palpating the tip of the ischial .spine.
and the .n eedle .is pas~ed; either -~travagihally or
trans petineally , through th e sacro-spinous
.ligament just medial to the tip .o f.th e ischial spine.

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~
~'
p:--
58 SECTION 1: BASIC CoNCEPTS OF HUMAN REPRODUCTION

- -~-
This results in relaxation of the muscles involved The .superior hypogastric plexus is formed by
ar).d elimination of perineal pain. The coccygeal the fibers of the preaortic .pl~s w hichare'joined
plexUs is deriv~d from S4, SS, and Cl anq provides by lumbar splanChnic n~rve.s of :L3 and lA with
innervations to the dorsum of the sacrum a.11d the some .contributions from the sacral sympathetic
skin arou.n d the cocc-_y..<. ch?-in. This dividM int.o the right and left
hypogastric nerves that .descend into the pelvis,
join the inferior hypogastric plexus :(on either side
a
of the rectum) which then l>ecomes m.ixtUre of .
postganglio.nic. $y~patpetic;: fibers and
pregangliomc : pw:asympatl)etic fibers {from the
pelvic $ptchnic nerv~s). Stimulation of the
J)ar;asymp8,thetie division results ln eorittaetion of
the musples ..of the bladder and l)owel with
relaxation of their sp.othctd3; ~matation 6( ~
ve~l$ of the e~tile tissue.of the clito~s :and the
'p1:rivaginal plexus, and J)erception or pain and
-dilatation of the bladder and the fectirtn. The
;.yinpathetic; fibers. provid~ .motot innervations to
the involuntary .st)hineter4 of' the 1'eCt:U!n and
Figure 3.10.1:'he somatic, mptor and sensoryinn.enr;itions
bladder.
of the vu!;ra and perinet!Iil.
The.autonomic fibers supplyipg the ovazy me
,,... ' '-' . deri\teQ-,f.r'c!Di ,the...r~~d~orl,if;.,PleJt\1.~ ~ ~eJ.
foUcwth,e .'OV:ari~ '~:cy .~d enterthe .~inal cord
- at the l~l t>fT.lO:...~t o the.\J:.t erus.Js.-:derived.
dir~:fr9Il?-tht:ov.ari8.p,W1dl.l:ri>o~~tiic.J)le:xllses.
-TheVic-vl~.:ato~s.'$Sl;IPR1J.~:by tx>Pl.- It;Js, :piin~~Y ,t)).e, .$YIP.wtbe:U.c. , :p~glio~
ofu~ ~pathitic;an&para$~patb~ti:~#~'$. Of ' :: fi~ f~!Jl T~~. - }:;1 ,Of\~e.:~~:cor~tthatsupPly .
the auton'Ol'Ilicnervous.r.sy.sk.J.'U. The :.sympa.fh,etk . mostparta of t.)e :fen;iilc ~:getU'+af~. J~~ufthe \1teros
iibe~ ma.Y :anse'4itectly from~ the::Sy,nlpatbetic . also.tecclve soine pamsyt:npathe(ic. preganglionic
trunkS .:in the pelVis~ ()f m~ . ~l)l~b th~. fi~ rtom S2 - S4.: The utero~ plexus of
$upen6'f~an'-d1i\te-not;hypti'g,u~c:pt~~-whi~h n:~~~$s"through-ihe.:~A~.c~U~eiit
ptovide~Detnlongifficrsllon :e.:~t~ll~tr.1iliers-tp- - Witb'~uterine. ve.ssels;"''f.lii~lexua-reaclte$-the
th~ fe~Jl:aie organs. The ~synipathetic fi~rs ut~tus at the level of 'the uterine. ist:luilus 'EUlQ
arise either. :d.ii;ectly fi"pm -.tb pelvic ~P~~c con$ists . P.rl~arily of visceral afferent and
:nerves:or i,n(Jirt~Y frotn 'the .it;Jeii~r .hy-po~tric
sy}np~thetic cl;re.-ent fibers. Pain .fibets (rom .t he
:plexus: 1-bey rU-e compoSe(t ,q the pelVi~ Visceral body .of the ute111s .enter t:lle spinal cord 'ijtrough
nenes (S2,: S3; .and :S 4l an4 .t4eir .synap:tic the la$t t:Wo,thQt.aeic nerves.: These.,netves mediate
connecti~ns:With the ~ iA or :n .the walls . ~ sen~tion t:huing the
fust .stage of lal>Qi.- and
ofthe-vistera. Affere.nt(sel)socy);fi~rs ;aeoinpal;ly is referredt.o the lo~~t thoracic arr(i.lurnb,a.tregions
the
hoth components of autonomicneni'.ous .sy~teril. the hack.a:t

POI~TS TO REMEMBER

Anti-Mu\\erian hormone - a .glycoprotein secre.ted by the Sertdli cells which causes regression of the
Paramesenephri<_: (Muller!an) ductsinthe tnale embryo.
. . . .
.Bartholin glands- also known as greater vestibular glands, these accessory genital glahds.arise from
the urogenital sinus and :are homologu.es. ofttie bulbourethral glands.
Cardinal ftgarhent ofMackenrodt~ also l<nown as transvers~ eervicalligament, is'a condensationof the
ei'ldOpelvic fascia fi1at extends {rom thecei\Jix to the -p~rieta,l pelvic: fascia and contains the uterine
vessels'and nerve 'plexuses~ .. . .

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 CHAPTER 3; ANATOMY OF THE'FE~ALE REPROOUCTlVE TRACT .:::.... 59
--~------~----~~------~------~--~----~------------

Cervix- .a barrel-'stlaped stmcture deriv~ from the Mullerian ducts that extends from -the isthmus
of the uterus to the upper portion of the vagina.

Clitoris - the female e;ecti!e organ that is a homologue of the penis. composed of a .body, crura,
I .
and a glans. -
Endometrium -~he mucous membrane cfthe uterus, lineq by columnar t:pithelium, that undergoes
cyclic changes during each menst~ai cycle. .

EJX>?phoron - the function.less vestige of the cranial group of mesonephric tubules.

Gartner's duct- a functionless remnant of th'e .paroophoron which may aeveloplater iil iii'e as a
cyst in the walls of the vagina and the uterus. ...::
a
Hymen:.: thin plate bf mucous. membrane that surrounds the vaginalorifJCe, composed mainly of
elastic.and conagenous connective tissue.

Internal iliac artery- also known as hypog<!strie artery, is derived from the common iliac artel)' .and
is the main arterial s upply of the perineum ancj ~me.pelvic organs.

Labla majora- a pair of fibroadipose folds of skin, rich insebaceoqs :glands, that form the l ateral
bOGndaries of the vuiva.

LilBi<? minora - a .pa1r of thin-folds of skin, devoid of hair and sebaceous glands, that fie beJ'.veen
~~';1abla majora and -flank the .v aginal mtfice~ . . . . ....~ .. . ~ >,. ~

Me50nephrlc duc ts -alsO known as Wolffian ducts; in the presence o~tne t~stis-de.terminin9 f actor.
Y.cti romosome, and testosterone. ultimately diff~rentlates inhthe mare .g er.itai1ract.

.:~~netrium ::. the m lddl.e Jayer.of:ih~ uterus ~e up of i.ntertacing bundles of :smcOth~.~-~sple :;.f.~- :
. ;;noegr~n preonancy- it tf)icken's signifk::antty ;by' hypertrophy and'hyperplasia.
. :::~ i:::~ . - .
1
- . .
~ " ..... -~~~:-t' .. :
:.;!'.~~- .. ~ .. it~-: . ,",
Ovaries - .paired gor)adal structures, attached to fue lateral pelvic wall by the infundiOOIOj:)eivic';'l~.~:
. the uteroovarian. ligament
figameilt, and medially by .
Par:amesone.phtic .ducts - also..known -.as ..Mullerian-dlJCtsi in the-absence oHhe an!Hnullerian
horm!me, differentiates .into
. -
.the.feinale-ihtemal-.oenital-tract

Par00phoron- the functionless vestige of the epudalgroup of mescnept]ric tubules

. .
Perineum- a diarno11d-shaped aiea at the fowere nd .of the trunk b etween the thighs ;and buttocks,
divided into urogenital and anal triangles.
~ . .
?udehdal nerve- the major sou;-ce of muscular :a nd cutaneGus innervations pf.the perineJJin,
derived from spin~i nerves 2;'3, and 4 .

Testis-determin(ng factor - produced by. the somatic sex c<ird cells a nd encoded by the y.
chromosome, c~uses the differentiation of the medullary region of the gonad 'htto Sertoli ceils_

Uterus- a .thick-N<illed, hollow muscular organ that serves as the site of implantation of a fertilized
ovum; made Lip of th e inner endc;netrium, the middle myometrium, and the other serosa.

Vagina - a distensible musculomembranous structure that serves as the female organ of

copulation.

Vulva :.. a collective term for the female ext ernal genitalia which includes the mons. pubis, tabla
majora and m inora, clitoris, bulb of the vestibule, and the vestibule of the vagina. :i::
.~----~~------~~~--------------------------------------~--~~~--~~
~
~~--__J

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~~
._!

60 SECTION 1:. BASIC CONCEPTS OF HUMAN REPROOUctlON

..

"-:-- ~'!-~

~NC8 3. Cunningham FG, LevenoKJ(eds); Williams Obstet,rics,

2 2nd e d. NewYonc: McGraw Hill Co. Inc. 2005.
l. Sumpai~ WS, V'Uianueva:-GutierrezR, P~-Luna
L, Negre-Paieja M, Ramo&MM Jr, Baja-Paolilio H {eds). 4. : Netter FH. Atlas ot H~ A natomy, 2nd ed. ~
Textbookof0o~, 2n.ded. Quezon.City: AssOciation Jersey: leon Leanllng~tema., 1997.
.o f Writers of Philippi..-1e Textboo.ks of Obstetrics a nd
Gynecology, 2002. 5. Wynn RM. Obstetrics and Gynecologf. t he Clinital.
Co.-e. Silitd. Philadelphia:~ M~ :Febiger~ 1m.
2. Betek,JS.,BerekandNovak'sOynecology,l4th'e d.lkw .
York!UppincottWilliams-!-Ild Wilkins., 2007

..

,1f

' ~

... ..
:
.. ..
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 4

PHYSIOLOGY OF THE
N0~"1AL MENSTRUAL CYCLE
DELFIN A. TAN, .&ID

Neuroendocrinology of Reproduction
Gonadotropih-releasing Hormone
Synthesis and Transport
Pulsatile Secretion ..
Regulation of
Secretion
Action

Gonodotropic Hormones
Action
. Two-cell Two-gonadotropin Concept

Ovarian Functions and Control Mechanisms

Hormonogenesis
. ~~r.pi~ ..Jionnone Production
....:!:tO.:Jl::$J~r.~ldJ:i.or.mooe Production
.EcillicuiQgenesis:---.. -.. .... ~
Spermatogenesis
Oogenesis and Follicul ar Maturation
Early Follicular Formation
Gonadotropin-independent Development .
Gonadotropin-dependent Development
Ovulation
Resumption of Meiosis
Luteinization
Follicle Rupture and Oocyte .Extrusion
Conversion of the Granu losa Membrane from Avascularized to
Vascularized Status
Corpus Luteum
Requirements for Normal Luteal Function
Suppression of New Follicular Growm
., Endometrial Progesterone Receptors
Luteqlysis
Lut~al ''Rescue" in the Fertile Cycle

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~y.
rit~:~ .'.
.. 62 . s~CTION 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

- An understa nding of the physiologic integrat~d with events in the endometrium to . ~

mhanisms involyed in the regulation of the properly prepare the endometrial bed for potential
nQrmal menstrual cycle is critical to the nidation every menttrual cycle. 1-s
~gnosis and management ofmany reproductive
pr6bles. The objective .of this chapter is to
sut;niharize current ba:s:ic c~ncepts regarding
me.n:s.t rual physiology with emphasis on data that
ra~ be clinically applicable.
. !: ' .

T:he success of human repro-duction

. dep~nd3 :o.n. the h.i-ghly coprdinated
~lnt:er-$.cdo~s-: between th~ bypothalanrus,
. anterior l>itti.itar:Y gj;EU1d1 :o~e8~ and. uterin .
.en4(>:xnetrlun;. . :that .occt,\" :d~rln.g .a,.~otw.a,l ..
m~n:s~~~l. .y,~~e~ . ln "the~e . i1;1 tt~cate
;il:lteneJationships," the .o vary has .b een
~4i:ti{m~y viewed as. playing a secondary role
to:~~ . ee:nters such as the pituitary and the
. ~..ri&iJ:.alat,nt!s.. Cuirenttiata ii;l:dicate, however,
:t~.it~w-e:ovaxymust be c,onsidered rath~r -as the
. :m'*-'!Ster gl~nd::. the fun~tions of which t,tre . 0
~tated. by .~the. contribution ~f the. variou~ ~lf'\o ~o
~ ..
. . .- . - ~
..
. - - -. .~~
. . :..
~
.
: w. -
'~
.
..... :viheF,:e~co.m:p.ommts,: o.f the ~ . hpothatarn.ic- . 14<.;.~ . O.IM~-. . ~.._.,.; .
. :pifiri~:-o:rarl~"endom~trial ~s:, Ovanan . : lon:Cio
~t}gri~b-d~tennine-to' -~ ,lar;ge.'exi:ent-'t...'le: ,n.ature .
.oftb~~ctiv:itie~:of.thc hypoth~amus, pituitary, .
,. ,a.clu.endometriunl.. .In fact, it now ap~s that
... :.th't{~Y.ari plays .an a ctiv,e r.~re .:yrhile the
: hyJ:i~fp;.~~mu~ . and th:e .p~tuitar.y.. a :s suflic .. .. _
.~JlenJs.sive-_. role<l iii the~ "ini.t ia:tion .and:
:ID.am~ce .pf the enaocrine events that are
. : ~~~.9..9_t~n..o.rm~~~atl.<Lw.!":~il:.tiW.Y .f~rtiv~ --
..g.cl~_J..ikewise, . .th.e..:~ppr.Qp.pat~ . ~~_e.qlJce.n.G~ . :Of
-'O~ hormones is integr'ated wit$ events in
~ .iii~-.:enp_6metrium to px:operly prepare the o l 1
.
ro l'l ~~ :s 11
~
20 ll i< .lG lt ~

.:eudometria:l beci for .po ssiple nida1;ion.

. . .. :..;
. Pl~s, the ova.ry is an organ with coll;lplex
. .:TQ,nciions with a S;ingle. central objective, i.e., Ute
. ;ge~~qitlo;n.pf.aful,ly niature fertilizable ovum that
.h. ~(ied at cyclic intervals to allow for the
~t;Vement of pregnancy. Indeed, the tt";leologic
:ba;~ for ovarian func tions is the fundamental
--~~to preserye .t:D.e species.
.. lf.&UROENDOCRINOLOGY OF REPRODUCTION
, Nonnal ovarian function, and, ultimately,
. . s:lic;e:ssf~1
reproduction, requires that
:neur'oeildocrine mechanisms .b e coordinated With
tb:i ;pr.oc~sses of cyclic foliicular development,
., oY\Uationr and subsequen~ 1-q.teal functiQI?- "in the
.-.. ; :o"~)(Figu.re 4.1}. It is likewise necessary t:p.at
~r.. . .the ..appropriate sequence of ovarian hormone~ be
:.~~ . .. .
.~~~~: <. . .:.
... .
I
Fl.gUie 4 ~. biagramm:a:ti~ ~presentatio~ of the higwy
coordinated . :int~etio'n :hetween:hYPoilialamu~ anterior
pituit;aiy.gl:artd, ovanes and uterine ehdon+etrium during!'!- .. '
.nof'Dl:a:l,mens trual"cjge. .Modified from Danforth D~, &ott
J R(edsj: Obs tetr.icsand Gypecql6gy, w 5 , Philaddphja: J. :
B. Lippinco.tt, 1 986.
The . hypothalamu~ and the anterior pituitarY
gland are th~ tv,:o major ru-eas within the brain.
v,:hich are intimately involved with the .oV'alj...in :..
the regulation of reprod,uc tive and menstrual
functions.
Go~dotropin-Releaalng Hormone
The hypothalamic hormon e tha t controls-:the. -
gonadotrop~c' fu~ctiori of the an.t erior pituitary is : . .-. . .(
th~ gon~dotropin-releasing hormone (GnAA).

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 CHAPtER 4:PHYSiOLOGY OFTHE NORMAL MENSTRUAL CYCLE
------~--~--~~--~~----------------~----------------------~
Synthesis and T'Qlnsport of GnRH
GnRH is synthesized by highly specialized.
neurosecretory cells within the hypothalamus.
The cell bodies of the bjpothala,mic neurons
that Prodllce GnRH are concentrated mainly in
two areas: the anterior .hypothalamus and the
medial basal hypothalamus. 'file :grMestnuinber
oi GnRH-producin_g neurons ...is roun:d. in the
.arcuate nucleus of the ihedial basal
hypothalamus. . and potentiates the pituitary response to a
. Th~ major route of transport of GnRH is
through the tul>erointi:ndibu1a,r ~t. GnRH is
transported along the ~u.s of these rteurons
from the ateuate nucleusto the media,n.eminence
where G~1.J is sectete.d into the inte~t,itial spaces
Md diffuses to the pritnaxy capil}ary_piexus cf
the sup8ior hy.pOphy~ _ aitery. Once m .the
blc. it"is: trarl$po~ 'Via s~ po~ ves:Sels
to th.e ~~tior pitui~ glai"'l(l. The portal ves~ls
forma ~~ndaty caj)illary plexus that promotes .
the mov.~mept of GnRH to the pitqitary
gonadotiopes. The gonadotropes . ar.e the
pituitary cells which produ~ the g9nadotropic
honnone~:J, luteinizing bormon~ .(Ll:I) ..and folliCle- .
stitnuW~g hoJJilon~ ~H). After leaving the
pitui~~~gland; the Ckc$tion returns :to t he
~p~).>1exus, allowing pituitary ho11lionc:s to
help regulate the secretion of GnRH from the
median eminence.
An alternative roUte e!iO:Sts~ AXohs ofthe
ruoeroin!Uifdil5liiar t:fiicrtiWiij)Ort a~I~I=rdfrecUy
into the thjrd.ventricle. A speciclized .e pendymal
eell~ the tanycyte, extends ~rrom. the._iumen of the
thitd ventricle .into the outennost zone of the
rnedian eDiinence. Fl'()m the thitd ventride,
.3nRH is trimsported into the pe'rtal system via
"the umyeyte$ and 'their microvilli. . regulation of GnRH receptors that" OCCUOl -W ith
Pulsatile Secretio.n GnRH
GnRH .is secreted from the hypothalamus fu a
pulsatile manner. The amplitude and frequency
of the pulse vary throughout the menstrual cycle,
with the frequency being more rapid in the
follicular phase, about one pulse per h our, and
slower iO. the luteal phase, a:oout one pulse in 2
to 3 hours.
The p ulsatile nature of GnRH secretion effects
a similar , pulsa tile . 'Fe lease of pituita ry
gonadotropins. It is now clear that only G.nRH is
Scanned 8y:
- 63
...,
-~~
responsib}~ for the release of both gonadOtropins,
FSH and LH. This inter:mittent hypothalamic
stimulatio.n .of the anterior pituitat:y is ttucial to
normal gonadotropin $eCretion. .
The _n umber of GnRH receptors that are
present on the g()nadotrope detennin~. in .l arge
part, the magnitude .of pituitary response. At
lew l evels; ,QnRH can increase th.e number of
its own receptors. This primes the gonadotrope
subsequent P'-llse of Gnl~H. At -hi:ghet levels>
however, GnRH has the .opposite effect .
EXcessive stimulation results in a sharp fall or
down-regulation in the concentration of OnRH
receptors and decreases pituitarY sent!tivjty to
GnRH stimulation. .
Th~s~ ~nly iJ the stimulus of .h ypothalainic
G.nRH" is providedjn 8n intermittent. pUlsatile
fashion will normal gonadotropin ~tiOO oecu.r.
The pituitary . gqnadot;rope appea.ra:, :to~. be
exquisitely sensitive to -alteta.tions"' ili ~-:'Q~ .
rhythin. . ~ven th~ most .subtle i:lterfertnceiWft:h ..
hypc)thalamic an.RH cii.""l have sigrillicant'i treas' .
on gonadotropins Secretion and t an pc:)tenthilly
interfere- With reprod\lctive functio~. :<
.. .... ... - . . . . .. . . .. ~ . . --:::\~; .~;~
:.
CllniCl;illy, the loss of the noririal. PW~til~
rhythm of GnR" release appears to- !~~tli1:
1
und~~g ~t:poppysiol~gy in. S9~e WQ@l~I_l W\tli
disa.td~rs of ()vu_ta~on Mdfor ~en-ses:-dtie tc a
ilySiunG'trcn oi"tlle" liypolliata'mrc:.-r~__, ...,.liillt.
Tfiis. is.IDCely.. atso. .the ciuse o f th;~ seriotis
hypothalamic-pituitary failure ob~rved in
association with s evere weight loss, strenuous
exercise, an~ anorexia nervosa.
On Ute other hand, the phenomenon of down-
excessive or constant infu s ion of GnRH has
allowed frequent administration of GnRH analogs
to be.u sed to inhibit FSH and LH levels and thus
d ecrease s t eroidogen esis t o treat hormone-
dependent conditions .s uch a s endometrios is and
leiomyoma.
R~&.ula.tion o r GnRH Secretion
It is appa rent that the control ot~;pisodic
. . ~-
GnRH secretion is extren;lely essenti.alffor the
maintenance -of the normal cyclic acti~s .of the .
pituita ry a nd ovary and, ultima tdy, -o~nornial
men strual and reproductive functions. -
~
 64 SECTION 1: BASIC CONCEPtS OF HUMAN REPRODUCTION .

The key concept . is that normal . menstrital Catheeholestrogens are steroids that resemble
function requires GnRH pulsatile secretion that bo.th . catecbol.amines and estrogen. The
maintains botti the frequency and amplitude of conipounds 2-.-hydro:lltyestradiol and
GnRH pulses within a critical range. To this 2hydr0xyestrone, as well as their 3-methyl
effect, the :secretio.n -o f .QnRH seGretion by the derivatives, are present in hi~ concentrations in
hypothalamus is regu:~ted or modified by the hypbth&:lamus. It is hYPQthesized that these
1") the stim.ulatpry a~d inhibitory fe~dback compounds may n:n>dulate the pi'od.uction a nd
eJfects or: tbe ovarian steroid horhlo nes, action oi cateclloiamines.
. ....
e$t;;adiol and proge11terone. 2) the inhibitory .
feedback .e"tfect -of the ~o.nadotropins, FSH and .A ction of GttP.H
LH, 3) inhibition of GnM .$ynthesis by GnRH
itself, and, 4) .s everal nenrotrart'~tWttetil and GnRH, w~~n it reaches the anterior lobe of
neuro.modul~tor.s. the J,Jituiwy, ata on the pituitfirY gGnadotr:ope
by bi~tding to .'$ pecific. m.emb rane r:eceptot-~
:N~'IU'Qttau!!ilttera GnPJ:Il$ u~iqile among releasing honnories in
that it .Siinultan~usly r~gUla~s the secret;ion
Gp~Jl relea~e is influene~d by o"f two ,horinon~s .... F SH and Ln. GnRH
neurot:tan$liittets which ate .synthe~ iJlhigber stimulb.t~s tbe i>Jtithe.sis and s tor,age uf bofb
&reils ()f th~ ~-a;rtd wh:idi m~y & .funuenced FSH and t.H. ~e-ti~g throug h . .the se:Cond
by ta:eioia $uch . .1:$ $t~~$-- or t.motiotrs. JiiefJ'Senget cyclic ac:Jeilo-sine 3s
Ne~~~rs ~ l>io:gemc ltinin~$ ~tat. n}.Ql)~p~osphate~~~) . . It also amn\ilates the
b,Y-~-,.J.Ve:i:~~~Etli!lt~proaq.ce;:$:h.'l\9tl~-:oti-:~otlier: ,. .ret~ .ofboth.L:H:,and iFsH' ftottt the same eell .
Cell~ : . .'Tl',i~ : Jilos.Li~pp.f.tl,mt ' ne~'tOttatl~tter~-. :m:.tJie:-:pituitaiy;gliU!d~ .. .
ln~~lli':th~ie&\J~tlott:'of;G~-re)~:are,.tWo:
_ cat~"Q~~~ .dQ~e a..rtd .~'O~}!(J:t1h..oille. ~-do~plc; ~n!lones

Recc;)\j)t$:forFS~ C.xi~t.pri:nlarily-on the tell

Ncuromod'lllators. meml,>.t"ane o f gnut~:lo~a c~lb oi the ovarian
f<>llicte~ FSH ~t~ ,.nneipally o~ l~e. granulosa
NeutomOdulators are $Ub~ta,nce$ .t.IUtt :affect ceUs to ~limulate folllculat -gro\Vth. Receptors
the action or n.e uro:transtl)jtterS. rile~ agents for LH ~~t on -~~ theca cell$ at en
sta-ges or
.int!ude the _ol)io.ide, prostaglandins and th;e #l(:n;.tr:u~l ~yde; they are ukewis;e:.(>n
catecbolest,togens; granulosa Cell$ a fter th~ .foUiele matures aS well
as on the
cQipus luteum. The main action or
OJ the lllr~e s,u b:g.r o.u p; .or Q piolds LH is to stimulate ap:drogen synthesis by the
(enkepltalin~, endo~hins ,Mtd dynozyl:Wls}, it 'is . th~ cells and progesterone synthesis by the
a.,._eitdoi:phm that is conc;ertp:ated ;i'.Wrlnly in the corpus luteum.
arcuate .nucleus a:nd JDedian emin:ene Of the
as
:hYPOthalamus, well as the pituitary wand. Both Two-cen Tw.o -Gonadotropln Concep~
~stroge.n and p-rogeste-ron~ seem to increase levels
ofa..endorphin in the brain and UtJs increase m_ ay The :two.-cell two-gon~dotropin concept is
account for the decreased frequency of -GnAA
proposed to explain the pro~ess . of steroid
pulses in the luteal .p hase.
hormQne production by the . ovarian follicle
-~)'<- . Prostaglandin~ may m~dulate the ;retea:re of (Figure 4.2). It states that:LH acts ~n the theca
: _. ~.rtRij. Admin.istra,tlon of -prostagland1n E 2 cells to produce androgens {anc1ro~~enedione.
;~_;: .: >. significantly increases GnRH 1ev.e1s in the portal .and testosterone), which -are :then transported :
v-~1'- ~~. - ~blood. . . . . . . to the granulosa cells, where they are converted
:.:;\ :_ ~: ~~~:~~3,i ~~-~
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 CHAPTER 4: PHYSIOLOGY OF THE NORMAL MENSTRUAL CYCLE
to estrogens (estrone and ~.stradio~) by the action
of FSH. The aromatase enzyme catalyzes this
conversion.
Oleileltei'OI
J '
Aodrost~~
t:~~
i}~f~e ~tlm}~_.h~nfj (f~li<:yiat lluic!
Fipre_~-Two-cell two-~ruuiot:topin conc;ept- of- ~arian
" I SfefO~~ From_ Mastroianni L. Co\lt:if~-
\ion: J~Wrooui::tlve Phys.tologyf Tht: F1GO Manual <>f
.:Hliine,n~t;:>duction, New Jell!if. Parthenon PubUshin_g
House;. 1990. . .
.RSH -also sthnulates follicular .g rowth by
int,ea:~g ~th FSHand -,LH rei:eptor content in
-;~~ ;fgzinulo;Sil... c~lls. _ This- actio.n .i's enha-nced by
.~estioiek: - -
LH ~cts-directly On. the gi-anulosa cells to cause
Iuti:iJllZatron and production :6f pi:C>gesterone. UI
~t'b" ~ttm-utates prostagtandmsynlnesis oy
i.ijU1iCenutar proat;.cffon -orc-.u.tJ?.-- -- .- . -
OVA~UN: FUNCTIONS AND CONTROL
MECltANISMS
In a unique ma..nner, the ovary .c ombines the
.endocrine andthe gametoger.ic functions vital for
_reproduction. The secretory activity ,o f the ovary
is re!et.red to as hormonogenes.i s and the
.gametogenic acti-vity as folliculogenesis. 67
l{ormonogenesis
The hormones produced by _the ovaries and
secreted into the circulation are steroidal -and non-
steroidal in nature.
Steroid Hormone Production
. 'Three major steroid hormones .are secreted by
the ovary; estradiol, pro gesterone, and
Scanned 8y:
65
an9rostenedione. The ovary also $ecretes
pregnep.elone, 17 ~hydt:oJW:yprogesterone,
testosterone, dehydroepiadrosterone (DHEA), and
estrOne. The relative quantities in which these
steroid-s are secreted vary accordipg to the
morphologic development and state of
gonadotropin stimulation of th~ pva..ry.
of
The a{llOUnt o-.r:ar4in estradiol secreted daily
ranges from 1GO to 500 ug. E.s tradiol :secretion is
lowest at the onset of menses and peaks before
the midcycle LH peak. Outside:the ovary, ~tradiol
is readily metabolized to the biologically less active
~strone and then to estrone sul{ate. Circ'.US.ting
e_st,radiol h; l~ely bound to sexhormone-bincling
globulin lSHBG).
Daily progesterone produ~tic;m amountS to
abo~ 4 mg 9llting.:the tollicll4u' p}lase a.ud .30 mg
duritlg the htteat phase. Th~ :proJ>unced :~
in prog.e~ter<;ne .p roductio-n a:rt-er ovulation
e (e~s): . depends on .corpu.a luteum.-funtion. c~~ting
pr<>gesterone is bound to .cortiC9steroid.:::b.inding
globulin (CBG). ApproXimately, l()%; toA~o/o of
progesterone is metabQlized and ~xctete~. as
pregnanediol ,glucuronide. '. ' :
The ova.r:ie$ secrete le~ than 1- Xll:~~f.t.P~ r
to 2 mg . .fif androstene~li<?ne~: arid aPPro~tely
o_. l mg o~ testosterone each day. , . ,, ~~;.:1,_;:~:( :
Mo~a-sterotdal Hormone froductlon
Aside---frotn'-'stet=oid--hormon.e--p roductioil; -it is
now-reeogiili;e(rthat-the ovary produces-certain
hormones~ factors that are supposed to regul:ate
or modula~e . the .gametogenic .as well as the
folli~ulogenio functions of the ovary itself: These
putative or supposed agent$ may be secreted into
the circulatioti or they may act locally within the
ovary._ T4e. local action may be accomplished
through .~ paratrine (interce-llular,) or autoerine
(intracellular) m anner of intraovarian
communication. Para crine communication
involves local diffusion of the regulatory agent from
producer cell to distinct target cell while autocrine
commun~cation. involves the action of the agent
on surface receptors at its cell or origin.
The non~ steroidal hormones or factors
secr.eted by the ov-ary include . molactin,
folliculostatin or inhib.n, oocy.te m"irturation
inhibitor, luteinization inh-i bitor, go~otro.pin
binding inhibitor, insulin-like gr:owtJ]~-factor- 1,
-epidermal growth factor/transforming growth
C
 SECTION t: .BASIC CONCEPTS'OF HUMAN REPRODUCTION

facto.rs~a, transformin-g gr~wtli f9;ctor~~ 1 . 'l'he process of meiosis is characterized by

.interleukin~ 1, basic fibroblast growth 'factor, ~or
'necrtai!r factor-, 'and ovarian renin-angiotensin
sjstem. ~ lis~g i~ far from ~mplete, a~ it is
'e xpected fuat novel agen~ will .Qe uncovered in
fue fpteSeeable future. These secretoq products
ar~ now incr~singly ~ing -recognized as playing
imp<n:tantroles in the r.e gulation .o f certain events
.in th~ ovaria,n cycle, '-adding more complexity to
-th~-:~9.1 p~ ..p~ysiolt>gy.
F~ll!eu:logeil,~sis
~~qcgenes!~. ~ the.co~ ofwhiclnn~
'b*.a are to:t:med 'fi-om ptimitiV'e'; i:rogon~a.
S~~nesi~. which results in 'ih<! p~uction
of ~iilids, sbare.a basiC b.i~c feature of
~~'ti9i:l. i;~~.reducti9n .~Skm. '{Figm:e ~-3}.
SUh:~~~:~&~.d.ivfsi{';n, IQWn :~ mci6sis,
i~ :.n:rnited .fu. g~ ce~.
unusual prophp.se, and involves a
9. 'lon,g .and
process that provides for the exchange of
genetic materjal between homulogous
chromosomes an:d the re.duction .-of the diploid
nuniberofchrompspmes"Le., 46, toti,l~ haploid
number, i.e., 23, In inan, the diploid number of
chromosomes is comprised. of 44 autosciri.es a..Tld
2 sex cliro.m:oso~es; -durin:g mei~sis. ~ature
~ametes are tot.med, i n each of whiCh thm are
22 autosomes .a nd 1 sex c hr<;>m-osome. T he
diploid nui'n'ber of:chromsomes 'is not restored
until fe.r:tifu:a'tioll. with the unl~ of.t;h~ ovum and
sperj:n.
and
Sp~rixuttogenes~

. \ ~-=
..
. The sp~rtna;togeriic 'cy'cle, . tb:e . seque-D:tia1
ch-an,ges o~cutring ih :a,n :in'dividuhl ..cen as it
develops from a ~pet:Ip.atq:goniu:m to a fully
differentiated spermato'zoOh, takes about 53 days

<'~~".
in man and normally .continues throughout' the
reproductive life of a male.
. .. . l&ll,..t..
. . " O.J,
_....,.. 2),1(
Oo:genesis .a .n d Follicular Mat\lnt;tlon
lJ.T.
23,X ll,Y
n..x
.:Fi.gnro 4.3~ o~$gs to com:p:are .spermatog,~e;;u and The morphological and physiolog.iqli sequence I
oo.g enesis. The clir9tno~~]J.e complem-Cnt.oftlie genn cells of events .that Je~d .to 'tli~ development of the I
.is .slwwu at eath .stage. ~e 'pth);lher des~~t6.lli"total
.uUQlbuo(.cliromosomes, including the ~::~tnosonie(s) mature. ov~;ln follicle ~d the release of. the I
ah<:iwn a fter 'fhe:cc>mma.. From Moore l,<L The I!>eveloping .:...o\ruin b egii).s,.early,. iri ;ernbryoiJ;i.c -deve1opment ( I
Huma.n,~d 2; J?hil~de~phia: Saundets,'1977. (Figure 4.4).-8 9 i
I
I

Scanned 8y: ~ I
 -~-----C_HAP_.T_ER_4_:_P_HY_S_IO
_L_O_G_Y_.o_F_T-,H_E_N_O.;,.
' R_M_A_L_M_I;_N_S_TR_u_
..,
~-.-
"'r
':i
e.
..3
-o .
'0
0 ..
0 ~ . : : ; . . . . .
.
J t:"'""
Figu.r~4A':~~rucle ccvelppment ~..s early .in empryonic
tkvelopment a:nd ends with QVU.l:ati.9n. Progre~ byoP-d
p~follicle sta.&e depends.on:gons.dott:o_pin stii:nUlaFon.
~:~.Oqcytes;.fro:tri~a~pment. to fertilization.
ln MisheJl..D~ l)avfEljSJ:). V, :L ooo.lTh '(ed~): _bfertility,
Coritta~i.t'ilfl & ReP.fo~b:ttlve Endcrcrlnology, ~d. 3,
Ca)::o.bridg~).iaS:l: Blac;l~eU Scientific Publieations, 1991.
. . . . . ... . . .
On approximat-ely day 24 of fetal life, the
female getm cells or oogonia-.a rise'in the yolk sac.
They Su:b~uently .migrate to the gonadal ri9.ge
dUJ:iig the. fifth. week cf.developm.ell;t 'to 'fo~ the
:Prinritiveor in:d.iff~rent go~d. Generally, the ge~
.cells retn.ain.'L"l the .cortex of ~e primitive gonad if
the gonad is to ;beeome anovary. Oogoruadivi'de
mitotically ahd possess '46 chromo$Qmes:
From about the third r.:::.onth ::>f gestation,
incre~sing number of qogorua st;:ut to enter their
flrst me.iotic diviston, thet.e by becoming primary
oacytes with a chromosome complement of 23. By
. birth, or soon' thereafter, all.fem~e germ cells are'
. primary O<>CJtes. Soon after formation, the P,rimary
OOcyte becomes surrou!lded by{!. :single. layer of
flattened granulo'sa cells to mark the development enlarges.from approxima~ely lS um_~-8 0- 100
of an.P. to yonsti~ute th~. prinHDr:'dial follicle.: Thf:s is ":{:Qro, .the .. z.o na pellu~ida is forme~~d the
a critical step 'designed for the preservati.Qn of the gr.~ulo~a .
follicie.'. Ge:rm cells dest~ed to under~o . a~esia . . ~~oliferate to form ~o to five .layers around
A.__L_c_Y_C_LE~-~---...;,;;. .. 67
..,,....
Prlrnorolal are inj::ompletely surrou nded by 't his mantle of; -
~ primitive granulosa cells. ~)'he oocytes pffetuse~i. .
'Eal1y
with so-called Tumer ka.i'yotypes are iilcompletely
~filoPing ,.. surrounded and premature follicular atresia .~d
!~ getm cell depletion result.
Further .nuclear maturation of the primary
oocyte is arrested in the :dictyotene stage of
prophase of the first meiotic divisioo,. It will
remain in this state until ready to resume
meiosis and potentially develop int-o a mature
eocyte. The duration of this resting state~may
last for as little as a few days or as long as 50
years.
It must be stress.e d t..l-J.at no prim.ary oocytes
are form.ed after birth, in c()n~rast to the
continuous production of primazy spermatPcytes
in th~ male after puberty. Tnus, the store ~f
ovaria;n fcHlicles in..::ested duririg fetal devcloj>In~ili .
is not replenishable_ .At the same time, it is
constantly. peing depieted by tlie -prQCess -of
degeJ+at~ti.on. pr atresia, Atresia ocdi~-~:ii:t:.;~
stages of follicle devel(;)pment and>9'eyo.Qf:.~s
are lo.s t in- this way. From a ln.axinirim ::of .
approximatezy 6 ~on follicles.in tll.e twP gc~~s
a~ the sev~th: month of in.tra~tciin_~_.:P.fe (Fiw..rre
.4.5),onlyabout2 ~on,suMY:etoie#.b:l;leg~
life. By the.time of men:trChe, ~.:.~~~f.~~as
been depleted to .only about. 400;()QOY~b1e
follicles. It,is hypot..l).esized that there is a fixed
'window of sO:$e i3 years befote mtil(jPiu~cit.tiihg
w1iiclf"accelemted~-ovanan- arre'Sia-taKes""place.
Thus; .. at app,.rOXim~teli-37 .5Ye$r.s,--~oocyfe
depletion is ~u~~i~rateQ... A~ the.age bf4Q..44 yean,
only, appro~~~ly. 8000 ptim~ follicles are
lefL By the time ~?fmenopa')..!se,:fue ovary'will.be
cOmposed primarily. e>f dense str.om3.1 tis:;~ue with
. only rare interspersed ooc.'(its ~e~g.
Gonadotr~pin~i.rtckpeTuient DeveloPment
The changes that occur. as the primordicl
follicles leave their resting state and resume
deve'lo:pment are believed independent of
gonadotropin support or stimulation.
. .
f'he primary oo~yte goes -through. a major
growth phase with m.ass'ive ,s ynthetic 'activity
and .roar-ked morphological chang~s. oo~yte Tae
. .cells become cub.oid
. in smipe
. ""'- and
.
''
Scanned 8y:
~
~
 f
<
SECnON 1: BASIC CONCEPTS OF HUMAN ~EPRODUCTION

the oocyte. These foUicle.s have no antrum arid acquisition of a theca layer, ~hlch i~ ~ted
are considered to be primsry or pre-antral from the granulosa cells by the vasc4lar lamina
folliclea. basalis. These morphologic c4a,nges .~
the development .of ~condary . or
antral fulliclcs
and mark th:e beginning .of gonadotropin
dependency.

Once .the ..hyp:otbalan:):io-pltuitary'-o~aria:n

axis assumes ~ -Qperatiye . :$tate after pubertY
. characterized by the p:cil~cl:le :Sectetiun oJ
GnRH.. llie ovarles,.:facilitaf~by its ~e
domiiY~t . struc~es "7 L~e. .Jl~O'-~tolY fOilicle
.and the -;orpus lu.t eum -7 ~te :th~ mllrSe of
:-
even~ t..~at 9ccuiti :dUiin,g . th~~tn~t;t.wil cycle.
The iqea:.ih:ed 2a-d:a;y me:Qcsi;r:Ua( cytk i s not
deter-mined by inde.Pendel.lt ~ve.nta .of the
hypothalamus ot pituita;.ry .gland:. but h; an
~, .... iritrltls'ic property cf tlle ::OV.at;les. Aa Cvldence~
ovarian. estrog~n J;rodutwh h~-1~~eiH:onciu.#vely
demoristratei;l '~~ :~e ](}i:'Un.a,ty d:e~nJ;i~ant vf the
cyclic pattern of gqn~dotr.opi,n ~ti<m obser;ed
in the normal cycle -(Fi~e .4,;6):~

.
: ,,.
- ~,-~~
. ;, . ~- ;~:~:: : .iii~..:.: . _..,..~
. 'l:!ifj~t
... ... "' ":. ':, .
. .. ..: .. ---- -- ... . =
- .JOo-
. T4i ~ufti~tio"u ~f .fo!Hcula.r gr'Owth :is a .rn
cO~tiiiuov.a proce8s and ~.-3 .in ~ age:s even C)

d~g.the Ptepul>ertal ~d d.im:a:etenc yeai:S. It IH

.7""-,_.,;..~-..~-.oo
~s p.nin.tr:ru~~ , duiing .pregn~cy and is
.n~t .a:{!ecled qi =. :ch~nges
in cireulati hg
~
.,0.
go:uadb'tropm or sex:stereio !liilieu. The tack :of
sensitiVitY 9f this p:::-oee~s to known endocrllie
faCtors tranillates at the curteni.fune to aniria.bility
to clliiically manipulate this stage o'f follicular
"gi~:~~h; .. . .. Fi&ure 4 .6. Temj)oral relations~ps. of :gonad~~ and
ovarian steroiq s~tion in normaJ.;inen~trulli cycle. Fritz
6;;~6~p{n'-Pepeiu:Ient Development
. MA. $p.ei-orr L.-ciin bbstet Gynec6ll9~;
. . rt6;647. .
D\lring the ne~ phase of folliculogenesis,
which O<;CurS from p:u~rty onwar.ds, development During the gonadotro.pi.p-4epe~dent:sbgC, the
. is deP:enaent upon continuous . secretion of morphologic ap:d endocdne d,ynamics of.
gonadoJ;ropin~ . As the.p.rimaiy ~!ollicle's mature, folliculog.enesis are w.eli defihed, and ,are. divided
s ma:ll loculi ;of fl\i.id l:iegin to forin around. the. into- the. interva:ls o'f rec~_it.trt:ent,. selection.:
gxanulosa ceils~ As'devdopmentprogress es, thes.e ..d ominance and ovuiatio.h {F~gur,es- 4 ,7 & 4.:8)~
i~)culi coal~e a~d a fltiid.;filled.'cavity ,or antrum These d.evelo~p:mental phases hav~ _pi:edlcta:J:jle. f
is .fon;ned. Coincl4ent with these :changes is the durations so. that the cyclic . growth . of a. .single

Saanned 8y: C
 H_A_P_TE__R_4_:~P-HY-:-St:":'I0-7:
---------C- l-::"O-::G-:--Y-:-O:-:::F:-::TH:::::::E-:-N:-::O:-=R:':M-:-:AL:-:M:7E:::N-::ST=::-R::-:-UAl'
. --:C::-Y:-::C-:7-LE::--~---...-,---
" ,:_:. .69
..,\ ~:r..

follicle with ovulation and corpus luteum function Ree:tuitmcnt

has been conceptual~ as a kind of pelvic clock.
Normally, as corpus luteal "function fails atthe
end of a no conception cycle, estradiol and
progesterone levels decline and their suppression
of the hypothalamic-pituitary cis decreases. This
1.&ENSCS
results in .a narrow window during ~ch menstruai
R s D p cycle in which the FSH levels increase. Only
E 0 E
'C l
E
M .... - these small antral folliCles that -have acquired.
R tfOWClEI I gonadotropin receptors coincident. with this
u
l
l
(;
.T
. I
'0
N
A
H
. '
E intercycle rise in :F SH will~ mustered lntO the
next growth phase. This _g roup . of follicle$ iS
~ N -c referred to as.'a cohort and their early stimulation .
.E E
~ and. development \s termed r.ecruitme~t.
T
The tncst :crucial .eve nt for the futtber: .
dev.elopment of an antral foUic1e is ,the actiyation
of the ar.o~W.:~e system by .~H~ .I t is ..L!.ow
aecepted that ea.cb small :antral .fQllicle ~ a .
1~1;i ""21 , -u-uc:shold -requirement for stiml.ilation by. FSH. .
.DAY~ CJ'ClE As t'()llicUlat de\telQpment ;is highlyasynchtonQus~
-~4.7.'1-enns-u~ to-destribe the gonadotrcpb- at the time oftheintercycleri:se.inFSH,th~~$
dependent ovar.an eveilts durinl the .illebatrual cycle. . . cQntain .a cohort o( follicles wi:th v~rig .
Hodgen GD~ Ficrti1Sterill982; 38: '231~ . sensitivities :to _FSH. The f~lU.cle .with the~ ..
F .S H threshold will be the 'first til un:(lergo.:
activation of :Ute aror;natase system and ..tegitl '
estradiol production. . . :. :.,

In addition to ind!-!ciilg aromati;ati9i.i:t,R$a- ~ .

induces the synthesis and raises 'il1e
concen.~tion ofit~own receptoraon ~
.. ~.!!~~ - -:fh~:;:t _ f$1L!gi.E}~:w!,tl!.,.~~-~: .W~~ot__~ .
-: ~:ri~s m!~~m~.-~on..tll~r~bY.. ~timulating..gninub>a ..
prt>Uferaijon, Tlmgi together~ . FSH. and es~en
promote a rapid actumulation of "FSJ-1 ~ptors
and allow gradu.al expansion o r tl_le fo):.Uct.;$
t:: . -capacity .for estto.g en produon. The creation.o f
(]) an estrogenic microenvironment i:! essentia,l for
en . continued fo.iUcular gr-owth.
.,._
t>
.......
(/)
w As folliculogenesis progresses an.l i more
estradiol is produced, the rising estradiol l~el:;;
induce a negativ~ .ieedback and effect a decline in
FSH. concentrations. This, however, does not
adversely affect the most mature follicles. In the
process or developing, they have increased their..
number of FSH receptors and are capable .o f
sustained growth eve" -i n the presence of lower
FSH concentrations.
' - 3 5- 7 9 ..,... 11 13 - 15 . . . ~- .

Dav of the -Menstrual Cycle . of

;Th~ pr~e~s recruitment begins atj e end .
. F-Igure 4.8. Time course (qr r~~~ll.:ft~nt, .selection,
..
ofthe1uteal phase of the .prior cy~le, from tb~'-onse.t
ow}atio~ atresia, Ho>Jgen GD. $erono S}'lpposia 1983; of menses tci approximately 5-7 days or"the~B'lirrent
4~1 ~ . . cycle. Eventually, only a sing~e follicle will be able

Scanned 8y: ~
70 SI':CTION 1: BASIC CONCEPTS OF ~iUMAN REPROOUCnON

to utilize its hormonal milieu efficiently enough pituita.-)r gland. It is hypothesized that,enhanced
to sustain development, and the interval of secretion of fol!i~ulosta~n from th~ cchort of
recruitment "is C()f!!pieted. follicles recrUit~ in the eaily follicular phase
may serve to limit FSH release e.nd decrease
Selection {ollicular stimulation. The balance betw~ FSH
anq folllculostatin ma.y limit the size i>f the
Be~een days $ and 7 of the normal 28-day emerging cohort, prevent hyperstirnulation, and
cycle, asingle follicle :becomes destin~d "to ovlibilte commence the pracess of selection. the foUicle
and (Qrm i.lle corpus h.lteuin. Thia is ~nned fortunate enough tp have achieved . perhaps e ven
seleCtion.of the do'IJli.fi~t follicle. When the fall the slightest development edge may seize- the
in FsH 41 response to .t he in~ised ~~ttadiol advantage to eme~e .as. do~ant. then express
~tibil from the groWing 'foilic:;~...a ~--. the, and maintain its dominartee .t llrough 'COntinued
follicle. -t hat .beco.mea selected l$ the one leas !l~bor~tion of foiliculoste.tin and increasing
dc},enderit em citctlhlting ~ls of.BSH. 'This it quantities of e.s~gen. :
pwbably beCau-se it had the low~st FSH threihold
at the :onset of the intercycle FS.a oris~~ 'l'be Selection is the .culmination of the pro....~s: of
selected f.outcl~ wUJ .nav~ ,had lol?itet' .tiJ:net o . recruitment and highlights the titne when the
a~tiv~~ its atouril.tB.Se ~stem. l~" fP .~er innu.e nee of .a single follicle creates ~;~;n
estta<\id.pro4~ction ,e:nd treat~ gR:nU!~ ~ll enviTc:mme~t in \Vhih -only it ean adequately
pro~ilbn than its rivets. 0~ -~ the mature and reach o--.'Ulation.
follile iscalled a Graatm,n 9r Q.olilinant .ft,Uide.
O!l.'~'t)tec~otb#''haadj 'th~~,resttnt'!tbe~ 'ci>bo:rt ~'.Qf With ~. eJr..ceptiop~ only a : .single foUi~ ~s
fo1Ut:te:~,~~Q1e : :tttre:tie; at~F$B~~is:)Sup_p~o; ""-... selctechandsdestin~:to"o~te-~m~~c,b'NYarian., ...
belOW:theii :own:tlite$boldlevel/m~~-ii\;tl'$H ' cycle. -This sup.pp:se.d "ovulatory' qnC>ta is..
levels leads to a decline i:n FSHiO:de"1ldn:t , maintilined ltith :!Jtriking ~nsist~cy apd ~ be
arQ~~ta-se ~acUVity bf'l:ess developed.Jollieles;. .ov~tridd~n only with .the admini-stration of .
Jim:lted e strQgen. production;. ,_fut~tion;_.;tif . exogeno1Us gori~dotropL"l$.
gr.Q.nUTosaproiif~ratiOni .and inevitablyh'l'evensible
a~ ~ges.. . i>o~tnauce
. ........ :

. . ..?l!t.:.U~:~ .. P!2~M!: ...:P.!. :.:~~J~~!i~..!h" .-~~~!!~t _ The intetvaiofgrowth precedingovUlation.but

.ph,Si,~~ent _mily _ ~sa '~I1tii~ute to the rouowtn:g-..seletuon
is cihrea aonHnaJ.fce;.:-Ttie
em~ce or a-dominant folUcle. .Riaing~s~of. &oiiiinii1T .rollrae refaini
ifi u11f4ue
eskadi~t. -m
conjunction with FSa~ in4u<:#. th~ . respo~~ivenes~ to the decline in FSH levels
ap~ce Of Ul ~ptots on the tn.:\ter.~)'.er of ind-u ced t;>y its -own estrogen production; . It
~U}o$8. cell$. This ~uSes-:a gradua;lth.A.tige m .. continues to grow With ,en~gemenfot~ antrum
di$tn"Wtibtl'of-gonadotropin-tepWrav.rliih may and 'prollfetv.tion ()f Ule graimlosal and the. thecal
.be criti~ for .further follicular -tle.v.e~op~Q.ent. layers. The accumulation of a grea~ mass of
G~clo$a:celis that possessed bothF$ij.:end l,H .granulosa cells is accop:).panied by a:dv:mc.ea"
re~ptora have been shp'wn to r~spond siniUatly develo:Pment otthe thcal vasculature -which
to.both ho_rmones in terms o( ~matase actiVity results in the preferential delivery ofFsH to the
and ~tero1d production. Thi$ indicat~s t hat .the .dominant follicle. LH and FSH receptors are
p~esertce of'l)otb LH and F$H receptor~ op. upregulated by the combined effects .of estradiol
granulosacells m~y fl..uther .p rotect the e~e::gi:r:lg andFSH. These events.allow the dom.itlant follicle
d9ttliJ1ant foll~cle .from declinlng FSH to ~ontimie .preoV\).la:tory development despite
concertt;rations. waning gonadotropin 1evels and to continue to
secrete incre.asing quantities of estradiol and
Other honnones probably involved .jn the estrone.
selection process include gonadal peptides, such
a,-s fplliculostatin .or . inhibin, ..and .possibly The continued production -of estrogen is
.paracrme/autdcrinehormones, sucb-~s ariun'iber critical in coordmatirig , the .development. or the
of groWth 'f actors. Fo1liculo.s tatin is ~a: ~ptide different-'pod:jons of, the ' reproductive.tract. The
-ni oiety prOduced by the granulo~ .cells that is hypothalaltlic-pituita ry axis. requires es tradiol
capable of suppressing FSH secretion f~;om the priming of approximately' 2oo p gfml for at ieast

Snanned &y: C
 CHAPTER 4: PHYSlOlOGY OF 'THE .NORMAL MENSTRU,A;~ CYCLE ~(\ '71
------------~----~------~-~-----------~--- ""':n.i _,...

36 hours to develop the. ability to discharge and

to surge LH sufficiently ~or ovu1ation. Although
thC? speific degre~ .o f pr:iming that is nece-s sary
is u~known, the ei:tdometrium al~o requ,i.res ~
est:radio~ pd.rillng in order .to.beable to r e5pond
appropriately to . th~ secretion pf progesterone
during the ~uteal phase~ S~arly. estrogen
sfun:watio~ qf the etido.cerJ'.ix and fal,lopilin tube
is required ror n9r~al gamete and en1bryo
transport Therefor:e, the secretory products of
the developin,g follicle -prepar~ and synch.ro~ L1te
entire reprbduc-'t:ive systeni for ovulation,
fertilization, .ru:ui implantation. .

Once eno~gh I,.H r.eeptors have be'e~

acqUired .by 'the' :granulosa. ~eus: the 'do.mjnant
follicle~ enter the fmal or.p re-.ovuktory phase
of gr~wth (Figur:e .4.9). rhe _. gram::.los~ . :cells
enlarge and acquire lipid )..nclusions. The 't'h:eca
become$ vacuo1a.ted and vascUlar_. giving the
prCpV\lit~T1' Jolli~le a hyperemic ap~ce.
Now,..-,d e:a;rly sin;gu1ar: and d:o:ininan:t, the
pr~tOry~follicie
.., . . conthiu~~
' . t9. .})rodUce
. ever-
increasing .~mounts. Ql e,str~diol. which
pr~uCfiOA -r~c~es'a ~ak; app~t~ly '~+.~
:h~;{p);iq:r; .to ovWa.tion, th~ . ~ed, e:S_tiadiol .. ~

. - . .
:s~M~ ~ ;..,"ljr 'silcP, . 'a highly : -estr~,ge~c i '.~A;: :.: .... -- ~~~.t{~~~l...:;,'
.. envii(i,ruh~~. 'Ul~ p.1,1ls~ freqP,ency :of'~ is . . . ;~~~~! -~ .:'.i\.t;.:~~:
more).rap~ .a nd'tlle"~~si~Yi!;Y-Q{ the .. pituitary
gonadotropin cclls to 'Gn.RH is greatWe:Ohanced.. At midcj.cle_. a number of -physiologic
These events :lead to -fu.e .midcyc;;~.:gQ~Q!tQpi;i P.r.o'cesa,cs o~cBr which _p.rovo~e. tJ:t~. ;:ijnal.
-surg~. a . massive . dischaz:ge of.. g~il*-dotropiUs . Il1~l~~~~~.!Y..:!}~ges; }Y"itlim~Pt~.Jo~e..:and.
a'bb'tit" 24"lloufs" aff'l!r "llie~~stmarar~-Th~ .iP..g~l.~. -.4.vula!iog;~~!:. . .. . : __- -: ........ .. - . ....... --~ '
in:creas~. ~,_'R..is . mu2h-~ore p~nou..~ced -tb.~
:the-.inc.t:ease in .FSH and, .. for .tlib r easvn, the The t~ s urge stimulates three 'inajorey:ei:l;ts; .
m:idcyc1e.gonadotropin s~;is o.fteri:Called. the resumption o f meiosis -<illoWi.ng tbC cOCyte to- '.
LH s urge. .' Thereis evidende, howev~r. t.hJ;l.t 'b oth undergo rmal tq~t'.lratioil. luteinization of the .
~ortadctropins .are nece.~sacy. granulosa and thee~ ceiis. with . ;in~reased'
prOduction ~f progesteron e, and fOllicle ruptrue
As '1:-fl reaches it~ ~ circtilat:fug levels 'of. with e#tusi6!1. of a mature oocyte. Another .
estradiol p_ lunge" Prolonged exposwe to high . important midcyc~e event is the convoen:ion:of the
concentr:.ations o f estradiol m-ay re ~mlt in gr~nulpsa membrane from avascula:rized .to a
decreased response. of the target ti~sue. This vascularized. status.
down-r.e gulation phenOJJ:?.enon, ~~ting on LH
receptors, may explain the pr:ecipitous fall in Resumption <>f Meiosis
estradiol level at .mid,cycle.
LHappears.t9.allowthe resuinptiondmeiosis .
: The_go~d~tropin surge OCCUti3 a:bout.24.hours with ~r..eakdo,wn . of the g.e rmimil vesicle and
after estra~61 conceri~tions-havereached a peak. subsequent extrusion ofilie:first p<)larbOdy._ This
Thus, the preovula tory follicle itself determines process probably isnot -a ..stimulatoiy evei:it bu:t
wh en it is' ready tq ').lndergo the fmm maturational rath~i-a release frqm prior inhl~itioa An~
c hanges that. culm.in~te in ilie .release .o fa mature peptide, termed ooCytem.a turatiot;l ~.xi{PMI) ,;..
oocjte. .. . . . .' .h as been isolated fr:om follicular lluid ib,d is

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 l .

72 SECilON t MSIC cONCEPTS. OF HUMAN REPRODuCTION

proposed as the agent responSible for preventing
early maturation .o fthe oocyte. It is hypothesized
that the rn.idt.")'cle rise in LH inhibits the.production
or action qf OMi, thus .all~g. matlinltiOn to occur
at the appropriate tirile._
Shortly before ovulation, the ~ .oocyte
comp!etea the flrst meiotic divisiPn. thllike the
corre~pon~g s~e of spenna~eai.. however,
the .d ivision of cytoplasm is u.nequal,; . 1'he
s.Co.!ldacy ooc;:yte r,eceives -~~l .all -O.f the
t:ytop1aiml and the lir$t polar~ ~.hai41y
AAY At ovul!ltio.n~ the 1\Ucleua of:tbo .~ndatjr
oocne be~u the ~~nd m~ot:4 ~:n, .but
pro.~~ qn1y. to metapha;$e~ wh;i"c .ditl$iori ~
arte$ted. l!!ertilb:ation ~:the ~meiotic
. diVision is cdtnpiet~ -~.most-c-.;;:to~ iaa..Pin
retain~ only by one -,~ll. th-e .~ cwum. The
otb~ cen, Called the .$ccond p61ar:14Y, i4 .anmn
~d $00n degenetates.
. ;: _
LUt~bt~tto.'J(,, . ..-
_ . . .. .-
Equally important, this rapidin:crcase in
progest-erQne -is responsible for promo~ and
coorillnating several of the physiologiC changes
seen. elsewhere in the reprOductive ~ 'This
includes alteration .of :the GrtRH -p ulsatility Jrom
the hypothalamu:s and . release of Lll from the
pitUitary, the onset o f secretory change "Within the
endQtnetriu.m~ :a nd conversion -Qf. cervical m~cus
from .thin ~strogenic: .s tate to ~ thick
pro.gestati()nBI s tate.
.F oDlce Rupture ':md Oocyte EXtrusloh
,.;.
Follicular rup~ ~d oocytecxtrilaionoccurs
approxitnately 34-36 hours foUowiog ~onset of
the LH eur.&e~ S'*eral meehaiittama m.;r 1><:
in..-t>,.ed. ih ~s p rocess.
In res~!l:$e . ~o 1lJe. go~d~~pin ~. the
<:9-rite:ntof'~ue--~..P~~~-(tPA)
.

':;~pi;;~~t;~~eJ.$.()f.ut. ~t~~t.H,;.,. ,_ .:~!~=:J:A.;=~=:~~ :

reeeptors: toin1'tiat~lutdil~f'4tii$n:oftb~.~ul~ . iu~nicubu' ~~~~ tb~. ,~.JltoClUCt:of. ..
:.
V..'lUlfu the;~~~ follil;:;l~ ~tJadiohuld LH PA ~cti(:;n 9n:,~.1aamb~~$en, . Whic);l ae.tln;a to
. i,tl~m-.;t;.U,l.; a-.::~;etm~tl,c._ fe;$.hi9D .tG :l.Jtimlllat~. 11~ :~e_;~~~ .._tren,gt!l=:# ::tll~'Jo~;~ ..
~hol~sterot.:stdei<ehtlil'! deavaie ~:.U~W.t :'tlJe - ~~:-~~tio.n, it.~ ~n ; J'i~~~ :tJ:iat,.P~ ~
:result is .ac;ttterated. p~ucti~~:tf- ~~Q1Qnc plasmm.~~aptrffl:~oll.:ol:~tent.~se
that. as the iitimecfiaw . ateroid~ -~. and:t:on~~-itii&.tes"t)le.-Qreo)ytic.d.~ni&\'':.a :
p~OlH A fife ~-'.prGgi!S~,~~ .-~ a JcadintrW ~11.. . . .
~ -tbe-~Uiie~f$..accom:r~:Q~bj..a.~ ..... .. ..... _ __ _... . - -:~
:but-$ignificant rise $n ptoge~~rone. ' ~nus-d.~ ACtlo.,;.of.,Otb~r-:MedJaton. .
starts about 12 hour$ prior to the ~n~,ottbe UI
s~ .&\.~:signals the t~ofll.l~&n \n;~se rto! Stagbmdi,ns .are. de!~hitely ~volved in '
.~ulQsa c1la With t H r~ptbt:J. How.cver, foUicular 11).P~ Ma.t\Ite Pre~ fo1iides, .
1Uteiniza\iOI1 t:eq\lires.th.e:~ surge'fot wt.npt~n-. undel' LR !ili:tn1.lla.tion, .:ay.nthesize PGE2
Thus, fO.Ufml.ng:4'1e U~ : l!nitge, thb f9lll~ eells (pro.iitacyclpt)~ OOF2o., :a nd :P.Gt,. j:'ll. p~ :
~<>nv.en -irom prit)cipa.Uy esttoge);l. -~d- ;ptQ~in mecilamslnsto.exptain the~~ ofp~
setttio.p .to a.ecr.~d9n i:it ~~ttAdil>t S.tld aeUon .on ,fQ,lH~le . ~titure . are l) r:GF,n J:ttay
progesterotu~. . . .. the
facilitate - . .. 'Of b:y
. Ubetatioh ..drola&e
. . s '....J~
-
epitli~Ual cells cavermg the (ollic;:le apeX. Wbi41
. Wi~ the .J.;H surge, levels .()f .pn>~~ne .i h in:i~tes. breakdQWil -of the :c~U wall; and 2) f<>Uicie
the preov:ulatocy ToiUde (;X)ntinue todsc up to the rupture ,~ay be achieved thr!)~gh vascular ~
-.time of ovulation. The progresiv.e. rl$e in chang~ inducedby PG12 within tbeJc)llicuJ.vW'81J.
progesterone may act to terniinatc the :Ui surge Histaniimi, which is found iri the. ovarian bihun
t
as negative feedback -en:ects ,a,re ~r:tcd pjgher
co~~ntration. . .In addition, .p.-ogest~ro.n~ may
around the ves~ets an4 wh.i ch _is
capable of
inducing _follicular: rupture, iS prob!ibly imolved
serve to increaSe .the distensibi,Uty 'O f -~e folli~l~ in ovlilation. t;lradykinin, a nort-.peptide ~ .
wan. Progesterone may enhancc.J be.activity. of at in:flamniatory sites. by cleavage of ldn,iilogens
proteolyti. 'e nzymes, s.u ch as .collagenase :~si by the ~nmne lq:Ulikr~in. also probablymoclu1ates
plas_i;nin; thereby causing the Ciige~tion ofcollagen . o'VUl~tl.9.n . Qy _,.s.t~mul~~ton or.
:prosta~landin
i.n the. follicula r - wail and lricreasin.g Hs synthesis and ovarian contractility andactivation .
.distensibility. . of collagenase directly or via PA.

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 CHAPTER 4: PHYSIOLOGY OF THE NORMAL MENSTRUAL CYCLE .,,: 73
------------------~--------~----------------~------------------

,1 '.;;...
-...-

. Mucification Current diagnostic imaging modali~es have

provid ed fascinating images of the process of
-l?SH -~..J.,H ~tbnuiate the production and ovulation. Figure 4. 10 shows sequential
deposition of hy8:luronit acid, a i lon.;,sulfated laparoscopic images of the stages of ovUlation.
giycos8m.ihoglycan, around the oocyte Within the Figure 4 . 11 demonstrates a color -Doppler
corona radiata. This ~Hsperses the . cumulus, ultrasound of.the corpus luteum in the ovary.
separates the oocyte-cumulus complex from the
granulosa membrane and facilita:.tes the
extrusion of the.
oocyte at the t ime of .follicular
rupture. Folli"!lhir fluid also contains sulfated
glycosa.minogtycans that inhibit .hyalu-ronic acid
synthe~Jizing actiVity by cumulus ,cells. The
:fu11ction of th~ee sulfated glycas~naglycans
.may be to hibibit precoclous cumulus expansion
which eo\ild result from the. FSH pr~sent in
antral follicles prior to the midcycie
gonadotropin surge.

:Mua~.to Activity

,,:SJJiPQU.i. PlUSCle is pre8ent in the follicular~

and ;cb'ailge$ m .oVarian contractility have been
()bSet';Y~'~:'J>er:haps t}}e :fun~on of :this activity is Flgutc 4.11. Color Doppler U)traso.wttd,,bf'Coj'i)u~li.-Uiwn
in the ov.aly. The scan shows Yal~lar.isa)~~~~~e>)Jj~~
-to maintain a constant tension on the follicUlar Ovary l;lfter.ovula tion . At centre is a . .
wall~ th~r~by assisting 'm the . rupture and . an ~ has erupted. ~s structure on ilie~is tbe~s
f acjlitag: tho extrusion of the oocyte ~nd luk'!lm,:and is S\lrrouilderl bybloo(lv~ ~ ~
funlc'tittt~~lhipse. :P.Ulttascund~.en,treofLaM~o)aine~'M~~-~).
:.~-~ j~~ ~~~- ~~- ~:~ ... . -. . . . .. . . . - ; . . . . -~... .. ~- . :r~..=_.!:S:' ; ...._

e.velo.p ntent .of

follicle. B. Graafian
follicle. c and D..
Rupture scar a'fte.r
o.v ulatron. E. Corpus
lute.u m after
ovulation~

Figure 4.10. Sequence of lap~oscopic images of the stages of.ovulation. Im~e A. Laparo~copicview of th~ dcile.l<)PD1erlt
of a follicle {red .sJX)t, lower left} in an ovary. Ima ge B. U!.paroscopic view of a Graafian follicle (swollen pink
ovary. Images C and D. Laparoscopic views of the rupture scar (red, lower left} formed by the release of' a egg
reproductive cell from an ovary. Image E. Laparoscopic view of corpus luteum tissue (yellow) form ing on an ovary after
ovula tion. CNRI/Science Photo Library.

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~
 74 SECTtON 1: SASIC CONCEPTS OF HUMAN REPRODUCTION

Co~ve~9n of the Gl'attulosa Membrane ftom

Anaculad.ted to Vascularized Statua

"Before follicular rupture, the granulosa.

membrane b avascular and the blood -vessels are
limited .to the th'ecal cQmpartut:ent.
Va~~uJ;amaUoP of .tile granulosa begins at
o~~ and Js:.~ by postovu1atory.:day 8
or't-.1-be~e.ftot.n an a~--~a.vasctl)ar
statu iis itBpQ.r:ta,n~
for the dellvety .>1
U~tetna . -~.O.ther )$lib$trtttes .u, tile lut~ ~
. ~~- . . ~C:EPTCR
c~~
Fipre 4.12. 'the ret~u"iremttitsfor norii)alb.tteal function..
From Fritz MA, Si;>erf>ff-L. Cu.nalt concept$" ottheendocrine ~-~
. :::n#C i& ,ptol)ably mci~ ~ ~.ue: ~ogenie . charircteri!ltics 'Of nonnal-mensttual fuhCtion: .t he_key to
ft\~ ,in$c:'Jo~1e. ,nmna:n "f~ :ft\li4.- as . diagnosis and manl\gcm~nt of men$ttu.al dbcrders. Clin
wen.:u ,~~in u,h~ ~en. ab~ to . Obstet Oyneeo! lS83; $.6 :-647.
,Mv --~~c ca~bllil)r. O:t btr an ogenic
t~ii.~-~;~~Q~~~ . e.U4.mt~teU'kfulf: (l~_t.l. .
. ~.Jl' ~w.aw:'th~ .proauetiOr.. an~ aettvatiO,tfof
-~ ~s,:d~e ~u,e.COJn.po~ent~ Ni;;::mai luteaJ function and prc).gt!$terone
emtbl.b,:1:a. the ~nd6th~lia:l eeUs to.- ~gr:a'\:e. :and production .will . t:oU~- onJy.. .optimal .p~t!>ry
. $.li{~tt t'otoj:ni.new ~~cl~. - . . . fo!lic::ular ,jev~lo:pn)eJ)t. -t,u.t eafOtunttl,( m is
..: . .. . de~l').dert:t wttt..q~~t:a~ply;::a~bqWtn~tively,'
Coqu'Ja~t~~ : - : ' on-n outtal developmentt>f.the.sranu1o$aani;l:t:lleca .
. . cells. duii~_g ,t he prcedl-rig. f~llieqla): .pbS.~ e.
' After. :(rvi:t~~Uio.n; d1.e d~iiima~t follh:}e.. lnaqegnate.PIY~ration. (If.these Us .<luiing. th~ -
~'idt.ea:~tii'i~~e.:the,- .~t-mtat.tu~~-{~u$,-~. : . fotnc'Ul.9.l: phast nr,_meoinp1ete tu'teini~t:J~ -~\l.rin~ .
f~~ ~p~_:_()f'the.;folliel~; ~piUarle$ : and the :earlyc.luteal :.p;Jla:s~ ' .f.esutts ;b;L decreased:..
fibto.~t~a'tJ.-~ fr.o;,n_;:,.~~~~~~~p~n~&~~-tt~IJ.;l.a,.: . .- ~eti~n . of e$tr&\i~l -~ :p~~teroA;. 'This in

~.s . =~s~iE :(lu r-eonc~ily;. ~the ruUfiil

in tbe .to1lit.ulat _
gnmulo~ ~~J).s, ~ndergo motpb()~g!c .thah_g es
"deci-eased~~9-ror.itl1platita"tlo~auecess.
. . .
CQ.liectiy~if #{e~~ to ~s.l~teit\b~t\iiPn. . These ~e: ootl)us JlJteUplJ~ no~--~ -~uton9mously
lattet ~~Jt~; -th~ $~rroundW:g Ui~~lt)~~tstitial furietlriNnst.UUt bUt:it'!iiife, ~pati.:~a.:a~dogenic
edt~ fl.ilpth,~ ,~va~_g:va$CU'lahitelti~t'!:#.ingie:to capt:lcitj a,.:pp.e~ ..d.~.pe:Jtd~nt_:*-n ~ntnlued LH
give ri$'e.:~ -t<>rpu4 :.tute~m. , s..."efe~on. -~ov~:t~t;i.H;~pPott,thtol,igb medical
' . an'Q ..a~t:$,ie~ :4mphys~ct'tp..:V ~r. neU;L'1lli:zing
..'lb~~ti'Ptis 1l4teu~ ,is ihe'.~aj~ iro~-<>("$~ . . .anu00die$.'f.9'1.lt ~s\4~ h) d~~sterone
steroid,'Jr6pnon_e:s secr~ted by the ~-d~_g th.e .. pro<luctiort and .shortened.luteal ,p hases.
J>()stov:ijlatory phase of Ul:e men$qual cyd~. .
LDL-'c~olesterol:i~ the obligatory s1,ib~trate for
Requlrmenta for Notill~ L~teal''Funct.lo~1 progest~ro,n:e SY1ithesis in the ~i-pus iuteum and
. . - .. .......
: :. . .: : . . . .. :. - . ".: : . . .. . . ..
is niade..available a!; vessels- pen~trate the
Nopnal luteal function -re_q uires . op.timal., luteiniZed: ~~. nulosa following .ovulation.
preov\ilatotycfoUicular dctvelo.ptrieJ'}t, 'COn~ued LH
secretion, ~ re:a9-y -supply of :LDL--Cbol$t~o1 A$,. : . .P,rolatin, in physiologic concentrations, may
the o:btlgatory SU"QS~ra.te of progester~ne . play a permissive role in luteal steroidogenesis.
produ~tion-, -and perhap~ the tropic .actii;>.n of
physiologic concehtrations of proladtin>(PRL) The corpus luteum maintains its ability to
.{Figrue 4, i~). . . . . secrefe estradiol a nd. progesterone for
. . . . . . . SO.
. VeFal
.

Saanned 8y: C
 CHAPTER 4: PHYSIOLOGY OF THE NORMAL MENSTRUAL CYCLE .
weeks if adequate LH or hCG stimulation is
.provided. The hCG stimulation seen during th
frrst trimester of pregnancy ma..intains steroid
productio~ well beyo:n d .the ~~enth__gestational
week, when p1aceb.tal stereid prOduction 'becomea
adequate to maintain ~'-;.e pregnancy even in the
absen-ce of -ovaries o:. exogenous hormonal
.support.
Progesterone ~cts directly_ on the ovary _to
effectively suppres!'J new -.fo)!icular growth during
the luteal phase. lntraov,arls..."l progesterone may
-inhibit aro~atization -and retard .estrogen-
dependent folliculogenesis . :Tl1is .action of
pmgesterone ~y- be complemen,ted. by its negative
feedl?ack mqdu:li!,tiqp. -of go~~otropin secretion or
epliancemei}t
. .
<?f.tllat ofb.ltet4
. .es~ j:irtxluction.
. ... ';'
~ ' rne'.j:p.duction .oi end!>metrial progesterone
recepto-rs iS P,ow.kti<>wn i.obe an -e:St::ro.gen-reccpi:or . ~tion :o f b.:Ulllalf -cho~nic go~4ottPPiFL-.<P:'$.h ~-:
mdiated phenomenon. Estrogen induction of
. :;m:ffi~i~l1J.:,~:}'pro~ester9!le , _"recep'"o:ts . allc:rws
. p~~~ ~ - stllp.:ulate.- ~iY -~ndon;te~ . J>ioSfa:$1andii1 synthesis; :hcG ' cll:~.l.~~ tim.ely
'de~eloni:nellt.;.
... - r .t t:: . . rescue.
-_,,;';(.:-;:.
.. The:.~ndaxy -ri~. in estradiol production
duriilg:-m~:,lut~ p~ ~Y ~rve utrepknish ~~i9o.g_~~jl!.J~ w .~t:a,PAAb;f4.' : _.'.--
th~filldni~_mg~!9:2:'l~-.!!:.~~-~~~EY.
. ;tp-...:~<t the.. _1:l.Q{)mem!:lfq. w.!fu fue g;~it:Y.. J~ .. ....:_ 'Thl-OU.YJ1'i&~~iil?Q'r.~tianor~c<:1~-tlie-CQ'~~P..~.s
reach secretory maturity.
-.,uteolyata
_ Norm.ally, t4e.functionailife:span Qfthe corpus.
luteumis 14 . 2 day:s. With -advancing age, the
cc:rpus luteum become.s pro,gr.e~/siv.ely les:s
sensitive to LH stimulation and its steroidogenic
capaci!_y 'decreases.
The mechanism of iuteolysis in the. normal
cycle may- mvoWe tui -int~truptie~ -gJ th~. tr6pi~
action of lH. The action may take .place within
t:Pe ovary and .may result from, jnhibition of L1I-
~indin_.g. Luteal tissu~ cont:aii;ls a noJ+steroidal
LH-receptor \)inding inhibitor (LH~~I} which
appears to increase in conttnt:n;ttionJhroughollt
the lut~ phase. ' JtHRBI catl.tinliil:iitp'rogesterone
.secreti~n in ~tro 'aq:d it h _as been U;nplicated in
the process o( lut;~olysis. .
Scanned 8y:
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In .addition, r~gression of the c;orpus .luteum
may follow a withdrawal of LH stimulatfon,
induced by the feedback inhibition of its own
estradiol and proge.s terone production on
gonadctropin secretion.
Estrogen-Induced Lt!teolys!s
'The-deel.ine-in prog~sterone productio:Qi occtinl
as estradiol agaln rises to plateau at the Illidlu.teal
phase. sugge~ting that e:s trogen may initiate
. lu~eolysis. There is f!viaence that est;rogen-
ind:uced luteolysis may be mediated by
.pros~g1an4ins. ,Estrogen appe~ . to favor the
synthesis-by the corpue luteum of 'PGF2--, whiCh
ir..hibits progesterone synthesis and is th~re!ore
luteoiytic, over PGE2 , . which stimU:Httes
pr~esterone synthesis.
'-..
. . ( .
Th~,ollieiwi~ inevita!:>ledemise 9-rP.l~ ::e:Ow.u.s
l~temn is _p revente.d ~ 'the fertile :cY,C!~:.t?]Ym~~
< :
.. By per haps interfering with locat
oftlieco.,...;.;u~-1\lteum
. -:o--r . .serviT-.'d,'.w''kh'ou'ilate~
.....~. -~-~ .. s~ ~ ~ "' :
continued p.mgesterorie prodn'clio.il!::alii1.l;'llilis- :
mainta~ luteal function. ru1tll'')jj'ii;~~~fi-1t '
. .
direcb the silppres~ion of any n=w .fcllicular
grOwth. Th~ hCG <;ombines with prog~tcronc to
create an unfavoraole intraovarian -environment.
whlle placental s:terolqs exert ~egati:ve feedback:
Qn _gomi.:dofi;Opin secretion;. At the
}1,igl:l.t of hCG
producpo:p., the coi:pus luteum beccmes ~ctory
to fur:tl~.er-stitnula;tion,-and its evenU!a:t~on
is perhaps the res.u lt -of down-r:egUlation.of LH/
hCG receptors and functional d eprivation of any
tropic s uppor:t.
It is now realized. that the ovj:uy; instead of'
playing .a secondary role, actually acts as the
'Jrlaster gland.. tu1d controls to a major extent the.
functions of the hypo~halamus, pituitiQ:, and
endometrium. this concept adds a new db:ri:ehsion
.tli> the complexitY and deli~te ' balan~~~f the
mechanisms involved in tlie r egulationt,pf the
r-..
~
 ~

76 .SeCTION i: BASJc CONCEPTS OF HUMAN REPRODUCTION

menstrual cycle. Thes e mechanisms rnay be intrinsic and extrinsic factors and result in
. adversely affected by a great divc.r sity .of VariOUS reproductive and menstrual disorders.

POINTS TO REMEM13ER

The hypoth~1amio hormone4h~t ctrols the .g onadotropic function of the anterior pituitary is IJ)e
gonadotropin"''ei~Sing tiO.tniOilt (GnRH) . . .
~ 1b, eea bodles:Of.tt~. bypo~~l(:neUtons .thatproduce.~nRH are ~ntrated:maln!)'m two~
the ~n~ hYPOthalamus .$ ld,l he me<rtatba$aJ hypothalamus. the majon-oute .Qf"tral'lS.port of GnRH
IS :lh~h the .tJbef:o1nfundibutat.~ while t'le t;;n~qio., a speclal!;zed e~ndymal ten, serves :as ~
alternativeroi,ite. f,

GnRH:Is s:refed from 1he:b;,~musin a pulsatile manner, the frequency :beil)g mOre raPid it Ule
f?llicOiar phase, ,abOut :one :~ .per .I'IQ\Jr, and s1ower li11he .JuteaI .phase, .about one pulSe in2 to 3
hours.
Atlbw~ve~. Gn,RH~:~.thenumberofit$.own receptOrs, Thi,prtmeslhe .gCJladotiope.~
J>QtetJiiaws the:pltiiitai r~ .ti) a'sub$equ.ent pt.ilse ~f GnRH. At higber levels, 'however, .GnRH
" has :~.,opPOSJtee~
..~~..cllriitaWN~~t~"~~4'>u~ti.i&.,lhytbm~or.~GnR.fl~telea~;.l)pPea~. fO.et>-QAtte,,.~jng; . .
. pa~togy;:Jn,;~t;>rrten' ~:,~Ctow~ - at1(ilcr.'me~.due;:tc.'a:.:dys(\jll0tioh :~ the..
hypothalamici>ftultary-unit observeifin:sev~re weight)eSs,:,~nuocs ,exercls.e anda~:newosa. .
....:. - . . . . .. : \ .. ... -~ . . ' ' . . :. . : . .. . : ' i . . '

: : ~.~tk?b:~;~~ti\ ~;~ ,C'"'~f:S:.~, ~x~{ve o,rct>.t:'~~Pnt)J~K.roft?~H .~

. FSHl~J:lliUejt~\&.na:'-'~::~~og~nesl$tov~tllohl'l(jO~ependentairiditions.!\Jdlas ,
e~iS~ ~:.:~
.The ~tk>tl.Ot~nn~H. ~ :~e. hypo~tam~~ -1$ reguiated .and modified:by 1)'the.stlmutatofy and
Jnhibiteryf~~-ft~:i)Nhe~rt~n:~tQKI. h~e$iiestfadlotandprog~eron'e.-2.)lnliDtory.-
tee<f~efret..~~Ul~'(jpna~~ESM. and. ui, ~)Jnhibitwn .of-GnRH..synthesis~by-'Gntnrw~.
arid:.4~ve~f:rieurti~~~-~~t()tn.odutatots - -- - .. -- ...___... - ....-~
Do~mlne and 'notepl~rim;~ .invqlved in the regulation o(GnRH release. Dopamine acts in the .
median ;f!iTifO~ ,f.<)::ii:\~'thC,tetease o.f $n~H. Norepinephrine stimulates the telease.ofGnRH.
Es~n and p.Q)g~~J\0 . , tQ.lnbt~se levels .of cx-end~rphin in the brain and this ;increase may
ac0Utitfor. th~ ~~JiAApeney (if GnRH pulses in :ttu~ :rutat ph~$e. .
Gn~H ,~~u~~~~ .~th~.:~rid $~~9e. 6f bOth F$Jt ~nd lti, .~ng ~rn~gn the. se~nd. ~
c}icl'te'8.t.le~1ne3'$rn~phOS:Pl\ate (AMP). :I t aroo.stim~late~ the reh~ase.of both :Lf:t.and .fSHJrom
-the :samtvcell.
.FSH acts principally on .the g~f\ulo~ tells to stiml)late follicular growth. .LH stimulates androgen
synthesis by the lh~ ~Its and J>(:Qgeste_rone: synth~$i,S :by the corp.Us luteum. : .- ~ , ,J. ..

The secretory activity .of the ovary is r~ferred to as horm~nqgenesis ; and gametogenic activity as
foll'lcutoget)esis.
Three major steroid hor:illOnes are secreted by the ovary: estradiol, p~esterone, andandrostenedione.
The.amount ofcvarian .estradiol s~ted : dally .ranges from 100 to 500: tJg. f;:stradiel seCretion is
loWestat:fue onsetOf mense$'and .pea!<s before the rnidcycle lH pea!<. Irculating e~tradioHs largely
.bound to sex hormone-btn~ng: gfobUIIn (SHSG):
c

Saanned &y: ~
 .CHAPTER 4: PHYSIOLOGY OF THE :NORMAL MENSTRUAL CYCLE 77

Oaily ,progesterone production amounts .to about 4 mg duringthe fOllicular phase and 30 mg dtling the
.luteal phase. Circulating .progesterone lS bound to corticosteroid-binding globulin (CBG).
The -ovaries secrete less than 1.mg .of DHEA, 1 to 2 mg of andro$nedione, and approxim9te!y 0.1 tng
Of testosterone each day.
The non-steroidal hormones or factors secreted by the :cvary indude prolactin, follleulostatin or inhibln,
oocyte maturation inhibitor, luteinization !nhjpitor, gonadotropin-binding lnhibitor. insulin..:like growth
factor I, epidermal growth factor/2ranSformins .growth factors.-ct, transforming growth~ J}1, 'inlefleukiil-
1. t>a'slc fib~blast growth ~. hunpr necrosls :factor-a. and ovarian renin-angiotensin system._
. ' .
In mait, the dlpiOkJ number of thrOI'nOSOmes. is comprised of 44 aut9somes and 2 sex chrornooornes;
dUring meioSis, . maturegametes ere :formed, in ~ .Qf which there are ~- aut.()OOmeS and 'i. sex
chromOsome. The diploid nutnber ot"dlromosomes ls r.ot restored until fertilization with the union Of
the ovum and _sperm.
lhe spermatogenic cycle takes about 53 days in man and normally continues throughout his repmductive
life. - .

on~ ~4:QHetai PfeA the ~\e g~-ni ceJJs OU)()gonia ~tiS(!' in the yolk ~c. The..Qe.rm celts rema1n in
the tQiteX of the p'l'3mffi.ve :gonad if ~- gOhatl 1$ tO l>eeQme ~n oVaty. OOgonia diVidein~ :and
:pOsse$$ 46 ehtomQSOrnes amfattet the firstmeiOtic division fr0.11 the third tr.orith ..of gestatiOn.lt-:giVes
rise':to.primary oocytes-with a ehromos:ome Cornptem'ent of 23: 6,<; birth, .all :female germ ~ .-are .:
>-~ oocytes. . . ' . . . .. . . . . . .. ' . . ,.: ;;:.~.:~.: . ~~:~;~.
. From .a maximum .o f 6 -million follick>.s in the two gonad$ at the seventh month of intrauterine !le1 only?:-~-: .
.:1i~~~- rJ1illk>n.$ufVive to teaCh r.~t;ll:ftfe. By the tim~ ,Of menQrtle, only at;>out 40(),.000 ~ , .
,, >fo-rerna~n: .At.31~~y~nr(;fife,.~.depetipnJ$':~i~ted. ntpe age .of40-;~ :~ :
..r ..SOOO'iP.rimQrdiEli';J01Jides anHeit. ~: :':"'':~~-:.:, .''.~:.~,~~

I
.

During.the gonadotrOpin-depetldenhtage, the tnorphologlet~nd endocrine dynamic$ cf follicu~7 "
are d"IVided into Intervals: recruitment. selection, dominaooe and ovulation.
The.m9st-.cruclal~ent-!<r!~ttle..J~!~Jt~~llm~n~.At@g~ !!u!!~t1Q.l1lJune.adl'latioo ..of.the:~
systeriil>'v"F'sll tllelaiticle.with the ~ FSH th~Lb.e.:thaJir.stto...undergo.:actrv-atiOn-d-the .
a-rom..~ systema nd ~in:eStradk>l~n. FSH1ndUOOs the$ynthesis-andtaiSestheconoentaa6oo
of its own receptors on granulOsa cells;
The proeSS of recruitment.tegins .at the end of the luteal phase 9f the prior cycle,.from -the onset of
menses to approximately 5--1 deys,of 1he.current cyde~
. .
Thesel.ection of ihe Graaf~an or dQmlnant follicle ~rs bet..veen days 5-7 of. the normal28"ly.cyde.
In the proooss of-selecti~n, ti$i.i)g !eVf;l$.o( estrndiol,ln.:eonj!.!ncticn wnnF..SH, InduCe the ~R~-of
LH receptc)rs on theouterfayerofgranulosa .ce11s. The felficle thatbecomes $e'lected is less~nt
on circulating FSH.
Folliculostatin, a peptide produced by the granulosa cells, is capable of suppressing FSH secfl!ltion
-~ from the pituitary.gland. The :balance between FSH and .folliculostatin may limit the size of the emerging
cohort. prevent hyperstlmulation, and commence the process of selection.
. The hypothalamio-pituitary axis requires estradiol priming at 200 pg/ml for at least 36 hours to -develop
the ability to discharge .and to surge LH sufficiently for.ovulation. E'$ttadlot priming is also requiredfor
the endornetijum to be able :to..respond appropnately to :the secretion of-progesterone during the luteal
phase. Estrogen stimulation of the endocervix and fallopian tube is required: for normal gamete and
~mbryo transport

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.~
'' .
78 SECllON.t :BA$10 .CONCEPTS OF HUMAN REPRODUCTION
I'

The sume .of estradiol from the pre.cy!llatoryfullicle occurs 24.,.. 36 .hours priqr to. ovulation. Subsequeotty,
the pulse freq"ue~ of'G!1RH .beCOrries 'more rapld andthe sens:!Nity of gonadotropin ceHs GnRH IS to
enha~. leading.lo :.the mid cycle g-OnadOtroPin sutge1-4 hOurs after the -estradiolpeak. A$Lffreaches.
its pear., estradiol .level 'fulls.
The LH surge stimulates three major events: TeSUf:!1ptlon of r:1eiosis,1uteinizat.lon of the gnir.u\osa.and
thecc:r ~ls with irr9'ea$ed pro4juction of"prqgesterone, ,a.nd .follicle. ryptura \1-{ith extru:;ion .of~ mature
aoyt~.
...
lt ISh}t?Ofu~!zed fria(t:M midCy~~ rise Jr. .LH mhib1ts the production :or.action.of 0Mt; thus albwWig
maturatiOn i>fthe 6ocytW to.()Cct:it: ..ShOrtiy't>efore 6\iutation,-the pnmary Oocyte completesfue firSt
metotlb'tfrii@n. Ato:vu~ ~ pijdeus.of fhe .secpnda~ o6cyte :~ins the second.:mcloticCMOOn.
b\Jt~~:~r:re$.daNhe~. ~ -~~o~dlvislOn is~mple~ed .o~.fy~n ~
.ocetJI'S.
signifiCant .i jse }n :PfP9eSt~e startS. in "!2 ho;Urs :Pflor to the onset' of the LH surge.. Wteioizatioo
tqu,ires :t:,H .~ge 1br ~ . th~ prpgf'eSsr~ -ri~ in, p~~r-one may act. tq terminate ihe Ul
sur~ as M9ative feedb~Ck. ~ . . .

Pl'<?9este.~~-fn?Y.~~Tl~.1fie.aefuiity,..of.:~,a~ P~il1~~g the d~~ .Pf.~ .in

tne . . .. . waft,:
_ :.folik;Uiaf . ai\(F'
.. ~ 'itS
.. id mcrease.attets;
, . . 'l lt$. ra.P..
-Ol$tei~&Pil!t . . . , ..GnR.H
. .. 1'\1.\i....;t>atV .. . ..the
..,,.............!'1. ;from
o :h~~ an~HJ.:f:f~'~!'PitP~cy.tr.e.~ ~(:se:tory .$~g~
wiihin ttfe.,~ndom~tii!Jm. ~r)d
. . - -~ : . ~:t~;:~~,~~~-~~~~~~-<~.;~:in~.~.~~:-~ :a~ ~:~a! ;~~~ . , . .. . . .
.. -F.oJlidi~: ropture::ahlf. c;>Oeyte,~ :oecuts'-~xmmtelye~ -~ $ :hours: follo:Ningot:tset-.ot~~:tit .
. . sur.ge,. . ..

..
-~ ~illationbf,~ ~~,~;~:~tes .Synfuesis~of.PGE2 .PGF2: <and~-~
~~
:to.~thj; .~!(dOWn ~.$f.;the.~fotiU~cell ..~., .J:Us~tami~..;?OQ. hf:adjkinin:.are also ..~pable.:t,>fJ~ :
totflcuJar. NP.:ture..
...
- ~-n.<W~_tne.gtanO~:i~Ul'S~at~OWtat:imfarl(h~~tcbypo$tovu~cr:i~Y"~or.~;thi$b'
.. .ifn~nt.rtt.~ij~.:o'r~anfro~sUt;s~~-~':.fhe-;totwc:e~:-Angiogeo1ciact6rin1be ...
fQiftCie.~. ~~rn :t~,.~~. &qtet1ettl<ln+'t. -~ ,~ies: .
. Mer OVUlation, trnt .dOrfl.inaotfolticfe .~rnz.es to .~ tnec;Qrpus tutet.Jrn. .
Nofrriai ~ ~fuOclJon r~,;~lpre.ovul@ry :~tflcol~ir .development.'Cohtlnued LI'J:~ a
reaeysupp1y of'.q)L~t~_:as;the-obl!gatx:ii'Y~~te-of..ptogE'sterone 'producliOO; a~ =trwtc~
of -pfi~tpgiC .:CQOCehtration$ ()f.:p~n.:
.ln~~iia'n :~~~~~iohefu3y:
. . ;. !Nl:Mrt'af:Om~!i00 ~od. reta~'eslrog.en-<.fependent:foiJico'l~:
The secondarycise<in .esttadioi:.P.rMuctiori duting the luteal phase may serve to rep! en ish the endQmebiaf
pr-ogesterone r~pt~ ,~rY .fb pr<:>vide the ern,femetnum with the. capadt)r to r~ah 'secretory
~~R~ . .
f!uoctionallrr~ span of the CO(pUS.M e!]m i-s.14 !..2 'da~. Regr,:ession of.the corpus lt.Jteum may~ a
wnndrawal.ot LH stimu.lati<>n. induced by 'the f~back inhibition of its own estr?diol and progesterone
product!Of\ OR gohadotrOpRl secretion. . . .
. . . . . . . . . .... .. .
'In th.e corpus. luteum, -~,favors the ,syntM$iso f PG'F2.ci. over PG E2 .that inhibits, and -stimulate
progesteo:>ne synth~s;~resi>ectlveJ. .
By Interfering with local :prostaglandin synth~is; hOG .~ff~cts.a timely resc.ue of.thecorP!JS luteuin anq .
the conceptus directs me
suppresslon ofany newfolltt\Jiar growth. : .,
. . ..

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 _ PTE_._.R_4_:_P_H"-YS_IO_L_O~G-:-Y_O_F_TH_
_ _ _ __ _ _C_HA _E_N_O_R_M_AL._M_E_N_ST_R_U
1. MoghissiKS (~tion ed): Reproductive Endocrinolo.gy
and Fertility. In Visscher: HC ied): Ptecis IV: An
Update in Obstetrics and Gyneci)logy. American
College of Obstetrics and Gyneci>logy, Wl<.shington,
1991.
2. Yen SSC. The . human menstrual cycle:
neuroendocrine regulation. InY enSSC, Jaffe RB (eds):
Reproductive Endocrin.olo_gy: Physiology,
Pathophysiology and Cliniw Management, ed -3,
Pbiladelph!a; W. B. Saunders -Co., 1991.
$, MBstroiamliL. Coutifaris:C. (~}:Vol!. Reprod~ctive
Physiology, The flGO ManualofHuma:n Reproduction,
. New Jer3eyt Parthenon Publishing Ho"\lse. l990,
. 4. FtitzMA. SperofiL. Cur:rent concept3-oftbe endocrine
~<::teristi~ of n ormal menstrual function: the key
to ~sia and management of men'stru:al <lli!order:;.,
Cl!n ohstet Oynecol19B3; 26:3.
5. 'Tan DA.. Fbysiology of the menst:tuai-ycle: -~ and
'.:cliniCal ;implications~ In Tan DA, Almeda LA. ArceoRB,
: '. 'RDA 7.!>;
Vera MTR (cds): Practical Reproductive
, \{J:ndoctin(>logy and !trl"ertilit"'f, Manila: Phiilpp~e
: :.O bstetrical and G:;-"71eCJJlogical Society, 1992.
.. , ..... . .or,.;
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.E_ _ __ _...._.;.:_
_A_L_C_Y_C_L_ _; ~ 79
~:~.
6. Tan DA. Follicular' dynamics. In :Wong PC (ed):
Proceedings of the Fifth Postgraduate Course -on
Clini:;al Reproductive Endoqin"ology and Infertilify,
Singapore: MediAd Associates, 1993.
7. Scott RT, Hodgen GD. The ovarian foUick: iife cycle of
a pelvic clock. Clin Obstet G_ynecoll99o; 33: 55 1.
8. Hedger.. CD. The dominant ovarian follide. Fertil $te..-i!
1982; 38~281.
9. Hodgen GD. pvarian fun ction for .l!lultiple follicle
matu.raticn.. Clin Obatet Gynecoi ~98:6; 29:127.
10. Iria.nni F, Hodge~ GD .Mechanis:m -o f ovulation.
EndoerinolMetab Cliri. N Am. 1992; 21:19. .
1 L Yo~ma Y, Wallach EK StudieB ofthemechaniam{s)
.of mammalian ovulation . Fertil .S tezill987; 4-7;22.
12. Adashi :EY. The ovarlancycl. Iri. YenSSC, Jaffe RB
{ecisl: Repr-oducti:y_e ,l:)ndocri:no~Qgy: Physiology,
Fath~_physiology and Clinical.M6.1>,~t .-ed 3 ,
?h.i:b,\d.el.phil:i.: w. B . Saunder3 eo~, 1991. . .
p. Adashi EY. ln~Ya.rian peptides:I-i.flmiilatff/:t~~d
i.nlu'biton ofT6fficular growth an.d;.di:frcRritfation.
Endocrinol Metab Clin.N Am 1992; 2r;L'' . ":t.;:'-:- .
C
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 .):~~-

REPRODUCTIVE GENETICS

CARMENCITA DAVID-}>ADILLA, MD, MAHPS

EVA MARIA CUTIONGC0-DE LA PAZ; MD

I. PrinCiples of Genetics
A. Introduction
B. Chromcsomal Aboormaliti~s
~.... 1. Numeric;al Abnormalities
a. trisomy
i. Trisomy 21
'ii. Trisomy18
iii. Trisomy 13
b. Monosomy
i. Turner syndrome
.c . . Polyploidy
d. Mosaicism
2. Sex Chrorno$omat Polysomies
a. Klinefelter syndrome
b, &rf .
3. .StructuraLAbnormalities
a. Rearrangements Within .a Single Chromosome
i Deletion
n. Duplication
iii. Inversion
i'..'. ls<X:hromosomes
.,_ Ring Chromosomes
b. Rearrangements Involving More Than One Chromosome
.i. TransloGation
1. Reciprocal Translocation
2. Robertsonian Translocation
ii. Dicentric Chromosomes
iii. Insertion
C. Mutations
D. Mendelian Genetics .
1. M~ndelian Inheritance
2. Autosomal Dominant Inheritance
a. F<:lmi!ial Hyperchofesterolemia

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 b. Marfan Syndrome
c. Ehlers - Opnlos Syndrome
d. Neurofibromatosis Type 1
3. Autosoma1 Recessive lnherit~nce
a. Phenylketonuria
b. Maple Syrup Urine Disease
c. Galactosemia
d. CongenitaJAdrenal HyperpJa~ia
4. x - linked Dominant :tnheritance
.r: x. .~....t;'ed' -n.:...~l:. ._ . ' h~........
. ..n
..
V.. UUJI. :{'.~y:g tO <;U\QH~ . '

a. G,FJcose ~- 6 ~ Phos:phate rMhydroger:lase O~ficiency

b~ Hemophilia
c. DUChenne Muscular Dystrophy
6. Y - linked :nheritance
E. Non- Menctelian tnh&riifince
1. Triplet Repeat Expansion Disorders
a. f=ragile X SynW-pme
b. Huntiogioo Disease
c.. Myoto.ibc~Oyw.o~y:...
2. GerJ0n'iic 'lfi'lptjritil)g'.'~'
'3.: HnirafentakbisOtnv.:::.-
1"'- .,
4. MitochondilatiDisoroers
5. Miiffifactorial Jnherltance

... IL GeMtics
. . :ofPregnancyloss
-. . ... .

IlL Genetic History Taking and Genetic Counselling

JV. Newborn Screening

v_ Stem Cells
A.. Classification of Stem. Cells
1. Embryonic stem Cells
2. GerminaiStem Gells
3. Soma~c Stem Gells
4. HematopoleUe$tem Cells
B. Stem C-ells for TherapY.
1.. Embryonic stem Cell Therapy
.2. Adult Stem Cell Therapy

VI. Cord Blood Banking

VI!.Preimplantation Genetic Diagnosis

'I

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 ... . 83
, ..

PR.lliCIPLES OF GENETICS

Genetics is the science of heredity and

biolog ical vari.o .tion. Genes a.re the u a its of
m.heritance. The set of genes of an or:ganism is
called the genotype, whereas the physic al
manifestation of the gene is called ~e phenotype.
Aperson's physicpl deve1oprnen~ depend$ -on his
genes, its interaction 'with one a.."<J.Qther and its
interaction with tl:te environment. Different
v~sions of a gene that 9(;cupy :t..he same .locO.s ~e
called.alieles, Individ~Jals with identipa.J:~eles for
.a given trait are ca)Jed 'b.9mozy.go~s. wher~s
individuals with :differing alleles for a t;rtrlt are
-called heterozygous. All-eles dich;lte traitS that are Spurce: httP! I fwv.'W. phoenlx5 .orgf.g!o~sary fgra.phlce I
-either dm:p.inant or recessive. If one -of the _g enes o:t!ChcoqtoDNAGene.gif, Ace~ on April-2S, 2008 -
iu.a pair ~es th~ phenotype 1n pref~ce to Ffr.i.r:o '5.1. Structural o~tion .of.the g~om:e...
the ~-g~. t.hen~t triUtiS . do~t,. Trai~
or. dl~~ tb.&t occur qnzy- ~hen both wPies of
. tb.e'gene are.-
the .~e' are ~ . tO .be.~v~.
Ce~"3/9,f ~ -~~ 'body, wiilithe d~R.fion
I . . .

. . of .genn ee~; _cop.tafu:4~ pairs of . ~oniosoek

: <knesare :<;;ontained fuCbromo~~ -wttich (F~- -~~)'Ce~ ~n~ :22 pairsofaut\)Si{J:#.~
cii.~~: iii pa_in- ~4 ~ .r~gio~ _of .tl1e- cllro;p~me a.pd--a pall' of ,sex.chr~m9S6nre poe in .fetfialestand-
wh~. :~ -gepe is. -fo~d ~ ~ed -~- 'locus {Fiz-.u:e . X'{m.:~. Th~ :eggs .a nd spenns a.re . _fu:e. gen~r1
.s.:'J-~:.'.0-*-i~.::pr -t1ie ~'brt?~~m<?. _p airs -coin;eS -~m ~s, .tl,)e ~n>ducijve. ~- ~ch 1:n.a;tUie~ g~
th_e:~~~- aoo.W,.hile the. otlir: :C'O.~s. fr9m '.the cell t~ hiiploid -and
~ontain-S'' a .smgJe
,~t:;:~t~.3<
fa~: 'EaCh chro~oome 'bas ~ c;entro~~ with chl:-o:nios.~p:{es. The Infern~tion.al' : Syst'~m''}Ior
one or two arms. proj~ fro,o;1 the cep.tromere. Hum:an C yrogenetic N.onienclat:Uie (ISCN) ,deYi~d
- ~,~ti,Q~ diW:l~-~e.f?.h!-~o~~~~t9 -two .th:e .stim4a.~::nomenclattfre-.for 1Calyo~;-1'he'
~- 'the short -~denoted -a~ for :P.f<~ ..Ji.nd total-n:iini'beF-ofehr--omo~~e.~C<)mesiir~ollowet;l
:,,~-- ~~-.rohi;artil]d~oo~A.;:.;,z:ib_eJe.tt~~p). by-..~e-:~-ehrQmosome-then-tlre-cd~riiptiorr'ot'

ll {'( k )( J) U'll u11 lu 1:1 . ., ' ~ ..

)l !fH }t t( Uit
i 4 .6\ . ll - t
l .II _-ll 1:1 !-f
lo t t ..... ...
If. "

I~ ('

u ~~ .~ ,;, ,, . ''
,. t ! .I ll., l.A' ae" II Jl"
II .I.& ,,
"
~
)
"
.... ~
1.1

4
A IJ ~-
. ..
. 46,)(){ 46._\T
S.ource: In!!tifut~ o~Hum:an Geneti~s, National ~nstitute~ of Health, -Upiversity of the Philippines~~
Figur-e 5 .2 .. A. N9imal felnal karyotype. Ba Normal male karyotYPe~

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.;t \'.

84 SECllON t BAsiC CONCEPTS OF HUMAN REPRODUCT10N

the variation or the abno_x:-mality. detected.

-Duplications are denoted as dtgJ. derivatives as
d~ .and translocations as t For example, a normal
female has a chroi:nosomal complement ~oted
as 46;XX. A fe:::nale with ..tri~nmy_ 21 has a
.
chromosomal complement of 47,XX,+:2.L 1 .

Chl'O.mosomal Abnormalities
.I
z~ ~'
Numerl.cal abnorma.lltles bf throl:no.sQmes
C\.I'e la!.o~.~ ~eupl_oidy. An~uplpiey~~ vm~n
. a ha:pl~id ~ete or <$_plo~d cetllacks otis ~!excess
bf the expected n:\lmber -o f ch.rom:osom.~s: I ;~ . . . frio<Jmi .'~ .. . ..
A'neu.pl()i~y. inC1ude~ m .o rtos olliy, tri~my_, , sO~ Aqapted. trom,;. Co~:selii:i;g Aid:, f,or.Gehedci~t by
polySQmy, pqlyploidy .apd IP.O~cistn. the Greenwood Genetic. Center
Figure.5..3. MeiQ& non:,.ilisjUIJ.ctiqn.
Trisimty is the p_resen~e .qf ~ ~dt:lltio~al
chrc.mctsome. trisotn.is C;on1Ir!:o~y aris~ from
meiotic nridisjurtctipn (Fi~ 5.3). Wherem:the . tl!acrogJ.ossia,.f lat.nasal bridge, c~~With
chro:moso1!les fall to paif J?.P irt,itia!lj <>'r ~~-to pair ilatten~e ~o.cciput., ll'Psl.ante:d :pa-ll>-"bral
properly but..:separa~e ,prein;aturecy O.r not '~t all. . .fi~spi~~. snt,>r:t !lqgers. ~gle ~ ,ct:~..
r:~e-~k;o:f;n:on4i,.sjAn.~n-in~~~~~~ loose skin 3:t the,~pe. c~~~ly .and :ci Wicte
.
-'~e (attinau~~'~t}!~~~l!~~;.fh~ .., .glfp ;betw.ee~~~eJitst .and..~~d. ~- .QtheJ?.

~::rt~~E~~~ .. .r:nan.ife~ti.qn.~.iticiq~ec~~efe1;$. u~
.e nd9Ca(dW. CU:!!liiotl:~~f~Jj. .-iaSlioixitestinal .
. .atre:sia, thyroid ~ise~se. !p~rtic:u.J.~iy:

.ar&ur::se:r
.. prbft~~ti~ll:;jhi~~.PYP9.~~Si.s.:.~~c~~ ~,~teS;:t~ai ..

~st'!l~~S,~ro~~ii~~~n.,~~~~~j;hat
on~gamef~i'eeeiv~~~eppies--<>~.cbrt>~.me.
. .'P..Y.Po.~yroidis~~-. i\.p.d~.iA~nw~ re.~&q_.a tpe .
. .~ew~:or: -!dei:itai:-h:an~i>.~~~,Jro~. mild; ..
.... w~m.Od,~nt~e,,
2). T~D+-Y
. . . ~~a:tiob..:~~- ~:s{13'-(S~~J.I
. . . . ... . . . ,S.

18 r,>f E-!iw.a'rd, .~yg4t()~e ~.'in 1

in:c3(j(;j{)..~o-l:"i11S~.Preg]iaricldi1m.d:. ~'3':f<?~4 .
w.b.ft~-i.h(,-other -does-t):ot---h~vt:.:.a~y~uj)o.n.- time;>-mote.co~~n:-.amopg-!~1-m.fe.tus .
fe:rt.lltzation., the :g amete witl,l the extra is .severely gr-owth restrictea, Infants oom:V;ith
chromosome becomes tiiso~c whlle the other
g.am~te, wh~n .f.ertruzeQ., ..becom~s :onooo~ic.
M:a:~~-:ag~ fr~t :varies among::.chronlosomes.
A. ~~-portion,~! trisoini~ ban''~ : a.cCou:n,ted.for
by di~ption m.
paternal meiosis:. ''l'ri~ for
almost all chromosomes -have ~ de~bed,
HU(< .ltll
11 ntrlJ unu
1 t . .1 .,.

a~pt.fm: c~omospm~ 1. N~o.s ~:triso):~ie~ arera.w

with'the,~~pti$,oftqs~nny 1~\ loS atl<lQl, wbicb.
.~ .s~'Ve up .t-o tern. HoweVer, surii\ia). post- . 1 -.. :!' .v:
natapy varies ~o11:g _,:he three. Hi

L Tri39my 21 or Down Syndrome wa's .p.amed

\l . ~-..~ li...
after J.L~ H Down, when he identified the
~l,morm~ty in 1866. It is th~ .nipst copnnoi1
autosamal chromosomal abnornuility known ,. . ii ...
(
to m,an and occurs in every l .out.of:800- U>OO
livebotns . .Ninety five percent -of .the ta5es. is 47,XY, +21
due to Jru;tternal :q.<mdi~.unctioi)., 7~% ofwhich So).tree: Institute of Human Genetics, National Institutes of
Healttr, University of t}:le Philippines.ManilR .
arise trom meiostsI. Individ\l.a,ls with the . . . . .
disorder may manifes t. with hypotonia , . Figure 5.4. Karyocype.of a male with 'I:riso?'ly 2 1. ../

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 !-

CHAPTER 5: REPRODUCTIVE GENETICS i~ . 85

--~------~--------------------------------------------------------------~~

the abnormality have a prominent o:cciput,
short ~pebral fissures, small mouth, rotated
a:q.d malformed. <;t.uti,cles, -_short stemu,m, heart
:defectS, horseshoe k idney, overlapping' digits
of !he hands, rocker..:botoin feet (Figure 5 :6).
The prognosis is very_poor - 50% die in the
first week of life; oq}y 5 -.10% st1.0ive up 12 to
months .of life. Qf:j:he m fants with Tris~m.ly 18
who suniiv'!~ :inost ha~e .severe.mental
handicap. 1.s7
3j. Trisomy 13 .or Pata11: ~yridiome occu..rs ~ 1
S:,QOO to 1 in 12,000Jive births.
~. . .
Most .
~ants
.
with Trisomy 13 manifest w;th cardiac defects,
holopro.sen cepha ly, microcephaly, hyp<:~te
lorism, a bnormal ears, omphalocoele, .r aal
and cutis aplasia , polydactyly and proiilinent
abnormalities of ~e orbits: nose and palate.
Prognosis is likewise poor, with a mean
survival rate of 7 d ays. lS,a
Monosomyis a deficiency of'chromosOmes and
arises through a similar mechanis m.as triSomy c r
llirough ana pha$e lag. Desp~te tl;le similarity with
per trisomy . m.onosomy is ~o.t as$6ciate'd with
increa:~d mate~al age. Monosomie.s -are
. .
usuaily
. -

. ;.

~-

. B C .,,...
. . .~~ .
~institute o_f Human Geneti~s, National Institutes .of.Health, Univ~sity pf the Philippines M~. : :
. . ~

.Flgu.re 5~6. Individual wit11 TJ;iso'my 18 or Edward syndr~me 'showi.t:tg {A} typical facies (narrow: bifrontal.diamem; short
paipebni.l fis$Urea, small oral openU,g, micrognathia, low s et earS) ~) cypical overlapping of fingers, Sth over ilie;<yi:h.and
~nd over the 3rd .f ingers and (C) rocker bottom feet (arrow). ' ..

Scanned 8y: ~
 ...
J

F
..... 86 SECTION 1: aASIC CONCEPTS OF HUMAN REP.ROOI)CTION
.(

.~ ..'

.......
not compatible wi~ life, except..Monosomy X or
Tun:ler Syn~~e, and the conceptus frequently
di~ .prior to imp~tion. 1' 5

45,)( or 1'umer .Syn4rome

. Occu~ at e.:frequet1cy of 1 in 5000 individu~s

and is the only monosomy compatibJ~ ~tb life. It
.a~un.Ut for 2&k ,of}-JIQ.m aScll;'lally abnormal .first
~~t=r abor:tions ~i!d ~s the most co~m<;>n
.a:n:uP!~iP..Y in abortu$es . D;ue -~ an increased
inclAen~ <>f mosaicism. the ou~'Ihe ;of "Turner
syndrorile i3 :vaned . .It '-p;l.ay :resUlt to either an
a:ittioii. a cystiC .hygroma with hyd!::rips fetiili~. -a
.or to-a' liv~ born 'infant with the Tu;rner .syndrome
pb.en'O'iy,~. uveb:om5 1.is~ally .hav-e learning
disaJ>Ul~- b\lt ~.Y -h;ave ~ :n~:nnal IQ. They
pre~t ~i'$:.i.~~~Jj #Pi :~)t,o,tt: s~~. a :9r()ad
thet ~th-wtd:Hy..,~pa~ed ;nippte$. w.~l;?b.ed
:pos't~ti~t: #~k . 'l:ow -hA;~l'l~n9~: ~t~P:~.~~ttl;ll

~-iit::;Vl~..~:;;~~~~;~:, ,. :.:.....
_.dy~.iw~-~~3 ,:an4_ .. req:uir.~::lP:ef~~g:f?~9~onal .
re:P~.~~~~f. .. . .__:;-. :... .... .:
. .. : .. . ., .
or.poJy~iAi4j:~ -i~ ~P.i9:i4Y.:.-.la~ ~~i- ~!J ~-ui- oc
chroin.o s6ffi.e.s); :.rti'is>#i)e:~ :'Of. ~.fti.&xito~~;naJ: .

.:~~~~lr~~
""'

..

.,.. . . .. A . . . ... . _ .. _ .- . . B . . . .. . .
s~~. Mother- 1~ year old.patie nhiitliTu.i'per ~drome whopr-esentswit,h sh ort statur-e, (A} webbing.~fthe neck,~ :(
..-~)~net of breast develo pment', (B) low ~s(erior hairline and scoliosis {arro'IV~).

""

Scanned 8y: ~
 ---------~~-"""::C:-:"1-\APTE~
" :::"":::
" :::~:-:5:-:::-R=.EPROO~::::
------------~~----~~~~----~------------~--------~----~--~~
are patencl, it is called didandric~and results in
a partial hyda:tidifd:r:m mole with abnormal fetal
structure. if the chromosomes are ~ternal, it is
call~ di~c. ln this type of trip1ol.dy, the fe~us
and .p!acenta.dcvelop with the former being
severely growth restricted. T:riplody has also been
associated with complete hydatidifortn mole. The
~:.ripleid: .p-lacenta" has been shown to ~av:e a
"diBproportwna:telylat;ge gestational sac~th cystic
degeneration "~f placental villi~ heniorrha,~ ~d
bydri>phobic tro:Phoblasts; whereas the :trip.lord.
abbrtun may. have n-eural tube de~~ts.
.ompbal~ and other ,iruilfqfJIUi.tiOns. 'frll>loid
.rectttr~ mki:H to 1.5%, and parents :wht) hav~
had a conceptus 'Wi1;h triploidy sl!ould have
prenatal diagno:si~ in .subsequeitt pregmincies.
Tetraploidyrei\llts fiom. .PQst- 'zygotic ~ to
campicle an early divisi<?~ :and ~y -p~ses
:bejimd 4-. 5 weeks .age of gestation. Its recurrenee
rlSk.~ mini:i:'ui"l.l"5
.;~m:Js "the existel),ce.:.of
W;ro
cytbgclleticilly,qistin..:;t "cell line~ in ~e .~e
.in~"Phenotypic expression depe::nds.on the
~Cjnvolv~ent whefuir fu: the pUid;nta,
fetu~ et.bQth. ~'.(rue mosaiCism fP,volv~ bo.th fet'\ls
an4ip~~tfi~but is'VerY ~e~ :CO.Plined j>~tal
m()Shlcisxi{-,i_fuvolVe~ .o:nl}t the plaeepta'and may
remllt:~61fi~;tondisjunctio:n during mitosis or.
piutial correction nf a meiotic error. Th-e exact
., . mechanism ..of mosaicism is cP,ron+osome
s~l-s .
, , . .... -- .. ,..,._
. . ~ - '
SEJCclm:"d:M<>~oMA.I;; Ql./f86ii!ES. TrlroiDles
o[ ~ t:Qn?mosoyp.es are caned polysom:ies.
XXY {!(l:in.ef~lter Syndrome)
. '
Affected individuals usually preSent With
:iYn.eroma~t4., small testicles and ~fertility due
to gonadiildysgenesis. They may req\lire lifelong
te~toster0 ne supplementati9~ due to 'lack of
virilization. lQ ~ges from 7.1 'to 122~ which is
vritlrln the nol:mal.limit but usually lower than
normat controls. Some rriay present .w ith speech,
. neuromotQr and je?rning dis abilities, and .other
development-prpblems. 1 5
47, XYY
Males with this gen,o~ have been previously
assoCiated with criminals, but r.ete:r:t~ studies
deb~ed the ~~ev.ious theory arid :have shown
that malesonly have . an i ncreased .risk of.
-:-:uc-:=::n:;:VE;-;;::-;:::GE;:;N::;
" En~.::;;c::;s:-
. "'---------~f- .. 87
emotional di fficulties, mild depression,
hypera<;ti~ty "and aggres siverl"ess. Physically,
affected individuals appear normal but tall Jor their
age with IQs within normallim.its .but frequently
lower than their siblings. Addition of an extra Y
chromoSome results in physical abnonn.alities 'imd
mental retardation. 1 ~
:STRUeTOR:A.L ABNORA.LITIES
Major . structural chromosomal .abnormalitie:;;
are a~sociated with phenotypic abnormalities.
However, there are cases called polymorp~s .
or chromosomal variant$,. whe:tein tiie
"chrbtilo~omal abnormality does .not . l~aa to
pheno&p'ica1 changes. Structurid abnonnelities
may be dassified a s involvihg only a sil;igle . .
chromosome or involving two or more
chrbmow~es. l.l.4
' . .
Rearr:ant'ments Within ~ Single Cbx~u:Dp~om~
~ .
. ~ ~ ., ..._..~ ....:;.. . ,j
~r more .
..,...J.:.
Deletions are due to misiligp:ni~ni:~r
mism~cll)ng of homologous thro1no~ts~d.~
meio.$ is. ~ ~ .result in lo5S,of a'..~~~'ili:on.e
chromosome and .d uplicati<m in another. 'SQple
:deletions.. occur more freq~ently . than:"others
indicating chromosomal regions., that;:a.Te.
predispOSed 1:? breakage: If a child pr~seO:,;:~~fu ,
a GhrOm<:>so.al deletion, the parel;itS~~i>e
tes ted to determine whether either cairi~s a
bala~~~4 tr~nslocation: that may in:cnaae -
r:e..lltt.e.oce. .iiS.k... .SJidro.nies4ssoe~ted:.:..Wifu:..a
chi.o.mo:s oinal. .de1etion-:inc-l\lde-Gri..,:cfu...,c hat
:syndrome. {Flgiue 5.9fThls s%d..:.c;me involves a
deletion of the shorta rm :of chromosome s.: Its
main fyature s are hypotonia, s hort .s tature,
characteristic cry, n:i.icrocephruy. rotil:d face,
hypertelorism , bilateral epicaptbic folds, hlgh
.an~ne~ : palate,. wide and .flat nasal bridge, and
mental retardatiori_1.3;4
Duplication is tile production of .one or more
copies of a gene, piece Of DNA ,or somefun~ even
of an entire chromQsome. Duplication may ;result
from unequal crossing over in meiosis or ..from a
rearrangement between two chromatids during
mitosis. In terms of function, any duplication is
considered a trisomic state for the gene loci or
gene s e gment atrected. 1 .3.~
Jnuer:siorts are l.es~s Common fo;~S pf .
chromosomal rearrangements an:d ari~ ~~n two
breaks occur in :t he same:chromosome ..~d the
intervening genetic material is 'lost or ~uplicil.ted,
Scanned By: C
 88 SECTION :1 : :BASte CON.CEPTS 9f HUMAN REPRODUCTION

possibly altering gene funttiop. . .(Figure. 5.. 10) Isoehromosomes are' c omposed of ~i~er two
lndividu~s . heteroeygous for. :an inversion ahouid lollg aJ:lil8 o.r two sl;lOrt a.nns of one c hrOme some
k linically .normal 'ir'the!r gene.s -are merely that 'have ~n fused together JW.d occur when
rearranged. and do. n ot int<!rt.upt t~ coding the centromere brerucs tnmsver.sely dwing meiosis
sequence .of genes pre~p.t at fue' break pomts. or .mltQ~is of.rionn~l c:m-e-mo~mes :or from meiotic
Hciwever., adv~ -mel~ outCome!'> ean ~ as error in a ~hromosotne with .a Robertsonia;il
'a r esult of crossing over durlng hOttnal .Jn.cioSi.s. translocatio~. 1 -M
As .a rule, smaller .in'V'.er:s ions usw.dly pr.oduce
greater.gen:eticim~~..:in T~binant;~s Ring Chrptnosonte ~~~tfrom,:cie~~ Qfboth
and 're~wt in a mor.~ deleterib\J:s pheno't;ype. t:nd~ of a chrqmoso.in'e With the ends :uniting .to
htverslon:~ i~volvin'g "latge_ .po:rti~.n~ . i;>f :th~ fonn ~e riD:g. (Fj,g:ur~ :5. 1:1} Substa'!i-:ti2l deltion_s
~m~til'e mayhe leas~ ~car:tt ~~ ~ reSUlt .m_ :~ abn9nnal .pherio~. 'The -r:ii;tg form
large E!~lCt;iOtis ahdd\iplk;aw1ltl are trSt!a.Us ~ .a'Iso ~e:its n~:.alignroen~ during mi.~~
Invers lcns :i:n,..,olvin,g..-30 :. 6:0.'% o'f -t~~ ti;>ta l m~o~i!! . disru:Pti:fig ell d_ivjsio:n and ~using
chrt"iriosome ate tno'~t likely chara:~te~ij by abnormal .t isstic growth and ~o~pro~ised
du:p:i1cattan:s o-r deficiencies:co.m.patible With spennatogenesia -in" ~e$. Other ~tations
s:U:tvi~ U;~-. inch.i.tle . srn;~i sta.t.ure. .m~ntal deficlentj' .anq
.~or ,,dystl10'rpbisme~ u;~ . .. . . . .

$fj~~~te~~::=~~~~~~~~_
:P.hilippmeoa
H~t:J;t; u?fiennty<>r~e : ..
. of -~
"46X tr(i).(p3i,q""J5)
~ e:s~ Jkryo~ .~f:~ 1ndfvi4uirl 'with Cri-d'u~t Source:lnsti.~te of.H~ Genetks, N atiorull I:n.Stifuti::s of
- ~e. . . . . . . Health, Univei'sity of t4e Philippip_ell Manila
Fiture 5.11, Karyoty pe of an individual With' a ring
cb.n;m10some.

Rear-rang~$eP,ts . lnvolvlng M<)te. 7ha.:n One

Chromosome

Tr.ait~lf>cation i~ ,an .e ~ch~nge of gcne.tic .

mat~ri;;ll ):>etweep. two -or m o,r,e p.on ho~olngous
chrE;>-m osomes. The chromosom e product .of th~
transloc f,l.~io n .ev.e nt is ,.c41.le4 a.. ~e~vative .
chromosome. 'Translocation can be classified i nto .
two ty.pes :- Reciprocal translocation and
46,XY.inv{J5)(q1 /..2q24) Robertsonian translooation.
. ~In;stitute.OfHuman:Q-eAetics-, Naticina:l'-Institutes of
Health. l(~v?"a\tyof_the. PhilippW:s .Manila . . . 1) ~ciprp~al J:ranslo.cation -is. also .. kn.Qwn.:. ~s .
t~'l ...... .:."... tr~ ~
~ ..to ...... 5.1.0. ~ ot;ype qf an ind.ividua,l with. ,a chromOsome
. double segment t.ra
n_. sloca
.. tion .and arises from
1
"$.. . Inversion. . : . . .. . br.e akage occ urring in t w o .d~ffer~nt
.j .. -

Snanned By: C
 CHAPTER 5: :REPRODUCTIVE GENETICS
chromosomes and . subsequent exchange of
fragments before the break is repaired.. 1'l1:e
rearranged chromosomes are :called derivative
(derJ c.l:iromo~om:es. If there is ~0 loss in
chrotnosomal material: a balan!:ed
1:ranslocation is fortned resulting in: a
phenotypically .nonnal .carrier. However,. the
:defect can be trens:Ihltted to
th~ offspring,
. producing. unbalanced gamete.3 axrd an
abn:o.rrilal 6ffsprihg. 1.2
2) Robertsonian tra:nslcicii.ti:on occurs jn 1 :per
1000 pregnancies and results when tAe long
arms vf two ~crocenm!;:. cl>'..romcs6~ .fuse .M
the centromere forming -one CAtoPlOSODie
.:Robertsonian transl'ocatibns hav:e. ;'been
. d~ented for ehtomoS(}Jnes 13.; 14, 15, 21
and Q2 :but al::m.oStiaiway.s:m..:clve chrom~rne
14.J li tliiS'kirltf(}f~1~tio:h, camirs.imve
4S.-chrQ:wps<ral~s $.ut are ph:etiotY,P1caJLy Sdl:uenee or B.njmg-etn~t of P.NA.i :~e.; ~ be
..no-rmal :a s long a$ th;e -:fused.ffung ~ Jtr.e .
:~:intaCt rcaniers frequently have ,r.~uctiv.e
:;.difficulties.:.. . Un'Q:alan-oed Robertaonian
. trall.slocations pro<:\u-c:~ . phep.otypic
. 'b' . . rti .(F .~ ... s l2).:1;'1 .. . . .
. ,a nol1DZ!l- e$ .Igt....e . ; . ;: .
. .
=.:
46,XX;der(l4;21),+?-1
.Source: -~tUte- of Hutnan <knciies.; ~at.ioqel-!nl>titu.~ of
Health; University ofthe.P4iJ;ippines:Man,lla
~ .S.12,:'Kaiyotype of an indiVidual with'.~ unbalanced
ka...-yc;type :&howing a translocation o:t7Chn>mosollle1.4 and
21 kading to the dlagnosjl} o( a translocation type of~my
21. . . . .
Dicentric chromosomeis a chromosome tb,at
po~seS;Sestwo c~ntromer.es. due. to ~o j.qinh_lg of
two chr:omosomal fra-gments .that. both_ contain a
centromere; Dicentric chromosomes may ttnder~o
Scanned 8y:
cell division normally iftheir centromer~..are so
dose together that. they -operate as one..H.owever.
when the c entrQmeres are far apart, ~d are both .
active, the chromosome may be drawn to -opposite
pOles resultin_g i."l. th~ fommtion 0f ruume.ph3.:;;c
bridge between the two. daughter -c~p.s.. the
dicentric.i:nay be broken apart !"e~'!llt;ng 411oss -of
chrom.o,mal m,aterial. or th~y may be ~lu.d~
in both. the .d aughter :p.uclei,..3
L'lSerlion is the a9-dition of g~ne* material
between tw-c a,djacent .regions. of .a chro.mo.some.
The addition<U chromo~~ .material ,"'!J)?I.y be a-
duplic~tion or. may come Tr.om a dtfterent
chromos~me. 3
MUTA1'10li$
. .
A mutatjon is a;ny cb.;n:tge in the, cep.t:Ieotide
. Jl1utations t;hat affe.1h.e m,1mberor structu.re of
c:hmmos6m~ or m.'u.tations that alt.er.,iridiviOual.
gene:s. 1'he :keqen.c,y o.f chr~~~~o~:ai.:
abficnnaliijes -~S -~ ,SilO~ to mcreasei:wifu .
_Uicr.easmg_:m aterilal St. Q.ri:tbe:othei:~..hc4:~ne ...
mutatio(!:s -h ave.been o~rved .to: 'Q at~. N.~~ .
;requency'With fu~gpattmal~~- ..
fot.~utooomaf4Q~t.ge~es;:Muta~,~~t&~:
cau~ by .mutage113 m~Ch .a:~ .ioliiz4igfrJi~ti9.P, , i
a.Ut.YWffig~ents-~DNA ~ ~~--~A ~
mu~:ti.9n :m~t ~W'S ~.aturelly is ex.>~ to
:*\l~~~!.[~:~~~ll:~.!!r~. ~~-~~~~~~ :or~~~~-
. ln . Mendelian inheritance; gene .m utations
involve on):ya single genetic locusand depend on
whether the phenot:f.pe is dominant or reeessive,
imd wbethen the . -xnutationisiound
. .,. . in.an
. .autosome
.
or a sex: cllt9mosome. There are several pat:tems.
. of transmission: auto~.J;nal .dominant, -au~mal
.rec;~,ssive, X - l'inked dortd.nan t, X . .:. linked .
reces.siv.e, and Y - 'lin,ke<l..
Autos9mal J;>t~minant Jnheritan:ce
Autosom~ dotWo.Mt tr.aiJs. ~ expressed~41
more than onegeneration. In these kinds p.ftraits,.
females are equally -as affected as male~If the
individ~a:Us homozygous for the dominalft,trait,
then aU :of- the e.hildren will. manife~~ .t}l~t.. If
the in4ividual.is h eterozygOus for the trill'ti then
SO% of his children ~ll.ik~ly manifest .t he tr3.it.
~
 go SECTION 1: BASIC CONCEPTS OF HUMAN REPRODUCT10N

.._.

Autosomal dorninant inheritance has .~veral manifests .a s skin and blood .vessel fragility,
characteristics; penetrance, e.xpr.eas"ivity, hypete.xtensible .a nd tra-n sparent skin, and
pleiotropy, and 8ex limitation. ~ refers hypermobne joints .
to the expression of the : mutant gene in
individuals. Ifa trait is:expressedinallindivid~,tQls Neurofibr'Orr.litcsis typelorvcm Reck!ingbausen
carrying th~ gene, then tq~ trait has 100% disease is due to a .defect on the tumor supprusor
penetrat-ice. &p.~vity rde~ to the d~ .to gene NF-l.:on ..ehromooome 17. It occunin 1 out
whieh the trait is ~~ssed. Indi~uals'~'"'t.Ying of $500 Jive births. lnd.i'VidUals mtUUJ:~t with
the same gene defec~ do not .Alway. have -the-~e .. multipl;:: neur-ofibroma-s (~enign tumors" -of
phenotype. Exp~.ssivi*Y not only oCcut8 between peripheral nerves) .c::afe-au-~Lspota and lHch
fru:Jiiliesbut also Within f$nlily memberS. P'.e!J:1tlripy nod\iles ln the iris. They are :at increased risk of
OCCilD when a single mutant gene show d.btine~ . meni:Qtiomas and e~dymomu.l.1M2
pben6ti)'pi~. etfecf.$. Sex ~ t'iCICUi'a 'When
the .mu~tgene ~ita effects only~~- ~ AutQII9$al Rec~sal~ Inheritance
So.!De examples of conditions ,Wth aU -~U~ ,..
dominant inheritance indude :ramltial A.n-auto.soma1 t7ecessive trait is on)yexpressed
hypettholestrolemia.. Marfan syiulrome,. Ehien..- when an individu~ i$ homozygous for 'the ]#utant
Daru~s syndJ'!>.IJlC, and N~:fibrotna~$ia ty)e 1 . -allcle.Aut9w~ te.:essiVe ~bJ ~ ~
or vori ReCRlitlgH~usen dlSea:S~:t. 1~4; 11),1 ~ to ~ ~~tfn.l: .either :ey .-~~ 1>! b~~&QUs
" . ~ts; .tn wbioh the pr-oba.biUty ot a ,-..bi}d belYlg
-Fi,l.11ili4l Hyperch91estet:P~- i$ .on~ ,of the bo:ro.:c>eygo\1~. re~e.s~iv is.:2$%, .o r wt;en a
mo~i;<leo~tndn ~: in'bedted;.,,4ts4~4~ta~ .. ).Wh.e . bete~ote,~tes~wttb:~ ho.m~U!.:.m whi.eh
'her~"t.b~t~'lls~tattti. 'oC.u-trsi~in' <
1 -oU.t.,_of;$'00~ .- ca$e~~-;-pwbal>ilicyl-~ a,,~bildi:~g-,.~soua' . 0

incllildWJ.lsWh~:,tbe',li~~U.l! .tpnn(OCQ\l:h .::. ~:b.eQme$r:$0o/c-~:'C0naanguhl_~&~ts

m.t-:QutorrJi'Ullion'.bi'itbi~:disotdere.to . are. Jb0te. .likelytena\re ~a1fe<rted- :cliil<fu:n,heeau$e
. aeret
~ ;jn....th~;i~'W .;den.sfty. u~~r : ~ey . 'bav~ -ldeptical ~iele.s .. w~eb .~ley both '
gen-e. on: throin~s()~e~i-,'1'9~-.:~t?~-.ttsta: With' ... bthetitd'.trom a<~on :an~$tor....'fhe tate:r the
m~--~lt!of::~;cllo~~:l6.R;.or :: . ~tr-att;:~~mordikelY.ida-tliauhePatenis : .
fee4DiC1biiinib~tt~~4iMG;eo~i:~~-the~:~ ' -<>f-th'~.~liir.ectea:' itidiii"duals" arei~tJUJ:l:~s~
rate Jl~@g~~t: ~ ~~~l~~--81!!~~~ SoiJie~ples'~~f~u~nul1~-~~ce
an~ i.nci:~1used ~tiagy~ti' of .low~4~l$itY include pheny1klitointri~ Jl'JAple.-~Yrtip ~ripe
lipo"' roiett:ct>y;~tteropli9.ie-.:~ettntcau.r ffiey :wsea~; :gatac"losemtC'anacPi\geliillit~arena.I
P~~ilfwi"ili . eievited-serum ..Cli()le~~--~lfih .h~i:P1isra:r;2;4 -.
xant.h otnM ( aceumu!ation. of '.l~pid . lad.:en
macrophages in the $ kb:ih xal\th~tliin:as 111 P}l...Dflplr.eton.uffa {~KT.J), $ere.is .a .d~cy
(cholesterol deposition resulting.in y.~1lowi$ $kin of the liver erizy.me phenyWanine hydroxylaSe. It
leslon s around the eye$). art-d. :prema~\.lte is.o ne .,f;ltle most coQ;mlbn di:sorde~ .bfilniino.acid
atheJ"o$e1ert>.Si$~ 1 13 ' me~~li~in. With arr.e~uen#':;o( 1 Ptt. 100;000 in
the .Philip~fu~~t .Deficle11ey of ~CI en.zyme results
a
."ittat{('ltl Syndt'ome :~s . OYJ.~eettve fi.ss\i,e in accum~h$:.t'l9P of .phenyl~lanim~. "Affected
di~"arising front :a.mutat:ion in th~dibi'ilUn_gene individu~s ate rionnal at birth.but with.ln a :few
.o n thtotnosome V5q. This '9isP"tdei h as a weel~s. they ra,pidly qeteriorate .d ue to ~ssive
pievalence Of 1 in $000 m. t.be ..gen~ral-:popul~Uori: leve}$ of .phenyl~J~nlne wniC"h impair brain
Th~ mutation in the geneteadsto in~sculoskeletal development. If "Without inter.ve~tion, individuals
de!onnities (tall stat1.1re. scoliosis, chest wall may have severe :mental retardation at 6.months
ddortnitiei, ar-aehriodadyly), cardiov.a~cuhi.r or"~ge. /Ufected:.inqividuals are U.$U~y.lightbaired
disorders (m-i~tal .valve proll,lp.se, mitral and :f air sldmied, -due to a .deficl~gr, of melanin,
reguigitation, :aortic root dilatation, 'a ortic one or the end - products of the metabolic
ineompetence),.my-opia, and ectopia lerttis. 110 pathway. They may also have faclaldysmorphisms
and other neurologic api'H>rinalities. Recent
: E;hlers-DanlosSyndrome is agroup'ofinherlted adv.a nces .in .hewborn . screenit)g program!! :have
conneetive tissue: disord'er Wit}i.a def~t.in (:o~gen atloW:e<l for.the detection of PKU. Phetlylalanine:-
.s tructureor synthesis. lt results in an"abnohilal res tl:icted . diets have virtmilly elim.i nated the
production a,nd se.cr.e tion .o f colla:een which severe. ha,ridicap of the diseate.l.2~ 13

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 CHAPTER 5: REPRODUCTIVE GENETlCS .1<,
91
--------..,---:----~~---;--------=------,------------ _q:

Maple Syrup U~n~ Disease is a disease

I X - linked Dominant Inheritance
characterized .by a d,e ficiency of the pranGhed
chaln a1ph?. - .keto add dehydrogenase resulting
in ao.;-umulation .of bfanched chain amino acids
leucine, isbleuci..--1e andI valine. In the ciassic
of MSUD, Symptoms of poor suck and activity and
a chaxctcteristic niapl~. syrup. sroeh of th'e urine
.~all.tAlY. ~~ in-ilie 'rl.i"St few days of life ~er a
period: of. norm:~~ Other ~igna .and sympto-ms of
the .disorder are letr..arb; hypotonia ,o r hypertonia,
v.otniting; :fu~siness.\.a high~pitched .cry ~d
developmental delay. Treatmei}t ~s by die~
1
r-estriction ~r the brahched chain amino ,acids .
Newboms presenting~ with dassiciU signs
-symptoms' are ilsu~~ ~diagnosed with te~is
neon:atofum <hte to 'the overlap o.f' signs .artd
.:~~-.
X - linked dominant inheritance is similar to
autosoma~ dominant inheritance with the
type exception that fathers with the trait only pa.ss it
on ta their daughters a nd not to their scns. There
\s no niale - .to- male trn.nsmissien. The probability
for the mothers to pass the trait -is 50% for both
sons and da-q.ghters. F-emales are affected twice
as much as males, though m ore often than not
~est.littions b fem,a les are.less $ e'vUethan fu_
males. 'f:hei::e 'are some cases wh,ereiri. :an.X-llilked
dominant trait is lethai in males; Examples of X -
and linked dominant diseases bctude focal. d~rmal
hypoplasia, vitamin D -" resistant rickets, ~d
incontinentia pigmenti. 1.2

.s yttlptoms:. Mapl::~p. Uritle. di~~se. ~s .op.e of

the m.ost common iiiliented metab<:ilic .dioorde:ts X - ~ed Rec~ssive Inherltance.
m
. . . .u.tc _-__ -_ ,_ . - ~ , -4 . . I. _ ' .
..\_.;_- :, -nt.:':i:
r~uppmes. . . . - ~-. .
:-: . .. ': . . "- .The. X.- liriked recessive trait is .exp:tessed by .
. ,~iais. an ~levation -of blood -galactose all.mal~s .<md by females :who are J:loiD.(>zY,g'ousfx
lev~fi~aue:'to a ~~fiden:cy of -~y of tlie :three the trai~.The affected.~e, tra::lsmits-:tJ:_e::ttai~to
, ' .'r : . . -.: ) '
' "1\ I - , all of his daughters wp_o .become :cani~~.of~T.Qi~
e~~~~.:"f;i.f.Ihe galartose c atal>olk pa:thway:
gaj.ac~ose-:1-ph:-o~ph~te ur'idy1 . ~rait?ferase, ..tr&it. :9n th~ othef ~an4, the hetero~~f-e~:~i~i
~6~~ .or UDl:\~galactose-4--epime$-Se. lt though :phe.notyp1cally normal, has a SO?/ochance
~ .... ~- . ..1;. ~ . ..... -"., .. 1 "'r:: o
-o th '1-n..!,:.- of..tr:msmitting. the. trait .to ..her ..children.,s~
'~...~~'1~~~~~ 91 . _:I'"';. u . ~ ', e _-+~PP.'ln~s.
- .$i~-~d-::s~l't9:9is include.jaundice. ~bea, to auto~111~ '.re~t-~$ive traits,. ind1,~4-ua:l.;~~~~y
voitliqilZf"-f' ii_.f ~e .to ;gkh"l. W'e<.,.J>t. 'liver diSease. become ..affected.. if .they::~ ..hqrilqzyg6u.'S<;fot.?thh-
. :":.).~ . . --:- ... .;.:~:. . ~ : ~ .. , . . .
_ca,~?-~1$.; ~$.1 re4l(dation, and -even. qeath.
I . .
trait. EX:amples-o rsueh diSorders inG].:Q.'de:g!lie<}:~"'-
Sym.pto.IQ.S d.o nqt usuilly ap_rar at birth bUt can 6-phosphate dehydrogenase:: ~.de.fH::i~~rl.~y
~!,P..~J:W"~.~::;ri. ~ly ~~y:.~~y4J~go~jsis hem~phiU<! and ~uche~e muscu~ar ~ys~phy:1;
.imno~t ~to. pz;,Svegt.ieZel:e.Jie.
um1"'"""";,1-,~;.,...;.~_ge, .. .
....::::;;-.:;;. I . ~
. .~d d~Jh,.lJieJ.reatmep.t.of;galactose-pl.ia-iacludes ..~~T~~ii.~?f.-p_~R.fiiii!:-=dih!i:~~;;~~-rG6P-L>1 - ..
defia.ency -occurs in .1:-56 Filipinos. G6PD -i s the
dietary restriction of .galactose and lactose
throughout ~e.-+ I _. . rate limiting enzyme m. 'the h~xose .
monophosph,ate. shq.nt. This . path'w.ay prOduces
n icotinamide adenine dinucleotiae phosphate
. CQnQen{tc~.l Adre naJ: Hyperplasia i~ a
{NADPHl. whichis !!ssentj.al for r:naintemmce of ceil
.het~rog:_n~us. -g_roup 1f-<i_IS:OHi,ers c~te~.d
1

~embranei.."ltegrity, particUlarly ilned blood cells.

l?y a d~~Clency ~ any1-of th~ er.zym~s ~il.J.I:eQ' . Deficiency of.this enZ:ytne results in a~clatio~ ..
for_ the syn~es1s .-of .'1-IQ.os.ter<m~ and vortisol. of fr ee radicals in~ide the ceil, leading to
Th1s resul~ m .exc.ess,1v.e .syp.thes1s of,andrqgens
m.e m?rane -~amage. !"ffected ihd.ividual~ usually
P:Z:.J?ale ~ex .hofiilones.jin the iPhilipp~e~. it ~as ma~tfes t wtth non-ti:tlmune hemolytic anemia
~ incidence ef 1 :750Q_. Females .with the
upon exposure to c~rta.in drugs and foOds lfava .
disorder. present with ~mbigU~ous ..genitalia with beans), and also during .illness.
a normal fema:le r~pro.ciu.ctive tract,
masculinization a nd amenorrhea
l
at pub.e.d:y.

. I . Hemophilia is a bleeding disorder :that ~ due

Males .appear normal at btrth but become to ~he deficiency of bl0od clotting f~ctors VUI
Virilized. Individuals mk.y also have ~al~ wa~ting, {HemophiliaA) and l.X (Hemophilia B). He.mophilia
~ehydration, v0mitinlg, electrolyte- changes, A occurs in 1 out of. 5,000- 10,000 mateiiirths
adrena1 crisis,. ud catdiac arrhytlup.ias. Early wher~s f{emophilia ..B occ<Jrs in lout of1'i-ooo!: . i'
'd~te.ction is-es~ential_a~. aifected:~n<,livid-uflls.may 34,000. Affected ..i11dividuals inanife~ vtith
'
die sho J,ily :a fter :birth.~ inc~ea$ed ~e ndem;y: of internal :bf~~4ing, :1

)
I

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 92 SECTION t: BASIC CONCEPTS OF HUMAN REPRODUCTION

menorrhagia and hemarthrosis. Treatment is by .e nd the dgree cf methylation of the nucleotides

factor replacement."
Duchenne Muscular Dystrophy (DMD) ls:eaused
bY a mutation of the dystrophin .gene .f"esulting irt
absent or deficient production of dystrophin .
.Oystrophin is a protein the.Hs imp(>~t.fur the
connection of muscle fiber:s .to the extracellular
:matriX. DMOoccurs m
l .o'Ut-O.f~SOO to 1 in 4000 .
among ~~s. The primary symptom .of ))MD is
progressive J;llU~ular w~~$,8. i:QitUUly inv~1vblg . ~l" 1,000,000 of Asi_a n an;d African d~t.
. the lower extremities arid pelvis an4 e'Ve:lt-..uilly . Individuals appear nprmal at bit'f4 up to early
inwlves the upper extremiti~ The ll~ .:On$et
of sylilptom~ is between 3 . to 5 ytar:s bf Ji&e.
Affected. individuals suf-:r from mutu:ular
weakness that results in frequent falls, fa.~e.
and an aw.kwaro gait. There is nQ cun: for OMD
yet and trea:tmenFis e:itned at mln.b:nizing the
$"pnptQms ind improving Ure. individUal's .qU(ility
<'f life.15 -
determines the severity of the disease.Thenumber
of repeats is . usually stable when t:I:ansmitted by
a male parent 'but expands when .transm.itted by ,
the fema}e. Physically, affected mdividl!9ls baYe a
narrow face with:a large: jaw, long prominent ea.."S,
and .m~cr:o - orchidism. t,2.4.t6,17 .
. Huntmgto.~,Disease,oocur'in.3 to 7 per lOO,OOO
people. of West~rn European .descent. down to 1
adulthood with signs and $}11P.ptoms,o f the discaJ!e
t!UUJlfesth!.$ at a Plt!an ~ of 40 YUS okl. ~
ddet resUlts from a tJ:':iPlet repeat a:t~$0me
4. The number of repe~.ts is corrc;lated with the
~e Of onset of the dis~i;llre and.is inOS't':unstable
when trari.sm-itted 'by the lather. bidi'ri~u$ls
11Wlifest with progres.sive chorea, . btatiykin@ia,
rigidity, and dt:~erioration .o f mental furietion.u..

. Myotonic .dy$UPphy.,i s the ll1P~ ~n ad~t

.... . ~.:-. . : .. ' . mu~dy$trop\ly~mei:-tHn"-o~~'
.' y -linkedtrai~ are pas$ed fi'Qi,n ta~to $On . iii the long ~ ot
ehrom:osoJ;ne ..~:9~ ' lo~Q:tllS
b~t not tO .da~ght~.rs. Ttl'P:$ far .. "! ;;...JiJlk~d With the. d;i~o:rde' sll<>w. progte~ive .m~aCle
-~ .Qr.e unproved: itl b~tJ. ;wt~ifle Y ~tropqy. . w.e(\)tn;.~a. .jnyotonif.. c~diac
lm>~P.s0.4le :~~ l)eejt:.:sboM14o ~~~- . dh;~~.~~hi~ll~ impaiqnel:\ts -~~
dd~~~()n '.md rs~nna~gene$i~;~,:Mott;O.ver; . ~gona"'at :.atrophy;:.:inQ,utin: ~$istan~; :d~
;q!lt~thetau~mfU.doiilina.nt~t/Y ~'linked: 'esophtig~.mct'COlofdc:niotnit;Y;:~feh~t~fiiCcd
~bi~s~>maru.resf~th -v~ble:'~~vityf. e. .: . : te~ andmfertlli~ in women. n.~te the
. .. . .. . . . . . . P~ ,..~~. r=:r. ..uH:;:..,
.b...ili .: ." ~ .:..10.:
.. ... . ~~
:po~l - ...,;o:o ,.i'ue.iuu.:.:,. l;On....::..,uu~ Js:ua . e
N'ON ..:lJENI)'ELIAN
..... ... .......
YA'1'TE!UiS-OFlMHElUTANCE
... .. .. .. . ..... . - . .-- . ..
es~tfl-y~ting ~6fueil. t.nre-rns~te
~ '

vanaJ>ilffY orlliea:riea~ -wrtn:r.e-g&:r.a: ro-ilie

Trtptet :R epeat Expansion Dlso~den systemic complicalloiis.

The DNA is so :unstable that the .si$e .and -Genomic Imprinting

functiOnofthe genes ar.e altered whenU:im.sferred
to
.' .fro}ll :j>are!)t chj:ld. TPis ~urs in 1 ~ecy 1000 The . 'd.Lfl:~rent ~ression or .a lleles depending
on ~e parent of oP'gih is known ~s impr..nting.7
xpa.les,and in, l every 2000 females. The; .'Ffa',gile.X
S,Y'ndt<>me ~d tiuntipgto.n disea~ .are ~ples There 'is a ~ef 'of,genes .whkh ~ irihented in an
of this type of disorder. inactivated and tianscrl:pti.o nally Silent state. 111~
inactivation is detennined. by the tratismittiilg
Fr~'gile .X syndrome parent and may be re\.ernecHn the tte;d generatiOii.
A classic .e xample of this diseau ia the
This is also lmown as the Martin - Bell chio'mooomal mitrodelet.ion at 15q11- 13. {FigutC
s yndrome and is the most common inherited 5.13) If the deiet~d material i$ paternal in origin,
.~U$e.O.f ,Q;le~uu rewdation. Theoverall prevalence the 'p henotype seen .is Prader - Willi Syndrome
in males .a,nd females is est:.i,n)ated to be .l in 2000 which manifests with hypotonia at birth ~th poor
to 1.in 3oQo. Fragile X is due to a mutation in the feeding and then . there i's a .remarkable
FMRl .gene triplel _repeat s~uence atchn;>mosome . hyperphagia obsetved after the .farst 6 months 1:0
Xq27. Non:p.ally,the FMRi- gene.eontains..betwe..e n l year of life leading to obesitY. There is also thort
6 and 55 repeat~ oftheCGGcodon.lnpeople with : stature,. small ;hands and .fe.e t, .and' mild tnental
the .ftagile X ~yndrome; the FMRl "S:~lele h as over retardation obsmed. If :the deleted material is
230 reptats of this codon. The numper of repeats maternal in origin, the condition is Angelman

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....

CHAPTER 5: REPROOUCTivt GENETICS ....,. 93

-.-------------~----~~----~~------~------------------

....."'!.~. .

Normal Abnormal

Mcl<lP~~PPcfl hybMizcd ....,ith~'St.Pr~ ..

\\'ili!Aii!feli"har\ rcgi6n:ptob:e. ~-of oronge-
pit\k$J~l;.~~chr.<?n.1~-15~ate: -.
~tiOr. of pte~~ tbe -~

--~ -In.Stitu~ olH~-~eti~Na.ti91 In~tl~tes ~f.Healfu, Uiiiversity of theP.rulippin~s .M

. : .<;~~:\s~-13;~ "Flo:ur~nce-tn,-s~~-hyb'ridization{FISH) studies doue. on_ an indi'1d~a1 with ,~d~-;~ . '..<?'
. :~~;SJ.ii~m~_ . . . . .. . . - .!: ,-~~:; :_ _:i~~:L
. ~~ .
:.......~..~-
'o I , ' , .

'-~.'. : :. "'".\ =,.. I ." ' . . ..."~ :...~;: .."f~ '11.' ,(hL
. .. :_.s-y.@T.p~-~~-whlch -man~ests: . ~fl- :?-n _in~i'P:idual- a -~aract~ristic cilled.~plt;!ST!tY wb:t:fcifi:.h.(
-._ : hM'illt'~:sta~e and w:-igrt:,. sev:ere'.inental anr.iitodum<b.ii will h ave tliesairie-.tiiutalions~<l-- :
-r~tar4a'ti9n::. abselit sp.eech, seiziire di$order, _ a sp:el;:ific rit:Oohondrialm utation tp.ai or:ma:i:P:,~t- ~
ataxia ~ .ann I;hovements .and .inappr.Oprla.:te n ecessarily he transmitted to the -offs_iip:lig~
la:if@~~ -In {}bs.te~ric~. cil~plete. ~ydatldifoJ;rtl Examples of i!iitocbortch>ta l disor.der.s ~fu.ciudd
:rP(}le~~patetnar~pnnt~whereas--ait-"'varian "my-o&lon~c--epilePS-y-,w~~h""'t'a:gged-ied..:..fi~e-i-s- -
t:era'toma:-isa:m:a:terilld--imprin~1 - (ME~);kberuiheritedopticneUropathy~ I:eigh
s_yndrome, -and pigmented :r etinopathy.u
Uniparental Disom,y
.Multifactorla:l Inh~rltance
Th!s occurs wh~n both homobgues.o'f.a given
chrom6s6me are d.erlveci fr~m a single parent, - Tmits. that~are goveme4 by more fuan o~e gehJ
-~ro'Oably as a re_sUlfof ~ulsion ofa ch,ro:moS6fne . are cal-l~d j>Qlygerri~ .traits. Such ttruts inc~..1de
from a tris-omic zygoti. This _phen<?'m~non is -height; weight, hair color, skin: color:.. blood .
deleterious i;n some _chronio~ines but .not -in pressure and more. --Polygenic tr.aits show
others. 1 continuous v..ariations between two extremes~
Thus, a child's hafr color may be intertriediate
Mitochonilrlai Disorders between .i.vo p~ent~; -an off:q)ring's height may
be the acl.ditive height of the parents and w forth.
Genes can als o be foUrid in the mitochondria Multifactori;ll inheritance on_ the other hand, is
and most rcit~horidrial gene-s .are transl~ted.-futo traits ~at ~ affected by the enVironment. It ~s
proteins w:hitli participate 1n the-energy _imxiucing very difficult to distlngti~h between 'p 6lygenic and
reactio'ns. During fertilization and .zygote multifactorial inheritance, however, \-vith the use
fonnaoon, most or'~e cytqplasrn -comes ftoin th1e of monozygotic and dizygotic twin Wf:Udies,
-mothe i. -Mitochondrial dis'ord~rs -are thus sei~ritlsts have been able'todifferentiateqne ti.vo.
transmitted :only through females 'to bOth ma.J.eafid SO"me .cha~acteri$fics of _.p olygenic. inh'?mta nce
remal~ offsprings. Mitochondrial di;orders display include: 11 > ~- ...

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~
 SECTION l: BASte CONCEPTS OF HUMAN REPRODUCTION.

lj involves a single organ system or s ystems of luteal phase .defects, thyroid abnormalities,
th~ sameembryonit: origin diabetes mellitus, intrauterine adhesion-s or
~) concordance is higher ~ong monozygo~c synechiae, incomplete I;IllJ.llerian fusion$,
than dizYgotic.twins leio,m:yo~as, incbmptent mt~al :cervkal os,'
3) recurrence risk inereases :after mqre-than ~qe ini~tkin~...~tiPh.:o.spholipid -an~ .t.jndrom.e,
prog~y.'ls affected. . hyper-co.~glilable states, allo~ihit.nf! ~s.
drugs~ chemicals, noxious age.nta :and other
envkonenW,f~etorn.,Aithou~ ib.~l.a~ may
be.non-,g~Q;etic, -~eiridiVi~ual;ima:y. ~ ~ .
Pregri~ny. loss 'a~ o:~c:lft :Qht:h ill . t~e : tQ ~~e 'becau~ qf.thcirJtjh~t;g~~ .Jna,ke-
p reclinicai d. clinical
.. .an . ., .. s+;;.
.~ .. .aCtUalitr
~c.. In .. . most uP.
. .... . 1;19 . . : .
,, .' .
.
embcyos f'ai[ to -~plant Md .~ jost ~ ~f.Q're . . .
pre,gxlancy ;erut ~ ~e~ Tb~ ,.mo~t -~ol;funO.h G~~:T,;;~ ItlS~oOR)t TA.ItlNG. :AW .G:ZNET!c
e~ of~ly -~ .t()ss ~ :-~.and COnNSlml:NG
cyt;Ogene~c --~~no~ties:1 :1 ? .
: . the .~d~ . in- fut:last:teW:~d~ h ave
Cbr-o~~~Ill:a1 .abn~t~:~~litie~ Jlie the .m~j~r . .alloWed 'for the trea.b;ne,;t ,o:( ~~ou.S ili~ Of
c;a'lise:ofcliiliciU;lY ~ p~a.ncy los~s.. genetic -origin. :a:owever~ p ij.or to trea~a1t it is
AutosottUtl triso~~:tistittt~ tb~~si: Si:Qgle n~5acy th2.6~-~ ~te ~ -~ mfuie. A
gr~:up o.f chr.omoso17t~1 c.bmpl~~~nts i:Il.. .systern:at.i'c means ..o~r bbta:fiUiii into~~ is
Cytogen~y abnQ:r:fual :~.ntarte<>:Us ab:Qrtions fuhdamerila.l to.a;l. a~t.e .-gnetic di~Osis. ID. .
..wl:l~:Moh0s9my,X. ~. ~~-most -coll'llh~~ .~le . the.M.~ti~-h1s~ey;-'iHs~~.PO~L9tlttQ.mqu:-eabout
~c~.oi:n~~~:-~~~:~~~trf.~ X~~~::~~J~fu,~~.-~~' ~.~ry.~~~t~J_glit~:h:~~aJ~l~;~crh~.~~. -
..poJypl!).i;g.y-a:ccounUt -~.o.r:Q:s- ?OO:'o.-of P,;:egnancy of~~latJ.v~s up:. to fue third .degr~~ . -e-bnonnal
lc;>~;:S;tiuct:ura:l)~hr-P,no$0ma:F~g~m~~- e.re- reprcd.uctivc.-ou.tcpmes; pre~nt ~d .pa~t ~g .
.lnipor'tap;t - ~us~~ :Qf.'ie~ur.r..ent s.p'n~aite.o.~s e:;;,:pos~e !.lf th.e :w.o:tnall. :arict: th~ partner. an~
abort:lon3.:and o.y -~ . dllii.ni,.~e~~s: .parental. ages.;. jnat~~-e.l- . ~g~. b_e~g :'the. ~os~
or. ~m~-1~1Jiy;}.n.hef.it~tl':f.~~~. ~t~~ 4!!P.~~~-~~~;;:;TI:f~.~ . . COrryr6;e.~.indica:ti<i.~:iQp}~~~~~--~me: ~ ~

:=~~~$~~s;;~vt:=i~I
~g~tit-~a.'dirfgS~o~ffi:egp;~cy~:tnat ~ ~n-:el'#~.l.'~fi.'2~!(~!:~E1f?.:ffi~s ~Y.~~r.thnLc .
be ~~l~{f' ~ret.f"as'(~~~i~t6~;r=aQ<>mcn :
... pr~sposition. ~se.n:~ <!frisks mditale~ a~
a .for chtomosomalstuqi_es.1 ..20.2L
or :a~ CO!i;ibi.nati()rj_;of.S:.bortjoti and.:ab'n:()~ live '
birth. 1',19 .

Frolfl history takit).g to . di~gnosis, genetic

Multifactorial ir-h~ritatl.G. alsO a~up.t :ip. part couns~~g is ~ :~ss~nti~ part .pf th~ .p_r'Qcess.
fOJ; :pr.~il,n~y ;~9~~. -'$9!Il.~ tl;>~pl~s ..~e J?J.Ore ' Gen~tic ;Cb tli;J,Se1in,g is ...'1e. in~thod by wJ:iich an
.p:i:'1s:'pc_~~4 ~o~~d cih;~nno.s.9~~Y. abFton:Jlal indiv~4~a1 -?t 14~ Ianl4,y. is .:Pr.ovid~ 'ijlfc~tjo~
~i.i(::;~ptu$es~o5t. fwh~cnre:Stilt tq.-:spontaneou:s abovt a~ real 'o r <:1. pessible gen~tic proplem. It
agol}ions. ~kn-es .e:xe'r:ting {ll.~s effeet ~ct 'by involves .not just .one. physl.ia~ or hea1thcare
disn;tp~g,~p~dle formatio~; centr~tn.ere: S~billty, p ersonn el,' but a number Ol speCialists, often .
recozri:b lnation and .o r.<ier.l,.y !iH'sj:uncti'on of including a geneticist. Information -must l>e
h-oPl.ologues. Qt'h~t CO~;ple.s . may ~1-so sh9:w proVided in la}rman's te~::; of,w hat the di~ is,
r~:pe(itivr; losses of :ch-romqsomal~y J)or.mal how it is diagnosed, transmitted, treated. the
a b.o-rtuses which may be que to mendetia:n complications oi the di~_se and <ither:info~on
mu.ta:tions. 30 - so% (lf chrqmo~riuili-y n ormal p~ttinent. to th~. dis.Order: 'J 'he go3l of genetic
abortus~:pnay have s~gle -g ene =muta:~o-ns. ~ 19 . c<;mt}seling.isto .h elp th~ individu~s .and families.
-adjust psy~holqgiqlily and socially b~ their genetic
Cytqgenetic . an4 . mend;elian cau-se~ ~~one : conditiop. All the. ~formation th.a:t is acq~ed
.account.for:anoverwhel.tnl.ng n11mber of.pr~glw.ney rega:rd~ng the' .pa~ient's h~.a lth as w~ll as
Io~: Aside.from ..the .genetic .cau;>es there a.re
a).so . mfon?ati~ri SQ:8!ed b~_.the patient ~d the family '( .

non- gc;netic causes.' These include tl:1.e following: members is considered -~onqdential. and must not.

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 .t.
CHAPTER 5: RE.PHODUGTIVE GENETIC:S -~- 95

P~Symbol.s Newham screening system~ ~:seek u;''i'aentify

Su newborns who are at increased risk forirtherlW-
Male Female Uzikown congeni.tal conditions (us ually asnuptomatic}

o.i 6 0.....
bas ed on :tl)eir screening test.results.22 Identified
newborns then receive follow-up e:valu.s.tionj

~- 19ll JQ
1 te$ting in order to dari..fy or-confirm the ~g
Clliiiul1y .a[f((;ted
I ! fm:~s. Early disea~ detection can in tum lead
individ\tcl '( lk{we .
~ i114yl\eze1)d)
A~~
{>~-~aooj
*-o. e to early clLT'lical management. Dependirig .o:n the
d.i~se, health outcomes resulting from ~tiYe
and efficient newborn sci-eening catj.l~ to notm.a1
or near-normal gr<lwth a nd deve1opme~t for
0 0 '0 detected patients. ver sus variou~ f or'm.s <;f
debilitaiiot1 when the clisease is symptomatically
ill 0 0 :aetecte<l at :a later time.
~
. Tradition~ . newborn screenirl.g was begun by
0 0 0 ~lly .1,4.::>\1
Dr..Robert G Uthrie wpo pioneer:ed the :u,ie -.a
h~~ 'Ql9_.s_pecimenahsorb?.d :on.to a special
of

U1 ~~- 0-sa
s. .
,.~ JIJ_'WIC.
.

3"~
.
fll~r ~~r::o When.4fled ami P.~.pq~_:(m~~)
to a testing la:b<lra.tory, the :serutitexi:raci:W::~m
the blOOds pot c duid .be used . f-or 'b'iochefuicSl
. ... ..
J~recn~;({''L t.e'sting procedures. While imtiallJ.:.u~tp)~
. ~ ~ .::1~.~~~ !.. -~ .<!J 0.. . ..
_..,.
pheeylketon~ (P.KU), thereby preY.eJ;i,~g~e
mental r etardation and institutiO.;ri;ili:~'p~:ii,
. . .. . ););i]>;'11i.M :.~

;6. A l)iood~pot .testing h as eXpan~ed t9 :-~'iny ~~er

A
-~
.
~
:.i;Cf . ...congenital ..condition~. Tod?-Y .as. m~.Y:,:a.JJ'.-.~
- ~SA11 .. ,; .
~: ~ J.... dift:er~conditions are 2routtne1Y.scr~~~Rm::
:i >./~.::...~~~;~-~;:, :; " .. ....,.. -
.
'-ol!o -~,~
. . : 4 t::'
.. s-cr.eeJUI_lg.l'!ro,gram$:
I . .:o: J:~.... ,.,.!\)J.OI'f.,i::a;:
..:..on
d._ .
tlJ.PA~.7'\:Urrei::.~.Y
~tiM:.er
. ~-froP.)
..- ~-
4i ~
. amenable

- .
:ro ...

.
dried bloqdspot scree~
.. ';.tJ tk~':J.r-''~s.h~..~::.::r:.
-~ ~' /m.9-~e
1-, \ ~~\1 '
f;... .

iMli fooo.ak :n~ vano~ metabolic conditions (amifio ag~ .Q.i p:n.ic

~ - A -~
. . . --- -'""'*---:'- ---~-~~ ___ _Ji..... ... -. -,= ~~=~~!:i~~~X\1.

. .,
-~
p.l'
Source: Be.nnett RL. lb.e Practicat'OUidc to 'the Genetic
F~}#story~wil<:y~Li;ls, Inc. 1999, pj92:n
Figure 5.14. Commonly-u sed.pedigree SyPlbols.
be s h a red 'to other indiv idualS without the
patient's consent. Breach of confidentiality may
result in stigmatiza~on and discrimin a tion. 1.2
NEWBORN SCREENING
Newborn s creening i s the ter~ u ~ed- to
.descnbe varl.ou~ tes ts tha t .can <><;cur early in,the
newbotn's life \vN"ch, when _;properly tim,~d- and
p erforme d, h ave the pote n:tial for preventing
catastrophic healt~ outcom es, including death.
h~@9gl..QpJ!lgP-atm6~ .cy;s.tic.Ebto~is;.g~.
o
-
Jf . . biotinidase deficiency, glucose--6-deh..:y~gen.a~
.llr . d eficiency, ~d- cex;tain 'inf~cti9us dbeasta fe.g.
. . toxoplasmosi~. HIV) .
. p/f . . .
D,ried blood.spot .scre~ning -prqcei;lut~s are
-lx;.lng e..eveloped for many oth~r conclitio:r:ts {$Clb,
Fragile X: q.iabete.s , et~.)- Additio_n ally,. o.Uu:dypes
of newborn screening proces.se~ .are. evol~gth?.t
-do not re_qW,r~ a b.Io~ spe~'l).. N~wborri.he:a:rillg
scr~ning ~s- a .primacy ex.aln.pie, but otlfer types
of screening (vision, ~diac, biliru:Pin. etc:}fit.ifito
this category. Since the 1960s, p._ewbor-n ~g
programs. have used. the criteria dev,elqped. b y
Wilson 8.l).d'<)'ungner (fable 5. 1) tod<?cide :o n the
co.nditi.ons to be. included in _screening .panels. 2 s
These population screening criteria.tire nit;..Sp.cific .
to n ewborn screen ing and are based on 1960s
testing methods. Recently ne\l(b~I'?-~Jeening
programs l1avebegun.t9 question-(!.Ild re1ise these
ctiten a to acco.mnioda,te m,edical and .'1treeni ng
advances. 26 . .

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 ..
~~-~.;o.
~.:

96 - S-ECTION l: -BASJC CONCEPTS OF HUMAN REPRODUCTION

Table -5 .1 .~ciples -of early di~ase detection - Wilson derived from .totipotent .c ells and have the
and Ju.ngner-l%8:u ability to produce different ee:;t types.
l. The condltion ~uiht should be an important ~ealth
problem. Unipotent cells produce only one cell cype,
2 . Tb~ s hould -~ an a<:eepted trea.tmcrtt for pati'!nts but ha ve the property of self-re;o.ew..:..J.
With recognized-disease,
-3. FacUities for diagnosis and t.reatt:ae~.t should be

. 4.
. avcilabli
Th~re. t~h6uld be a r~ogz:liz:.S.ple latent or early
. In the early phases .of c.eu 9jvis,ion. tl\~ cclh .
sy[np~o~-mt. retain their tutipotency. But :afi~r snbseqlit:nt
.5. Th~ sb:a.u ldbe 'a:Suitablct~tor-~m!natjon. divisions, the. eel! ll)ses. its. pcitential. :and..~s a
6 . The~~ or. ~atio~ s~oulci.~-~tab1e to the specialized :fun..:ti<>n for the aev:elopP'tent: ofmature
popu}aticm. . . . . prgans in :a proce.s s knoWn -~ de~tion.;."
7~ T~e nat;ural~~tpty"~f the C!)U4itiop., hl9luding
deV-elopment from 1a~tto a~ .di$ease,.-%hgrild,
be tl.d$titel;y, unaerst~. .
Class lfication o! Stem Cells
'8:.. Tbetc ~bould be -an agreed policy on whoi:IHo :treat as
patients. . ~tem c ells -cah be da~ s.ified inte '.&ev~tal
v. The--c6$t. -of~- fin~g f~uti.iz:ig d,ie,gno.s is end categories: eril_bcyonic .st~ cells, aqQ.l.tstem ~Us.
-tt~~e~t . o"t 'p.a:tl.~:n~~ ~~:o.ea} sMu:l4. b~ . som?:tic-stem :cells.and.he:mat:O;poietic-~ cells.
e~#.~@:i"~ally -)7;~a;i!e4 ;m-~~qon t~ possible
~ .-t;\l..t:oe_
6n~~.~.as:~"*~ . .
.iQ. :~~.din:pb.0U14.~ ~-ron,tin-uingp~and hot a
E_ :;-:<'~....;_. ~onic
>LA,JI-!7 .
Steni ~~_
~
-
11

-c-: ~~~t~:i~~~~:.1.':~~~- .. : . . . . . .
... - ' .. '". : ,.
,- ' . .
Embtyo_ri,ic -st;em
. .c~~ (E$C$)
. . ... are~-
. . from
;, . - .. -th~<~P,ib1a:~t-~-~f: -:t)+c;:.r inner~ c~ll' .'titas-a:..of ib:e
. . . . ,p t:d$pia:ntation .b~sttrcy:st:. U~i:ter -op~:
... :rh-e _;Ne~oom Sct;ee4'J;n:g. ~ogra:P'!lri. th~ : :congitions thes~ -edt~ .at~ ~1>1~- tP-~llierate . _
Phil'if>)?in.e~ : is ,~iifi-pl~-~-ent~tt~~.oJi"Wla~:: .~d~ .. :iQ.af:!~t!7-~Lik~S; :\ltiae.t:.'m.4l,it;~ ~n5. -

,_~~=;::~=~~~~::=~~~-.:~~~!~:~~~:;~=~~-
~~0-~~~ p~~~.Y:tk~t.?n~;_:and::pucl>:s~.:,O:.. , they.<can not :: tive~riSe ~-to 'the-~~bcyO.nic
.-
.-:ph,Q~~~~; .4h.'t.~!r~~~- ;4;~$~. '!f~W,:~m me~'Q@P:es. ~r t}l~ .p~c~rtta,.lll
:lJ~g -~ct:eening: i:s _;~iu:pg~Jl/~ ~.$.:~t~ .
;...........~,:..., ,in...&r~.me ~P3: A N~m. -:scteeiring Germin_
- . -~- ~- - iarsterr.~belG -
;y.~~~~--. -------~ - ~---......-.,.~~!:::i'-----------. .
Bill'-~s mtioduced .si@e<t
a&<i intQ ,J aw'jn 2004
as' 'Repu~U,e _
Act 928:8 ol" tile..~eWboni -~enmg Genn-inal,. st~ eetls .?Te forind in a_~ped
A~t 6(2()04:. TQls l.llw t<i;uiis .P.ev4>otft screenlll:g orgariism.and ll.a've .t he .abllity todivi4C-f;Uld~te
to -be off~red to .pj:u'ertt$ Of.n:e~fil~:ZT . another .cell:like itserr a:rtd .ais'o -divk1e -aiid :aeat:e
- .a :,~ ~ore <llirer~ri&i<1 ttUm.itselt Th~ ells
can he{oun'd lh-dilldren as ~2ll-asiin.ad:Ulti1.' Theise
1 o;us ~e -~~ . an4 .~m.~ ~ n~~ ;!>tit ._q m :'be
. -stein --tens ~ me ~r.i!# Of -_ij,ll -hu~m cells- foUpd ~11- tissues 'inc ludin:g um'biiiccal c-or.d
-a nd :_produce a11 fu:e differenti:at~ c~U :tjpes in -.an blpod. 26~i,32
in<i,iv1dua).. They have two blaj~r l:imp:erlie~-: self-
reriew8.1:and-poteP.,cy. $elf:..:- tP:ewal.:refei:S t o' the Somatic Progenitor Cells and. Nonnal' Tissue
a bilitY 9f the cell to:g o ur..dergo: hu:m ero.us cycles ReD-ewa(
of c ell 'd ivision w hile ma int-ainin:g the
undltfere_ntiated. s~t~. ~ereas_ -pdtency is the So~atic progenitor cells or .tranSit.a:mplifyihg
o;ipaclty of-a cell' to differentiate -into speeiafized cells are respon sible fo-r the contin.uou s
_cell t;rPe.s. There are.difterenHype'B ofcell.petency . replacement -of n ormal adu:lt.:o .rgans: :'Ibese;_c ells .
as. .follows:24-3S
.
are the pcogen'y of tiS$U~ sterp.. cell!! and th!!Y
pro,;ide a . popUlation P.f mitotically c<>mpeten t
. .Totipo.tent :stem cells can differentiate into tisstie determined. -progenitor: <:ills .andproduce .
etribcyqnic .a:nd\extraembcyonic 'Gell ,_type_s. pro:geJ;?.y that li.ffe~entiate- in~o. inorettiature cells
Pluripotentf-Multipoten.'t ste~ ~e=n s are .. tha:t' ~ no longer proliferate."l4 .

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 CHAPTER 5: REPRODUCTIVE GENETICS
------~-------,------.......,._.,~---~----------,-
Hematopoietic Stem Cells
Hematopoietic stem cell,s a,re found in the bone
marrow and are responsible .for the continLicus
repla~ent of l;>loo4 .c ells, which are some of the
most rapidly .replacerl tiss-qes :in th~ body. The
majority of circula.ting blood cells can n?t
moliferate, h ave .limited life span~ and have rap1d
turnover.:TllUs tl1ey reqUire an enormous number
of .precursor c lls.28
:S tem Cella for TheraP.Y
. . . :~
$71'..b-~>o:tic stem CeU Therapy
In 1981, .it w as found that .iit. vivo ESCs could
restore lost bone marrow stf!in cell~ in lethally
irradiated mice. A fe~v years later, in Vitro cuiture
,of hu~~ ESCs that can d 'i fferentiate into
~ge. bone, muscle, neuton,s a.."1:d many other
cdls was accomplished. ESCs are <?b:taii:l:ed from
the e~rjp;~d require ~ series of; signals t'?
prod~ pftJgen}' of .a lll;'ore highly differe:;::tpated
-cype. ro date,.ESC:s remain a potential s ource for
regeneratiVe: medicine and tissue replaceiD,ent
a:ftr,i!l,h,ixy or disease. The 'only limitation .of ll>:e
t~~&~~its..low ef!i~ieney and ~e Io;r1g ,tim_e . l ) .. avoiq;clini~ p.r~gp<icy ~;n;:.PGD
.. t:eqmt'di.fq~.,it to: diffeti!ntiate' int~. ai;lult .GellS .. .: ..~i.t~: inte:rventibn .bef(?r:e ..t~it?re~JS:;~pj~
~. ~ .are. , still' noa:pPri:r?ed~ ~tments
or hllrilan'l:hlajs \lsing E$Cs. 23 _;l0~.35
Adu4 $lem:C$11 Therapy
. .,_ .., ...
Adillt~tem.cell-trea.tments -have been Used fer
many years to treat leukemia, through bone
.marrow t;ransp~ts: ;'he:-p,zo~.pe<:tive u~ of adult
stem cells for Parkinson's d1sease, spmal cord,
br ain and .cardio.a~cular injuries, .neoplasia,
deafne'SS an.d blindness .:at-e.' curr.e ntly under
invest:ig4tion. The u s~ pJ a9-u1t stem cell's , ~n
research a nd thempy is riot as controversial. as
e mbrypnic $tern cells , because the p roduction of
adult. stem. cells does not require the destruction
ofan embryo'.27.3034
CORD BLOOD BANKING
Umbilical cord blood contains hematopo1etic
stem cells and progen:itor cells. B ecause .o fthe
:pOtential use of stem cells for the treatment of
numerous disorders, cord blood are currently.
be~ng ~ollected and stcire.d in c9rd blood bank
facilities. Umpilical .corCl blood s tern cells .can be
:potentially used in transplants to treat nume.rous
Scanned 8y:
.. 97
disor<~ers including leukemia, sickle cell disease,
and inherited metabOlic conditions. An au~iogous
transplantation, of which the origin is from the
same. ipd ividual, can oe performe d if clrild's a
umbilical cord bloo.d h as be~n previously stored
L.1 a.cord blood bank. Hpwever, there are ~till many
controve rsies as to the benefit of co:rd blood
collect~on a;nd medical societies haye varying
opiniort with its use.36"38 .
PREIMPLANTATION Q'ENETIC l)lAGNOSlS
Pteimplan:tation.genetic ~osis {PGD),is a
.preconceptional approach. that is a relat:iye)J new
addition to prenatal diagnosis. It allows the
di~gnosis of a disorder priqr to establishing a,
pr~gnancy. A successful PGD . program requires
high quality assisted reproductive tecb::lology
(ART), micromanipulation skill~ suffid~nt to a
optain. a ~pecimen for analysis and mo~lar
. . . . . '
.technolqgy mo~ 5ophisticate~d thahthat reqmred
for traditional p~enatal diawosis.. .lh:~ddltio~.~o
the common indications for prena~g1$~Tic
diagnosis. PGD has som_e ~nique :.indi~flqns
which. inclu~e .the. followmg:1 .:l9.' .. ..:.. . . .
ro
. recognition of'pregriaficy. ~ "Llf!~;;.;:o::~:t-t";. ..
~ . . . .. . ..., .,4"-;~~.S~;.. -.'::'1<~...
~) Patients with exceptionfll .genetic ri:sks: PGD
is. preferably offered to couples at:b.igh. risk of'
._,g~Ji~ti.G_ J!i~pr~l~~-i.....
31 . PI-enatai diagnosi's without disciosure pf th:~
parental genotype: All embryos are
;s qcened
and O'nly normal; unaffecfed .embryos are
obtained or transferred.
4) Couples -requiring ART: These mdude women
gre~ter than 3.5 year.s o.f ;:tge.
Aside from these indications, there are also
cytogeneti9 and mendelian indications for PGD
including: 1
1) Aneuptoidy detection for advanced maternal
age or prior tri~my. This accounts for more
than 2 /3 of the indication for all PGD cases
and makes use of fluorescence -- in - situ -.
hybridization: (FISH) with chromosome,:;pecific .
probes to confJ.rin euploidy. -~
.. ~ .
2) . S.tructur~l .cl;lromosomal. abnor.fii.alities
inCluding balanced translocation~ .. ,.
' .
C
98 sclioN t: aAslc coNcE?rs oF HUMAN REPRooucrto.N

,., i: a

3) Sex determination .for X ~ linked rece.s sive
disorders and various aut0sot:aa1r ecessive and
autosomal dominant disorders
4) Repeated spontaneous abortionsor fVF.failure
5) Improvement of ART pregn?.ncy .rates
6) For gene therapy
PGD requires ac.c e;ss to gametes or embryos
befo~ 6 . weeks post concepti<>~, tPe time where .
irn:plantation cccur:.s. Three. apprq.ache~ ar
currently being used. 'f.h~ 'first ~que. that was
developed is blastomere l:iiopsy, whe.rcinQ-4~ cells
-ar.e aspit'a'ted for t~e ,z.~n:a: p~llu;:id:a by
raeeb101niW .oreherni~ c:lissOC:iatich.-The .seebP.d
is polar body biopsy: 3 polar bodies and one oocyte
are produced during g;:unetogenesis. Once a ~lar
body is obtained and analyzed and bas been
shown to :have a mu:ta:n:t allele, then this means
that the oocyte e ort1plement must :have the Mr.rilel
allele. ConverSely~ "if the polar body .contains the
normal co~p~ement, then the oocyte ~'Q.St . have
the mutant'a llde. 'the third teh:!).iqueis.biopsy
ofthe.:trophoectodertn. :also kn:ow:n asa blas~st
biopsy. This technique eiimi:n:B.tes the diffi.cu:Ity
. ohf>erved with the other tw-o, wherein few cells ;u-e
. obtai:n:ed. More <:ells cim be Obtained in a 5 ~ 6
qp.y blastocy-st, however, ..it is less readily
obt:.ali).able a~ 6 - .8 Gcll. erilbcyos~ U9 .

. .
G~neti,cs ~ the scren:ce..t>f 'heredity .and .genes are the I.!nits of inheritance.
. .,, . . ~. ' .
. ~ !!~ The .~t.of genes.pf -an:'C)fg.anism Is:~!led the genotype whereas me phy.si~ :maffrfe~t!Qn iS'.the
' .. .. . . phenotype. . . .
i!~~ ~tk.Jls,oon~:.~~;Pair$:At.~lJ.~~es>722 pairs.of.a~JtosPmes-a~-.~ . ~kot-~x'.ru-~,_
Germ ceiis>are egg$:.~ .s~~. ~is h~p~ and iop~in~. 23 hr9fil>so~. : .. . .
:..~UtiS.-ot!~;~ r,oe;9assffi~.aShufil~ri~r,~:swciu~t': . ,
.:::~um~ia~~~~~~~f~~i.:af:e::k!'owtf~~~e.llplcrdyand~XW.S~enat~~~ . . '
or _diplbid~cell:~kS-:'Or"r~~-m:~~~of:tt~e'e~fYcted number ofchr'otnP$0mes~~ AnetJ.ploidydnctuoes
tnsomy,~;pQiysO~y;:~ po~oiQy and ,rnosa~m;

[~l!Yf.-15.-::tK~:Jif.~:~( :<m,~~~~f@.i:i:\2}iij\e ~~~. ~.suajiY...r~~~~jrom. rDf!io~.tt~o~~~;

Examples InClude T;lsqmy.,~l{OOWi\syndrome), Trisomy 1:8 (Edward syndr:om):anq Tiisbf.riy't3(Patau
.syndrome).

Mon~my is ..a deft,cH:~n<!y ,cif ch.rqm~s.o~~s ana arises through a similar ~~~hism ~stiisomy pr
i:Jim~h anaphCi~,.@.g. . : .

~olypi~~Y.OC.C~r$ ~rj:the(e atf? more. ~~ntw~ hapioid {2f\} ~el?.of.brol'1W$me:s_

. M95Pjdsm is t'\.e : e-xl$tenee~f~t--M;i):ir'inore =<;ytogen.etlcally distinct ~ell lin~~ in ;ttJe ~me mo~L
Sex Qhrqmos:o.m~l pqtyS<lmies are tiisomi~s '()f sex chromosomes -and .include :t(1inefetter syndrome
. an'd 47,.Xf(.sy"ldrqme.

Structural p.:bno~mami~s 1r.clude deleti.ons. .d uplicati9ns. inversions . isoch r.omosomes, .rihg

chr0mo.so.rt\f!s,
. :~nsl:atiOn$,
.. dieentric chromosomes
. . and insertions.
Not ~II :congenrtalal;mormanues :ari~.e. from chromosomal <;lefee\s, some arise from gene mutatioos.
MendeUanjnher.i.ta~.d8$Cr:i~,..9er.te mutptions inv~ving, <?f)ly,a s.ing le g~n.etic .~s :ao9 :d epends oo
wh.e~r.the. ph;enoty.pe lg:dominant br:t.ecessive, and wh.ether the mul~tlon i s found in an aut~QI1HHlf
a sex chrQmOsome...
. I
~ :Mendelian patterns of-:tr~~smission ,.include !3-utosomal dor:ninp.nt, autosorra.r.recessive, .x-~~ed
domin'an~ x--.nnked r~cessive, and,Y .:..}inked.. . : . .: .. .. . .

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 CHAPTER 5:REPRODUCTivE GENETICS . 99

Autosomar dominant inheritance manifest in more than one generation and are characterized by
expressivity, penetrance, :plelotropy and sex limitation.
Familial hypercholesterolemia. Marfan syndrome, Ehlers-D;imlos syndrome, and Neurofibromalosis
type 1or von Recl<linghausen disease are examples of autosomal dominant Inheritance.
Autosomal rece.ssive traits are only expressed When an individual is homoiygous for the mutant allele
and dise;1se examples of this mode of transmiss!on include phenylketonuria, galactosemia, maple
syrup urine diSeaSe and congenital adrenal hyperplasia.
X -linked dominant inheritance is ;imilar to autosomal dominant inheritC!nce with the exception. that
fathers with the trait only ptrS$ it on to !heir daughtel'S and not to their sons.
X -- linked -~sslve traits are -expres~ by an males and by females who are hgrnozygous f!)r the
. trail~ affected male.transnms the--~~!Q all of his daughterswhe;eas the heter~)'9ouSfemalehas
a 50% chanceof transmitting the trait to her chlk;tren.
X-linked r~cessive diseases ,inclu-de hemophilia, .Duchenne muscular.dystrophy.and .glucose-6-
phosphate.dehydrogenase ~eficiency.
I. .

l Nonmende(tein patterns of .inheritance include triplet repeat expansion disorders, genomic 1mprinling,
uniparentat disomy, multifactcr.at inheritance and .mitochoilQrialdi$()rders.
~ les of ~.plet repe~t expansio.n dlS()I'ders jnclude Huntington disease,
.Examp_ mvotoni~d}istrpphy and .,.
""" ~: :tragiJe ~ syndrome: <'
,.... ..~:""
~ Earty pregnancy .loss are most.often.dufi.t6 genetic and cytogenetic abnorm~rrues~AQtosrimal-tnso!nieS:: ,. .
.. (:lre .the largest !;ingle group of chr:ol'nOSOmal complements .in cytogenetically_abnormal spbii~~@...:.;;,: -
... abortions whereas-.Monosomy X 1s the most commonSingie chromo.$ome :abnormality. . . . ..
--~ Adeq~e cU)d. ~ppropr.iate tre~tment of.genetiC disorders requi~e . ~n .accu~tegen~Uc t:aistory.vdl~;: ~'\.
. . ;;,,_,_ . in~.es~lic.iti~h?ritable fami)ytlisordets; healt.~ status.ot-~ekitivesypto the third degtee;.;4~1~j,
~'- ,~,,~.:.~~~~ rejm:Jductive oqtcomes, .present and past t!ru~ exposure oi ,the woman and the partner a,~"ffli&~S~
- .. _,.... -ages:
,.'
Genetic couose~ing :~ ~e me\b9d t1f \'Jbicfl. ~n lndiVidual or the family is provided info~ ~ooufa
'reator a }X)ssjf;)tejt~~ti~;J>~~Eilli.,____ . .. ...
.
....,.;;;;;~:;;~ng-is:theprace:s-s-Ui-arK!ehlifies infants iri a popuiation Who hav~ inl).erHed. metaboljt
cotld.itions for which early 'tr~atmsnt ~n prevent or ~essen the consequence~,-"-fn the Philippines,
newb;Qm screening lnelude.s five conditiCi>tls namely eongenital hypothyroidism. congenital _adtenal
hyperplasia,..galactos~mia. phenylk~tonur:ia .and gto<:ose..6-phosphate detiydrOenase deficiency.
Stem cells are totipotent cells .that are the origin of all the Cells of an individual. They have the property
.of self"fene\,ral and potency. Th~y -~rrte ~cl~ssifled 3S embryonic, ger.minal. somatic or hematopoietic
stem cells.
Adult stem cells .are currently being used for treatment of various disorders inh.Jding cancer, whereas
the therapeutic use of embryonic stem cells are still controversial and under inv~stigation:
Cord blood-b<=~oking. -~ !he ~torag~- of umt.m~al cord blood in a private or public iacility for f!.Jtute
ther.apeutie use.
Preifl)pl.cintatio!l gene.tic diagnosis is a preconception a! approach that allows thediagnosis of a disorder
prior to establishing a pregnancy.

ACKNOWLEDGMENTS
.. . . . .
Maria Theresa . H. Santos, MD (Re:s earch Cytogeneticist)., Institute of Human Genetics,
Associate) and Nenes Cadag RMT (Senior Na tional Institutes .{)( Health Philippines

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..
100 SEcTION 1: BASIC.CGNCEf?"fS OF RUMAN REPRODUCTION
REnltDClt8 .
1. Si.m,pt.on JL, Elias S. Genetics in. Obstetric$ and
Gyne~ology, ~td 'Edition. Pennsylvania: Els:e~er.
Scien~. 2003.
.2. Cunningb.an1FG, HE\-uth ,JC, et <ll. W~'s Obstetrics,
22nd:Editi'on. NewYopc McGni'w~flill Cc~panks.lnc.
2005.
3 . l;!arCh -MJ, Knutsen T ~d -~pur~ J.L. The AGT
CytogeneUcis Labo:i:~toty i.;t~ut\1, -Phil&,delP.hia::
Lippmrott-R.aven Pu~lisl:tetao -tm..
..... ~ PS. r.an.d~atkis in ~ ~~es: :c:~~Sie.
P.~P.enWfth <Cc:min.entarle~J. N~w Y:o'rli:: oxror d
~Pre$S; 2004. . .
5. Palo G~ F . .OU\eti~. :cong~4si:t.lal:fonnations s.nd
inh.~ed di~.:m. Sumphl~ WW,.Guti~ez RV, et
{~~): TeXtbOOk <>f :OJ;>#te.~: Pby:siOlogic and.
a1.
Patholq~ <)Q~tet;d~$.. -Q11eUn qcy; . ~~#Ol;l of
Writ~-~f.the .Philippin-e :!'titboOk or:ol;ls.~~.triC!I cild
Oyneco~~;Jnc. ~-
{i. :Gre,epwhoo4~'&e.t;l.etic.Ce.n~r..;Coun:s,.!in;et:.Aids~for._ "
. (,1~:4th ~tiPll. ~- . . . .
7. &~oorRM:~-Baild:~~H. fb~~psot;lc:~~;f'
.~~~~;~-r,~~e-~_6~ :~di'fio_p. ViE
. a ~:andfu~~r~~<W~e;Diseases .
~ritef.,.P.~t~u'-:s;b:dY:~fue~ . ~;a:ua.b't~ ~t'h~t.P;ti
.. WW"N;%Jl'!:18:.'4_e~{/.~:t..'P!C/:cf;if'bi'l}'ta_s,e....:Searc~"php-
.~:~-~-~:-~~~~ ., . . .
9. xawui~~~R~skror:ru~ ~~can;~n~e
cof.Ob:itdrio.a.ns ~-~lqg.su.- 19;9. I 189. 1.42 ~
~a. . . ... .
1.0 . Theor:Ql~ofh~i;yandfa,in.ily:'b:i.stQzy. Nati?na1);~a:rtan
: . Founidatlon. '1-9'99_ .A'V'ailahle }lttp! If at
. W'fii1V~9rgfruPf{in,d~j$J:l. Aeces~d-.o_Q..Api:il28;
~: . . .. : . ,
ll,. H~ SL, et al.. Natur.alliist<iry of i:ieuropsychologj.C:a.l
abili_ty and 'r2~P.yp.etWte~si~~s ~n. . pati.ents With
ne\uofibn>matosi$1'ype 1. NeYirology. ~00;3:; 60 -(7):
..1139-.ll45. . .' ' . ' . .
12. Hym~ SL, "ttal."'I'q,e nature:an~fieq~ency ofcognitive
deficits in ch.ildre.n vilth neurofibromatosis ~ 1"-
NMplogy 29()5~:.6~: .~0;37-lp-44.. . derivt;d from transP,linted:mou~ l!ltUTUw cclh. Nature
.13..Rader D.J, Cohe n J, Hobbs .HH. Monogenic
hyper:cb.olesterolemia: new itlsight:s in p'a thogenesis and
Treatment. J ClinI~vest 70Q3; 111(12): 1795-1803.
14. Maternal P henylketon\;lria. Am.erican. College of
.Obste~:~ ana Gyri~ologists, No. -2~0. 20QQ;..l46-
i~ . . . . .. .
.. ...
- - - -
15. Ander-son LB and B\lshby KM. Muscular Dystrophy:
Methods an.d Prqtocols. (M:e thoi:ls in U.oleculat
Medicine)- Totowa, NJ: HUtil.arlaPresa. 2001.
16. Screet;llng Fragile X Syndrome. American 'Co"llege of
Obstetricians an~ Gynecologists. 2006; 3:}8: 111-173.
17. Crawford DC, Acuna JM and Shennan SL.-FMRl and
the fra.glle X SYl}drom~: HU+J?.?D- gmome epidemiOlogy,
200i; 3: 359-371.
.review.
. Genet"Med. . .
18. -,NC'SI :o.MIM: Huntin:gtcns _DiseaSe. Available at http:j
I w w w. nc 9 i . n l m'. nih. g 'o Y/ tnt rex I
. clispo~.cgi7idH~ lOO~A~ on-Ap012.8,2 008.
19- Oelietic~.alu.a.tioit oStill~~~N~Deatlu.
American ~llege ~r .Obstetrtc;;~s arid. ~!~
No: 257~ May 2001; 148-. '150;
20~ Harper F'S. ~cti~ Gene~c C6un~g:6th Edition.
New Yorlc Oxf?rd UniveriiitY ~ .2004.'.
21. Beoneth-R L:The-Pra'dic(\l:Guide ti>'t:he ~~Fa~ly
History. N~w:Xork:W:U~y~l,lss;;Inc: im~
22. Th:err~ll 8~.1J:S. n~m ~eerilti,gpplq dile;nlliuu
for the twtp::.ty-fust ceiltUry: .Mokc Gei:l..etic3 .U:~tal>
200.1;".74p 64-7:4,.- . : _.,
. . .
23. Qut:iuk .R;'S~siA.: A~p!~phen~~f<>r
1#: Iarg<; 'j)Opi.ilations of
.dete~g . plienylk.etqnti:,rla.
pe-wbofri.mrS::C~~:P-~tti:cs: J,%3,1"$2: :$.8-:343. ..
24_ :.th~lt::Br:.' :~~:j.,N~l.m~_. in ~-
. 'Ax:J;?:eriqt.J."Jnherid,fetaboi;Pis'2007;.:~!447:""<6S.
25. wq~n J.M,Q, ..J~zy~ f- .~~ ~. ~of-
. .. .
.-=~~~uru~~~<!:~:
F~nburg-WK.: .ScleCP.on- of:'d:iSea':lle.s-a:hdti:'3U in
pclia.tti.sqe~ Pediatri~ 1974;54: 612-{;16.
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Screeriihg Expat'Group; Ne-woo~ ~g: iowaid a
. 11nuoriti screeriing :pi!iie..l and 'sy~te;m. "Geiletka in
:Medj.cin~ 2006;- 8 ($Uppll): 1S2.52S
. . . . . . . .
. 27. PS.dill!i-:~t;:hmd Theqell-BL..'N<:wbo"rn soeeniilg in-the.
~ia Pacific region .. J 'IP..herit Metab I)ia 2007';" 30: 490-
5o6.
.28. StewartS ..Stem Cell~Hl!-rldbook. Nev:Jersc)': Humana
~es.s. ~004
29. Becker AJ, McCulloch EA, Till JE, Cytolo&icaJ.
demons~tion ofth.e clonal ,.natuie .ofsplecn~s
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30. Gar4ner RL. Stem Cclls: potency, plasticity and.public
perception. J Anat2002; 2!=H) (3):.271-28.f .
31. Jiang Y, J "ahagirdar BN, Reinhardt RL,. ct al .
Pluripi>tency of .m e~nchym~ stem cells deriVed from-
adult marrow. 2002; 41-49.
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 C"HAPTER 5: REPRODUCTIVE GENETICS "' 101
. 7 ..

32. Ratajczak MZ, Machalinski B, WojakowskiW, Ratajczak 36. Cairo MS and Wagner JI;;. Placental andiohWubilical
J, Kucia M. A hypothesis for an embryonic origin of cord blood: An cltemative source ofhematopoietic stem
.pluripotent Oct-4(+} stem cells in. ll4u1t bone marrow ccllsfor tran:;plantation. J N.n. Soc Hematoll997; 90:
and other tiss1-1es. Leukemia 2007; 21 (5): 860-867. 4665-4678..

33. Siminovitch L; McCulloch EA, Till JE. Th~ cii:stribution
of colony-forming cells .among spleen colonies. J Cell
Comparat Physioll%3; 62: 327-.3 36.
34; T:iikaheshi 'K, Yrun:imeh. S. Induction of pluripotent
stem cells from mouse ~mbryonic-!Uld adult fibrobmst
cultures bypefinCd factors. Cell2006; 1126 4: .6 6j-676.
37. Kline RM. W!::.ose blood is it, anyway?. Scientific
American 2001; 284: 42-49.
38. Kline RM .and Be~tolone S . Umbilical cord blood
transplantation: prc.riding a donor for everyone neeOing
a lx;me marrow transplant?. Southem MW. J 1999;
91: 821-827.

35. Tu:cil B. Stem cell~a clinical update. Austt:alian 39. Dela Paz EC. Prenatal diagn.o 'sis and its role in
Family Physician 2006; 35 (9}: 719~721. r eproductive risk screwing, prevention .and-treatment
of genetic diseases: Is .:the P'nilip:pi:oes .!ead:t ior il? Acta
Mica Philippina 2006; 46{2}: 5<h57

...:
.;.t-f,_. ,,._

!: -
, ..i.

.... ..
~
,1 .
. .:...:-:. .. . .~
.. . . .. . .. ::.~~~.~; - . -

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'(

-.
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 --.....
6

REPRODUCTIVE IMMUNOLOGY

WALFRIDO W. SUMPAICO,.MD

Early Embryonic Development

The Feto-Matemal -lnterphase

l)t.erine Re~ptivcy
Blastocyst Activation

1m plantation

:Stakehold~rs in lmpiantatior:t
Steroid H ormones
Prcstaglandins
.Transenplion and
Grciv.Jth F actors
Immunologic Factors

Clin'ieal .lmpli'cations and Future .Directions

. . -rnrertrrtVanaA'Ri . . .. --... -....... ... ..
:f>re9~aricy complications

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 104

The process of human repro.duction is relatively

inefficient. Maximal fecundity .{ the probability oi
con~n during one menstrual cycle) is about
30. percent and only 50-60 percent of all
ccn~tions adva.'lce beyond 20 weeks ofgestation.
Ofthe pregnancies that are lo.st, 75 pen~ent
n;Pre~nt a failure of imphmtation.and are the.refore
n ot clinicaUy recognized as pregna.""lcies. 1

~Y E~RYOlUC DEWLOPMSNT

. F~~tion Occur.~tbefatlo_plan ~be wit!$

, . 24 ~ 43 houn. ~r ovUlation. The initial stages
of ~C\~ent/fro.tn. fe~.~ to a .~or\lbl,
~ -~ Uie embcyo, ~n~ in a non~ad.hesiv
,i>n?tectlVe c;:oatihg known as the zona pellucida, Flcure 6-.tA. Apposjti~n a:ri<:J adhesion '(Adapted rro:tg . _; .
Notw!tz!l). . . .
Pa.~s through the fallopian tube. The morula
~let$ the uterine cavity approximately 2-3 days
. Q~~ ,f~t;l.on. The appearance .of a fluid-filled
~er ca.Vity Within the ;m.:"-t~s of cells tnar.k s the
ttap.sjJlon .from morula to blast ocyst and is
a~~~<Lby::~li:ul~ :differentiation; the outer
tt.~ph:O.b:lasts .: give ri$e:,to -. e~t:r,aero;bry.onic ..
. s~~~~ inclQding the placentt. an:d the inner
c:elhn~tss:gives risetothe embryo. Within 72 hours
. ~(:'~Q:t~ring. the uterine caVity, t.';le ~mbtyo
~~~~ito~.-tbe-zana.:.thereby.;:~singJts: out~r . .
. c:d:1~ of.lS;YJ\lcypal (m~tij:lUcl~te) trophoblasts .

. ~~~~tiotJ ;~~ anp~atdy :6~7 days

~t 1~.rtilization and probably includes three
st~:getr.1'he ~~nitial un~tablei\dhesion- of the
.o~snn-the'uterine: wall i:n:alled-appositlon.
Mic.rovilli oil the apical surface of syncytia-
~ ' t:rpph'ObJast~ interdi~~te with mietoprotrusions Fipre 6.1B: lhvasion (Adiipte4 fro~ Nqrwi~.
~m-1he apical surface of the .ut;erine epithelium,
kno~ .as pinopodes.2 This stage occurs tnost
ootj)~~nly in the upper posterior (fundal) wail of
th~ :~teros. The next stage, :cUl~le adhe~lQn: is
..,lj~-etetized l>Y increas~d phy$ical interaction
betwen ,t he blastocyst and the Uterine epithelium.
Sh'()f;tiy thereafter, th~ Ulird stage of invasion
be~s where .~yntytiotrophoblasts penetrate the
uterine ~pithelium. By then, the blastocyst is
orie~ted with its embryonic pole toward the
.
ut<:tit)e
;.
epithelium {Figures 6-lA, B , C).3
'
T~E .F ETO-MATERNAL INTERPLAY

Uterine Receptivity

Uterine recep tivity is defined as the sta te

. dtitipg ihe period of endometrial maturation when . Figure 6.1C. Early pregnancy maintenance (Adapted from: .
the blastocyst can become imp!~ ted and days 20 Norwitz'}.

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 CHAPTER :6: REPRODUCTIVE IMMUNOLOGY ';:' ''105
--~------~----~~----~--------~--~--~----~~------~~--~

to 24 of!l,,regular: 28-<!ay. menst;ru.al cy<;:le as the Several factors_ have been identifi ed as
optimal period. for implantation. The features of potential markers of .endomep-ial .receptivity. The
uterine receptivity in~lude a vascular and level of leukemia inhibiting factor in both the
edematous endometrium, enhanced secretory luminal and glandular. epithelium of the uterus
. activitY eftlie eiidem~triel :g1an,::;ls and development rises .ct....-amatica!ly in. the. mid-secretory phase of
of pinopodes on the lumin?-1 surface of the ~e menstrual cycle and its diminished secretion
epith~um..'-4 is asS9Cia,ted w;i:t.~ recurrent pregn9Jlcy lQss. 0 ther
molecu les tP,at are pro bably .involved in
Multiple. signals synchro~ t;he developm~nt endometdal. recept~vity i:nclude adhesion
of the blastocyst ~dthe preparation -of tbe uteru.s mo.l eculu .a."'ld proteins called mu~ that have
'(fa ble 6.1).~ The role of .steroid hormones is the. hig~ sugar conte..11t w hich cause ap. increase in
~st understood. hnplantatlon requires a pre- the e.Jq)Fessionnf oli.gosaccharide recepto~ on the
.ovu;latQcy increase in the secretio.n ()f .estradiol- SU:if.ace of endometri.al epithelial cells.~
-~.7'1.{~ whl~h :stimiJ.la:tt;s the proli(eration and
diff-ete.n tiation of uterine ~pithelial cell$. Human :J:llast9ey$t-Activation
choriQnj,c ,gonad.o tr.oph1n .(hCG) affects -the
continued proqu~tion by :!;he corpus luteum .o f The bl?-s.tocyst actively pa rtiCipates in the
prog~stcrone {PJ w hich in turn stirn.ulate:> tb.e process of implantation. Mechanisms t4at ena ble
. pro1,ifei1itloh . and differenf;i~tiQn of ~trormU.. ~lis. the blastoey.st to initiate iznplanW,.tion .{a.-p~
D own:stre;am '~ors of.steroifi Mn:t!ohe itcti(}ns termed 'activation}....include catech ol eStrogen~. a
~S~~e:.~peptide hp:rmones,. grqWth. !actors, :~:nd class . of. estroge.n: ..metabolites: ..Lab. media: where
cyt:Ok:in(!s: pre.-:imp~tationembryos .havebeen:. ciu~~fu.
...~ * ~:": "~:; . ~,~t.t: -
. ...,.., : j .)'
o \0 1 J..-,.~ ..:::,. ;,\.~""-!..~,:). 0

Tihler6~l. :Factors .involved.in .~plan~tio:l. and :ear.Iy.pregnancy:c{Adapted frbiJ1 Norwitz2j. . ..

_-:::~. :_.;..~:\- .. ,~t . . .. .. .. . ' ' .. . . . . ' . . .' . . . . : ... -~ .

... .F
._ _
,....~
...,....':.'.-.-...
~
.. . &
_ 'a
.m nles.
~
SU"bob
_.....e_et.ed
. . .R
. ole _' . t..~l"'~ !'~- .,:~
-- -: .
. .~;t;::
::.. ";

Gha'ogesin:epdometrial Hum.ancb:oriorJc-go'n'.Wiottopi..h- ~Ma:fu~~'tlrogesterone~Jroiii...

lumin.al,t;p~elium pinop?des;alterati~m1-in adb~sion corpuslutcum ..
molecule -and JnUcin expression Facilitate btastocyst,capture and
attachment; promote trophohla.st
differentiation an(l.:invasion

Cytokines and growth Leu.kemia inhibiting factor, .l].eparin-bindjng Fac;:$tate sigrt~g between 'Qlastocyst
fa~ors .epidero;lal gmwth factor;. heJW:tocyte and uterus; regulate cndomCtrial
givwt:h factor;interleukin; vascular mvasion, _proliferaticn, arul .
endothelial growth fa(rtor differ~ntiation; ;:-egul.ate:en.dometrial
vascular premeabili_ty and r=odelling

\mmunologic factors Interie,ukin-l.O; CfTY (complem~nt regulator} ~munosuppre:ssion

.HI.A-G Prevent hnmul).e ;:-ecognitioo and
rej~ction of feW semi-allograft
Indoleamine 2,3-dioxygenase Degrades tryptophan, which Is essrntful
for macrophage action

Trophoblasts proteinase~. Matrixmet.allopr.otcinases -tissue inhibitor Regulate trophoblast-inv~ ; faeili~te

inhibitors, and.. adhesion ofmctalloproteina.ses; cathc;psin B and L; . ." trophoblast vascul ar~
molecules cadherins; i.ri.tegrins

Others Cy9ooxygenase-2 Re~lates prostagl.andin p~ction.

. ,, .<;lxygcn:te~sion Regulates the balance :between
trophoblast proliferation ind'
differentiation

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.
.,.

'1 06 -SECITO'N 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

vitro .contains many bio-tran~form.ing gr.owth 3) The phase of stable -adhesion is followed by
factor, transforming gt9'Wfu factor beta. platelet- invasion, whiCh produces changes in adhesion
-derived .growth factor, -insulin-.like ~owth -factor mokcules. The inva$ieinof cytotrophoblasts leads
II, colony"'stimulatiag (actor 1, interkukin-1, to a decrease iri the expression of adhesion
.interleu.kin-0, prostaglandin E2, and platelet- receptors characttri'stic of :'s tem cells a:nct' an
adivatihg factor. EViti~I?-ce of signaling ~tween increase in th!! e?CPression of adhesio_n receptor3
the blastocys t ~d the -u~rus cqiJies froril ~tudie:; that are cnarade.ristic of vascular cells. Besides
in mici i n w}#h imp.J..antatipn h.a~ been 'delayed allowing Gytotropho~lasts tl~at line maternal
'i~di!funt:dy by the ma.qipulatfon.of the. hormones.5 vessels to -masque?a.d.e as vascular cell~. these
r~ceptors ,also i~prove the cells' aot.iity fo mvade I
~.;nbcyqs. at or -ncar ijie itp,pl~tati()n stage t.h.euterus. 11; 13
. eXp!.W _.epi<iecmil..grow.th~fac~or. {EG~~ reeepto,ts I
and hePci,ran s~te pr9~}""...ar.:s, both ofvihJch 4) Invading :C"Jt9tro'ph9'blasts -~so :i.J;lctease I
.il;lte;t:act wit,h. e,Pid~rmal ,gro/(th faC.tor~ .liga;ids their productib't!- of prot~in~s" They a<;:tivate I
r .esulting in eii;~.bryonic prolifer:a:tinn ..and m atrix m.etallopro:teiP,a:se..:9 '(MP--.9 ), which
-:ro,.s.turil.tion. 6 c onfributes to their irtvasi-:;~ness. The. I
simultaneous incr~ase in the .p roduction of tisSue I
irihibitor of:me~op:rote.iliase-3 '(Tlt4P..:3) .p'ioVides I
a m~chani~m {or- r~s:tti~ng .MM-P...:mediated. I
irivasion. MMPs -a.tid -TIMPs :ih. matemi::i .decidua
.1~t ~- oft~n- 'a$ke~l.~~y. :~e ~er;n.aLi.:IpmU.."le ap~ar - tc .hav'! .a :si..rnilitr role...ili t~gulatmg the i
. .'ey~:d~~npt:urejec:t:.il;le:fe~;:attti,ge<:k.:dJiii.ng .. invasion of tr.o:pq.o blasts. 6 ther..i.mp'or'timt I
. - ~ ixrip~~tio~:Frre~i+ite~qu0)t:'~~een>an~ll:ctiva:ted.f''proteih'a.ses.are.,~thepsiiit:B'antlft;:H'- . I
bhistccys,t and a . rec<!puve u~rus-. is part. qf a . . . .
:co~p~~-prcc~ 'that 1~s tq implaritati9n a:n4 S) . Inte~leji.k;inl incr~s.es:,'fue 'Pi'U:c:tiori of I
th~ ,f.8r~ .:s~ges of'p~~~.:d:~el?P.fu~ilt:(~e . MM.Pf.9 :1Jy cytotrQ'f:.h9b1<J.Sts ;~d/inter.I~Uin,.:l ''in I
6~2):-'~$evC;rl:lLry-~t{>r-Y.:--,~U::qs~~s.~l}avei'be'err . : e:rp.bryo :cultup~:-. :m .ed i'l,ltn -cor-relate. with I
. ~P.~~~~W~.j:,sRfA~l~:I>~~~-~ , ..:. . . : ~nr6ductive,..su~s ;after::.m.:~'vitro.;feiiiliza:tioli: io . . -
I
. , .-.-:'"-:::.;' ...-..z ,;.;, ..}:.-.,,.:;:-. ., ~:;: . ~i . . . . . Degd,ua.J.,;;v.asc_ulu.; endothell~.; g:roWt:h;,factor,,

. .l:fie~~n:iia-iil~ib~tipgifa~~-(IJFfl~ 4JlP.9rtant . (VEGF) l:>romotes angi~genesis, a key tleinent in I

tor. ~~ 'de,crdualii,aticn 'an(t :hnp\'ahf.ation. It is inipiahtaqo_n.'1 s / .- - I
produ~'riot-oruyPef6r.eimy,lar~.t~tii?'n1 m ~re:o>pc>nse
to~St-rqgi_n;if~;.pro:ges~erptre-::prim'ett:u:tennegt~ds,
.but alsO ~t the tirD.d :-~f WiP.Utiitatipn by stromal
6) 'Physiologi~ r-egulators :mi:ly also "he
U;nportant. For ~ple, o.Jcygen tension-promotes . l
cell~ .su;Quwr~g f...lp! ~t;tive" biastocyst: 7 tro.phobla~t 'differentiation and . produaUon of
integrihs. 16
I
2).lmpla'ntation requites the l:)io~ynthesis of
. :pr6~tagi~4ins. Cyclapxygenase {C0X} ; the .i:at<!-
'lin:iitlM.enziiDe m.:,.e. ~~v.e.r~ion .o'f a:ra6b;idorflc.
~c~~ .to :pros~ag13.n4it>;~. ,e;i'st~ 11:1 t2 :i;3o'fo.rt)is:
. G9n.stitutive{tbX-ll p..Udii:~q.q.dble {COX.,2).. In the
e ndgni:etrium, COX"l _pr:o\l~ctio-n q~crea:ses in
respo~~ to prpge.ste~ol)e .and ~stritdiol"l7-b., and -~
th~ -,endo metrial content of C OX-1 falls
.pr.cci.pito~sly hi. the mid~lut~a,l ph as~ of the
menslnlal.cycle in apqcip~tion of implantation.
ln. contrast, COX-~ _pro.d uction, w hicq is. no.t
af{ecte<;lpy stero~g h9_~9-~~s, is .rest!i~ted,to. the
site 'of ilnplii.n~tion and 'd(;pends on the preience
.of a .blas to~yst that is r.e~dy 'to implant.
.Interletiki.n-1 :induces the ~xpression of .COX-2
.....
-
_..
genes .in 'cultUred endori:ie.t rihl 'str~mal cells and
CQ.X~2 'iUs'o .prqduces ~ros~glandin 'i_e;9,to:tt 'I
~ .'. Fi~re 6.2. Th~ fete-maternal interphase.

Seanned fy: ~

----:-----'--"-----------'---,:....__-----~------!v.
STAKEHOLDERS IN IMPLANTATION
Steroid Hoi'Illone~
Proge~ler.one..,recep~or ant~g~mists '(Mife-
oristo:ne) readily induce ab9rtion if given before
;even weeks. of gestation. 17 Similarly, surgical
removal of..the 'corpus' ~:uteum', the source of
progestcro~e. results in. pregnancy loss.!!
Recently, Nikas pointed but that development 6r
endo]I).~t:ri81 pipopode$ fGr i.rnplantaton de~elop
under prog~iterQne stim~latitn and is .suppres:se~
qy :if<;pristone. 19 These data suggest that
adequate' progestero!le .prOducticn by th.e .c vrpu's
luteumls Critical tothem.alntenancc ofpregnancy
until the placenta tak-es ovei: this function at 7-9
we.e ks of gestation. The corpu-s luteum is
main:t::a.U:ied .through the continu;::dpro.ductibn of
choriomc:'. .g. onadotropin {hCG) by. .t rOphobiasts.
. express ctaic lila.J9r histocomp~:h9~ty ~ph
. . .
.~.;:Estrogen do~s ..not hav~ an essential role :in
e~ni~ :_;'human
nrin~ralocortico1as are not . essential, at).d
an'dto~g~};:S'' are required only for ~~xual
diffet.entiatio.ri in the Il}ale. The r;ole of
~h.J.t~ccOl:'tiCoids .is uncerta.in.
0""":'":"' _. 'ol6~ r. \:. ,
:-..,'1+f',: ~ ... j. -..
~-~~~.~:(PG)
0 .,;..:;;_;~. ~ ~ ~..:..
... .. . ab\lndent 'in the ute~s Jiu.tlri:g ea:rljtpregrumcy
...: PG leveisin:the early human decidua.-are lower
pr:im.aril:j bec:au~ of a d~se in. the Synfu~sis
cf ~~gl~ndms. ,&n~ue-!1?-Y; FG .pi-ec:ursor.s
rather:than-the-biologi:cally-~tiV:eeom:pounds~are . cytoloila.adlVily~~:Hur'nan:..t:roP4oi>last's:hdpTCciiiit. .
llie-ptedommantformsin-arn.mot.cIlui<;i~Chnost:. th~se-til{usuaJ.:mat<;rnal-lt:OmUn.e-~lls~o}r.;~s:
uterine compartments. The admiriistratio:n of
c:l(ogenous PGs - .intravenou~ly, intra-amniotically,
Or vagiruilly - induces abortion in all specieS and
;at'ariy'stage of gestation, These data suggest that
.ptegn?ncy .is ~aintained by a m~hanism that
'suppr~sses uterine PG synthesis thro~gh~')lt
gestation. Moreover, a defect in this inhibitory
mechanism may b_e associated with early
pregnancy 'loss.20 .2t.22
Transcription and Growth Factori>
The differentiation of trophoblasts.is Tegulated
. by s~verai. tran~cripti~n and growth factors. These
are . essenti a l in epltheliaf--m'esenchym'al
1nteractions that occur during early placental
development. In mice with :homozygous mutations
in Ule.hepatocyte gro.Wth factor:gene, 'trophoblast
differentiation is defective. Similarly, mke lacking
. the :P,epatocyte gro\vth tacto_r receptor .(c-me'~ die
CHAPTER 6: REPR.ODUCTIVE IMMUNOLOGY 107
.
.~.'
from pl?,cental ~suqiciency .~used: by a~~rmcil
plac~n~al morphogenesis.. In hunians.
mesenchymal cells within the stromal cores of
chorionic villi produce hepatocyte gr~wth factor
while cytotrophoblasts expre.s s c-met and
!lepa.tocyte growth factor which enhance
cytotrophoblast invasion. 23 .21 .25.26
Immunologic Factors
One of the most i..-1teresting functions.of the
placen:t;ais.the :ceguJation ofthe ma~ immune
re!>ponse so that tl1e fetal semi-allogiaft is
tolerated during pregnancy. Trophobiasts ru-e
presurD.ed 'to i;)e essential' .tb t his phenomenon
lY.:cau;>e they l ie at the -inatern~fetal :in.t:c:t:fuce.
where they are in direct c:o ntact with ceU's of the
~ate.~ immune .system. Tn)pho1ilast.S do :not
fMfiq class ii molecu.ie;s:. Cytotr.ophobia,st:S
~r~ ~ote mA.:G:, a Mfic -cl.as$ Th. :ciokbL~
pregnancy. .S_imilady, .as :theY irivaaethe uteru:s:this' observtitioTI;~imd
the fact that' . HLA.:G .. exhi~i.t'Sf';Jlfnfi'ted.
pciiy1norphisin, suggest that HEA::G bas'f'l1P~
~portance.n . . ~ -:~::: :_'. ~~;~~\
CjtotiQphoblastS~ friat-~ H.LA~G come'm .
dir~t <:;~1itaCt~th ~mate~ Jyinpho.@~tf~
(10-iS% of all c~~s). Th~se :_aeci?-ual';~~
are CD56+ ~tui:a.l killer. (NK).-ce11S. eom~~
peripheraFbloo,d !)rtiu~ho.cyte~ . th~y hiv~ .:law
of chemokines.24 ~;30
Cytotoxicity against semi-allogen~ic
trQphoblasts must .be sd~tively 'inhibited. The
factors responsible for the localized
imm~nosuppression iric~u.de cytot;roph.oblast-
dcrived interleukitl-10, a cytokln~ that inhibits
alloresponses.in mixed lymphocyte reactions, and
steroid hormon~s, including progesterone which
sti mulates a l ow molecular pr.otein called
progesterone-induced 1:>1ocking factor (PIBF)
derived from T cells. PIBF in tum is believed
-responsible-for the anti-inflainmatocy1b2 cytokine
dominance (IL 4,5,6,8,10,12) over the pro-
inflammatory -Thl cytokines (interferon gamma,
TNF -alpha, IL 2).jl.3l
~
. ~;, .
1;he complement system may also be~volved,
given that the Q,cletion of the.- com=p lcment.
regUlator. Crry in mice leads toJ~talloss as a result
Scanned 8y: ~
~
 108 'SECTION 1: BASIC CONC~TS OF tlt)MA'N REPRODUCTION

ofplac~nW in~ation. .Fin~y, pharmacol~gic Pregnancy Complications

rJ;ata suggest that trophqblasts express .a n enzyme,
indoleainine .2 ,3--dioxygena~~. - tha~ rap.idly At a functional level, the p lacenta must
degt:ades trYPtop:h an, w~ich is esseniia:l tor the integrate maternal and .fetal phySblogy, immune
.acf;i;Vation of'I' cells.33-~ . systems, and en(+oCrine eystcms. T he invasion of
cyt::itrophoblasts to the p roper depth ofthe uterus
CLINICAL IMPL!CA'J'IONS AND FUTURE is .a .i najo.r faGtor i~ detenn4Ung the outcome of
DIRECTiONS pregna:ncy: Excessive invasion can le~'d to
deficien.t devetopmc-nt .of the decidua w ith ~
mf.e~ty ~dART
. "1.~. ,. . a.\lt:loim_ally r:m:n attachment 'Qf the .plt'l.centa
~y onto the J.i;tyoi,netrilln1 (pla.~n~ ~.
. . Jnfef.tility .m .<'!-Y re;SU:lt from a .failur~ ~f placent~. e~~P,~I'i~.n inlo the niyQmettiw:x:i'
fe:rtill4tion or .fi9m. fue ~~s Qf Ule (erti.lized {yla~~nta inere~).,. or .invMl~ .-.!!lrough the
'bla$~~ -Wore impumt:atll>~ The UJ.ti)::ttate goal Ittvotn.etrium to the uterine seroSa. B.rid .ev.eninto
pf~q.e-~giixip~ta~ri. ~a;ta~~u~tev.el a:djattnt orion~ ~lac~-nti. ~~~-t_.:). .: . . . .
is -~9 impr.ove the dt9.8D-!:>~ls ail,~ ti'e~tent or
U;i,fer"Jlity. The . fail~""' c(imp~ta.tioA' remains f:\.
t~:i~Qfp~o\em .-4 -~yti.stlli:~:faillfy"\ifcifue L')B.~~qu~te inv.asi.on h~s beeA.in."Jp~ted. k
:re~~~:P4~tr~ .ifO:o'r .o.o,C.yte. qua.li~ o.t :d:elityed the .pafuopbysrology-!}fpr~p$...~~
imptan~q~"'"- ~e fiig"h hnplantaU,trii rate -9f . ca.-use _of preechtmp:sla .ts P.i:l.knQvwn~ the
. . . . . . . - . ch:aracteii.stic;: p,i:itl).bl(>gic l~~(>n i s the . .resUlt of
'en'\;!Vme\-I.
do~ . ..~}ed_::~~:t.~r:
.. . r.~ii
n . i?.:::-~~.":f.~"Jc'anu..u~
<..U.U .
n_::~'3!~! ~~t~~~t ,
...
.shallowmterstitia'l
..
iriva$ion

by. Mrl';,......._h.""laats.
~, :---,....-~.,.,
- ...~~~<:q~_tty'f.~tlie~>~~V:t~~~ia~~o~ ._. .. ::ma,.:nor:~ ~cp~~~~:~~trU.~~<.JimJte~j~dp.V:~..
d~t~~~~- ~~....~ee~, (f; ~P.~~~#~D.-.
maXimiZe pregn~ey ~a:tes .a fter ln vitro
.ro ~~~on..~P~~ps~.:e.~_u-o~,~t
-m;~~e:ut~ev~ls:Iail::to'S'Witeh..tbcit;~
.
{~~&i:>llt $CV~ ePiqcyos.o:f:th~..;~~gh~,.. ofaQh~slon.Iilol~es-to.t~le-$at;OC~ .
practice . -( :elb. Thus,.:the :u~e -art~les i el:tl$t ._stila}h. .
cell~e~traiisi~":the1lteru~ a
. :~~~~~.~~~--~- a:.~~~;~~~--in. bore, -h~gh-resis-~an~e- . ~esse'l~:.tha~.~n6t
. }:ugh~,~"9'!4ez:vJ;~n~;l.~pJ~.~g!;;sJAl:iP:n~,,:_A~tJiougp.., ?-dequatelr. :t:e$I>O~d. to ..the-:eyer--mcreasmg:ietal
tmnsfemng:f~ b~t0Cy'St:.-$t:Nte:eml)jyos m~'y deman:~-s .for'blood How.: b.etermining. the
eJ{t01ri~~:tHi!t. Pf(5bi~~ :li 'ffftei~(;\f~tii.hiilirg~bt n~lien~~- of xed'!iced -placentaL~~n :'by
'tli~~~s ~.ri:s1i5re:~~tati'Oiii~m DZ>kpi'~r!lo-w:'anU.llow"'iCU:ltrtrurfeif~~rmllie'
'h.lioW:Ctlp:ioans "tQ'.i ila"#iiiiu.~cy:ra~ :wlll}e . .21@~~c$iiaeten st18' orth[s~~:rf.iilijl'D:s 7

m;D'imiring the l:ncideri~ o{rn:Ul.t:ifeW ~e$tations. .art Un:portant ~hallettge;'"'~M

.: POINTS lO REMEMBER

.Start py revieWing tP,-s development frqm <'! ferti!~ed egg to -a bla~t~ysl

Three .s\?,ges .Of implantation pre -recognized

o -Apposition
o Stable adhesi<;m
o invasion

-Implantation fnvolves an interplay of f.etat {blastocyst .activation) -ano - ~temal (ulerine ~tivity) .
activities. .
o Uterine r~ is dependent on the act!on of s~eroJd horrnones, adhesion.molecutesaoo mudns. .
o Bla~tocyst activation.,is d~pendent -on c,ateth~l estrog~ns. and:transforming growttj f?ctors. ,-
Evidence of.signaling 'betweenthe.btast9cyst and:U1e .I,Jte_tus comesJrom studies ir:uni~ iri ~which
implantation has.:b.een delayed indefinitely by the manipulation of the hoTTl"lones,

Scanned lly: ~
.~ .

CHAPTER:6: R~PRODUGllVE lMMUNOLOGY 109

. . - .
The interaction betweeri an actiVated blastocyst and a receptive uterus leads to imp!antation and the.
. ~

early stages of placental development ~veral regulatory substances have bean implicate<! in this
complex process -
o Leukemia Inhibitory Factqr
9 Prostaglandins
o Adhesion molecules
o MMPs and TIMPs
o .. Jnterteukin 1
0 . VaSc~lar endothelia! growth faCtor
'o Oxyge.n t~sion

I Several subsbnces act a~ in:'I}U)rtant stakeho!Oers in implantation. The most prominent ones are-
...o St:erpid hormones .(Proge5erone, h,CG) ..
o prost:Jgiandins (Afa~idonic acid)
o Transcription.ano growth.factors
o lm~unologic factors {HLA-G, C056+'NK cells, lnterlcukin 10, Progesterone-PiB ~-Th2-Th1 cyto!qnes.

'TM application :of:i<now!edge Of the vaiious. mechanisms-in implantation is usef.Lil for infertifrty aod ART l
I
where ~1e q!.!ality ;-ather than. .uterine ~ctors determines the :success 9f implantation.
. . ..
:~Y..'-" The'"in-._;asior. of Cytotro!)hobi?sts to the proper depth'of theuter:u$'is .a major factor-in determining;,~
, ,<. . :ot:tcome.ofpregna.ncy. be~p:invasion Je~d.s to the. plc;~r.~ aecreta SYndromeswhile shallow.Pe~etra~f
: ~~,:-- .. .v..ith-iimited:endovascular invasion leads to pre-eclampsi? and pregn~~cyloss. :~ :_. 7~~.;.
: . . .... ;. . - .. :.'....~:.!. ! '.

.. -~4!1':.. .. . . ..-!. ."::6' .

.. .-;::!~ .
'oo~r..-:. ':"

. ~"~:.:~

: .. '"': .
-:~:i,~ ...~ : .. ,._ .:.
1. WllcoxAJ,WeinbergCR, O'ConnorJF, etaL Incidence
: oC.c;a.ri.y 1083 of pregnancy. N Sngl J Mcd 1988; 3 1~:
: l~i~~ . 8. MarlQn.s ' :L,. Da:nielsson KG. Exprt's slon': o'f. <:;y.clo-
.. :: ~- - ... :~-;
2: NorwmER:saiusrrtrruiifFisn~SJ: rm-pJa:Ot.alliin:-ar..d
the f>\U'Vival of early pregnancy. N Engl'J Mcd 2001;
'345.(19): 1400~~408.
3. Hertig.AT, RockJ,.Aciam:s EC, Menkin MC. 'fhty-four.
fertilized .human ova, good, .bad 'a nd indiffere nt,
rceovertd from 21Q womeri of-known fertility: a study
o( oi<ilQgic" ~a-stage in early human pregnancy.
PCdia'bic:s 1959; 23: 202-211.
4 . Bergh. PA, Navot D. The impact of em bryonic
d~velopment arid endometrial I!laturity on the timin g
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. ofthemarilmal.ian embryo and its re_gulation by growth
factor-3. Pev G~et l 997; 2 1:.91-101. .
6. Da3SK, v,lang XN, Paria BC, et aL Heparin" binding
.EGF-like growth factor gene is induced in the mouse
uteru3 tCm.porally by the.blastocyst s olely rit the site of
its apposition: a I>ossible)igand'.for intc:'rac~on :with
biastOCySt EGF-recept9r in implantation.Development
1994; 120: 1071-1083. . . 10: 1571-1578.
' :~-~.:~:, .... ::t~~:~=~'
'7. s'tewart ct; KaSpaiP; Bruriet r...:i;:.e(at; B~t
implan~ation depends on maternruf:expreit~ob.ofof ..
.~el,lkcmiainhibitory factor. Nature 1992;359': 761-79.
oxygcns:se-hr:.hu:m-an~~rrdometiium.:.dur.mg-ibe
implaiJ.tationi>eriod:MolH=Repro<H999;5:96I-965;
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reproductiv~ failures in cyclooxygena.se- 2-<l.eficient
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CJ, al-Abdul Japbar F. ?.r-ediction of succe3sfulembryo
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induces cyclocixygcJ;la.Sc-2 gene
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. .::r

Scanned By: C
11"0 ~ECTlON I; BASIC CONCEPTS OF HUMAN REPRODUCTION

~ '1tt,
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'

1~. Csapo J4.

Pu.l1c1qnen:M.ln~s{>C:Ilsabi,lity of the l:n~man 31. R()~ I, ~nY .[)~. J:.o.cksley RM, Abraru~ JS, J,.itton.MJ,
corpus lule\tin.in .the lAiilnten.~ce ij e arly pregq.ancy: . FiSher S;J. Hutnar1 plac;elJ.tal..cy:iO~j>hob\aSuproouce
:1u.~my ev1iktice. bb-~tefGjnCCol;su..rv t97.8; ~3: 99- the i.of.ztiun-o.su . e 'cyt"Okine inierlcukin.lO.JExp
8.1. .. Med l996;iaf~48_,: _
' '

19. Maathu.i3 ill?> Kelly.RW:\Ccnce:htryUi~ of PGF2 a and . 32. <Pavia, C, Siitt:ri:P.K,:Pciini8...71: J.D .;!?tit~ DP. ~
:~2f.~.:,th~. ;e~dome~;'.t.li.J:o4,gjq~.t:. ~e.,h,uljl~.-. . . . . of~~~f? ~geD.cic_ c:ell-.in.~~n.S by.~J:lormonea:
'Dl.cil3trualCj'C!c,-a.ft.e!-t,~tiO!;tofdcmipheue .. J. R'CJ)rod..~un.ol.1979;'l!'3~38:' : ' :
<>r.:~: .~ e~troe;~!.l:-Pf.9~T$tc;)_g~:O::,Pill.art~ fu'.cru:lY'
pregnancy. J End~l.1978; ?7:'361~37-1.' 33. xu'C.; ~~D. flok:rsVM, P8l.an.caB,Cl;l.~ AM, M<)lina
-tL A ~~cal.rolefor.murine cbD:lpl~cxit r~. GnJ'
20. Abel :MH, . S~jth :~'K. ~~d . D1,. :.S upp-ression. o inf:::~m.at~alt9lerance:. SO.ence:2'0V0;.287:-'l98-S~H.
~tra:rion:'qf.~dOm:etricl'ro.:m ~;..intr:a:.-u'tc;Iine; . . . . . . . .
:and~Ric:P.~sY;-'iD:woP?-CJ;i..~ ~d~ol-1980; .34. .~uno DH,:'Zhou . l.-f::.AftW?od Jr; et ru.. .~ of
:~37.9-..~.; . ' . . . . .. .anc~er.eic .Ietlili..rejCdiori-:t>y tryptcipoan:~-
Scierice 1998; .28 1: ,1191-1193.
21. J.~~ o~. ~hi-,Ft:A. c.run.~~. ~. ~4ili.SkiJ,
-7~un:k~lL~-d~d~ .?-<;iE.concsc!iatiCn:.in- 3S...J4U:i:Um)l!.a.~.s.. $,&U~hi,~~ X:P~.~~~ .:M. .~Selciiia .~
.-human.aJ;>orlion...B.z:.J.::Gpstet:.Gynaecol.l;9.a3;:9.0:..9.5Jl- ,Lo<;alization and dcveloQm ental-cbange cif:iD.doleam.ine
- %0. 2;3-dioxygenase.activity fu t,he .;l:nun,an placeritA. Acta
. I ..Med b~yama. 1991; 45: P:S-139.
!2::t,_.Ja,na~ur}..!J, Utset..-.;p;',Cross .JC, et al. A rc"j);Crtoire
. of. differentially e>t;Preas;Cd t:iti,n~ptio.n .~~~tax::; that 36. Schro<:ksnadel H, B!}.let-Bit~erliCb 0. ,Dapunt 0 ,
offer .iilS;ig ht ~n~o . mecliD.n~~~t~ of human WaChter H, Fuchs D . Decr~d platl.a tryptophan in
cytotrophoblast diifcien.tiation; D'ev Genet .1999; 25: pl'<:gx1ancy. Obstet Qynecol19%; ~: 17.:50.
. . 146-:ts7. .
37. Nikas 0 . E~domet."iiV .recep:ivity: :Cha.ng~ in ceil-
2;3 }:.u~:Y, , Mi:il.o~ .o,
Mo:ij. :c,
~t ~. P.1acenta,l def~ct su.rl'ac.e fllorphology. Semm.'R eprod :Med 2:06o; 18 (1):
. 'and eriibryo~k lethalityin mice lacking -hepatocyte 229-236.
growfu factor/scatter fe,ctor.Nature -1995; 373: 7 02-
. 705. . . 38.. Broscns IA. ,Morp}:lologicel 4langcs-in the utero-
: :. 'placent a1 bedln p regnancy.!J.YPertensio::l.. Clin.bpstet
24. ;Bl~dt F, Rlethmache.t :p,. Isen.mann s;: ~gu;izi A, Gynaeet)r 1.97-7; !4: 573-s.n.
Bin:hmei.e r.C. :Essen:tia i:.role.for: thec-I?-e.t rcc5ptor in .
the migration of ~yog~cpreC).lrsor ~lls into the limb 39. Meekins JW, Pi.jnenborg R. Han~scn~ M, Mcf:adyen lR,
bud. N,e.ture 1995; 376:-168-771. van As-She A.. A.stuqy of pla<:eJ1tallxd spifiil Oitex-ie3
and trophoblast invasion in .'n~rmal and scveie pre-.
-25. Saito S, Sakakura..s, Enomoto M, .Ichijo.M;.}.{atsumoto eclamptic pregnancies. Br J O~t-et .Oyna~l 1994;
K, tialcam.ura T. Hepatocyte growthfacto'r.P.rQmotes the l01: 6Q.9~74.
growth of cytotrophoblast!~ bY thq:>ara,crine mechanism."
..J BiOChcm (Tokyo} 199~; 117: 67~~76. . 40. zllou Y, D.amsky CH, Fisher .SJ. Preeclampsia i3
. . . . associated' with ~ur~ of ~U:oiru1 cytotroph oblasts to
'26.. Kovats.S, Main EK, L.'bra.ch 'C, Stubblebine M, Fishe r mimic a Y?Scular adhesion jlpeno{ypc! one
. cause o(
: SJ, DeMars.R. Adass I antigen; ~~G . exp~essed in defecti\e. endova~cular invasion in' this. s}rndiome7 J
h.uman trcphoQlasts. Science 1990; 248: 220-223. .Clin Invest 1997; ~9: 2152-2.164.'

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 7

ASSISTED REPRODUCTIVE
TECHNOLOGY

History of Assisted Reproductive Technology

Pioneers of Assisted Reproductive Technclogy

Egg Donation

Gamete lntrafallopian T1,1be Transfar

: .:sonog~phy

. New-Medications

In-vitro Culture of Human Embryos

. lntracytoplasmic.Sperm.. lnjectron

Preimplahtation Genetic Diagnosis

NICE Guidelines 2004

Future of Assist~d. Reproductive Technology

!
I
l

I
l

J
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 . I

. 1"12. SECTION 1: CONCEPTS OF HUMAN REPRODUCTION

~ ....
Hi$'tORY O.F ASSISTED REPRODUCTIVE Ironically, the ioddence of HOM ca:n be ;1,
TECHNOLOGY resolved by tr.ansferring a single embryo. Th~ j~
pregnancy rate when augmented with additional ::
frozen embryo transfer is no differ~nt to that ..~:.
The birth of Louise Brown in July 25, 1978 in achieved by multiple embryo transfers.
'Oldham, England started the era of assited
re~uctive technology. ART includes infertilit<; In vitro fertili;z;ation {IVF) began as an
tll6il:J}y procedures in which both eggand sperm experimental procedure in rabbits. Once it "Was
.. arhalldled in the laboratory. 'rhc most common recognized .as a solution for tubal infertility, NF
. . ART:prQCe1iure is in vitro fertilization 1Uld embry.o . flouri~hed in the past 3 decades. The technology.
. trans{~r. . . h~s evolved .,and . ~e proc~s.s has : beceme les~
. invasiv.e~ ~e: irtdication.s.ltav.e broadened andthe
.' 1birtY )':~.agos-jt :was .n ()t J,UlU~~al for .aoc~ri( cSUCCeSs:);ait;~}l~.;;~: iclpro.ved~ . ,. .
tr~ti;rig irifertility to ~ythat ev:~has ~ .
:trle4,:fu.at L'lere wa'S p;~ dpecfution for ~nrd::ess . .: No othen f(eld. in .mtdiciir~ ..p.as d~vet~i>ed .so
:$4"th-e time has come to reorient life with goals quickly. The rapid spread of thls Url"tnology i!l'a
that:.tnduded a4option or even a life witho.u t tes t?Jnent to the ~e .exch~ge of scientific ideas
.:. c~P.. and protocOls tliafmarkS thi~ field. After almost"
' . two ::lecaaes, this newteclm9logy ;ha$ reached ~ur
< :if is now se-ldom necessary to hold such shores res-q:}tingin the deliv;rry.cfoudi:i:st in vitro:
ci:>nV.ersation.. Of course ther~ are women with fertilization. and em"\:>cyo t-rans'fer baby on
;~~e or no oocytes., .men with:sperms too . Septe~ber 19, 1996.2
. . :fe~~~ten<Jor~iritracytoplasm:ie.:.sp;et::nl.!;in.jection:,,,,.. . , . . . .. . . . :.
- '{i'~I),.!Snd :women:.without.a.fuilctioniil,g :uterus. . W.ith;..tl;le possibHities -.of!:p:re~mplan tati'on '
' . .tr<?~r. for thosewilling'to' ac~pt':~' donor egg; . . genetic diagnosis and.tratsgenic gene . therapy.
6r~~9r.sperm .o r a su.n:ogate \). terus, there is :still there. i;>:eve:ry. indica:tion. th:a,t.~s ~sian .-~
.~~Qpi:+on. _. a~cele:.;ak in' the Y WSfaheaQ.. . ."
. ~ -: . :t., .
. .;fc>a'~y;:..aithough ,:the ... eiact:numb~~:~or;ivF.-. In. vitro:fertii.i2ation.has~incllideif~~~riu~eidu~:.'. ~: . ,,
chlldt'eirwotrifW:iO.e"'<is urikhown;-. i t"~fias ~heen. other .techniques. -asintr~aytopla~mic ~p~rm - ..
~tilia.b.ted
;- .-.:. ..to be 1.3 'm. illion to 1.5 million
. . . injection {ICSl) ~ The IFFS ~oliates data fn~m .. ..
.... _...
""'t~----- ~ national.xo~eistq.ot:..l\!.F-ficm-.diff~rent-GOUUtrl.eS' :
--:.:Sta:ttir.tg-:out asa bypass- proeedU:Fe-for tubal an.d--:p ublisn es the~e- da:ta in-~ilie-Fertility,-an.d~ '
. .~. additional majqr indications now inclu!fe Sterility Journal. The last sur-Vey included d~ta
'e~4b'JlJ,~triosis and oligozoospentl.i~. With some from the Philippines;a:hd was p'ublished in its Apri;l:
~~p~ns, IVF is fast l:leco~g pri:inary therapy 2007 issue. Curreritly,.-su~~ss. rate ofiVF hovex;s ..
:for t hese conditions. Ten percent are around 30% with a m'!itiple .p :regnancy.rate of.30%
.. j ~~eous probl~ms such .as .cervical Jactors, per cy cle :(Figures 7. ~ & 7.2)~ lh the a_uthor's :o'Wn ...
. iDi~!tinologic factGrs -a~d pr-eimplantation. survey cf pati.ents .done from tSO cycles th~ ...
..
. -a~o:~is. preg:Q:ancy rate 'i s 30% w"itl). .a. 30'% mult~p~e
pregnancy rate, 9 s ets of twins and 1 quadrup}ets'
.Tn:e primary major complication of IVF is the (Figure 7 .3) delivered. at 34 weeks. All of them
up;a~ptable rate of multiple pr.e~ancies that IVF weighed nearly four pounds each. Th e cause of
shates .with ovulation induction and ovulation the high order multip~e pregriancy rate was .the
eribancement acGompanied by .intrauterine trans fer of four-embryos. Since the last two y~ars,
in~m#la~on. The twinning rate in 2002 of ~31% t he transfer of embryos has been limited to ~o
:per 100,000 liv.e births is.63% higher than in 19 80 . and there are even cycles when only one embryo
'J;lte triplerbirth rate of 1.9% per 1000 live birth is is. transferred. The last five pregnancies in our
3
~h:"higher over the baseline in 198.0 . clinic are singletons.

: This multiple pregnancy problem generates The proliferation of ART has led to a greater .,
.iever~compllcations as well as mortality r.ate. of availability forpatients. The specialty has thrived.: ,
:33 .~~nt.fortwins and ~0.1 per 1000 for triplets becaus e i t has evolv<?d as a multidisciplinary: . 'I
coni:pared to 6.1 per 1000 for singletons. approach. Today, ART represents the intersection
. ..

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 CHAPTER 7: ASSISTED REPRODUCTIVE TECHNOLOGY 113

of gynecology, urology, genetics and molecular

biology. The advent of ART was made possible by
transvaginal sonography, clinical e.ndocrlne
a!says, recombi~ant folli~ular stimulating
hormones a..itd advanced cell cuJture t:ecil..n'iques.

The dev.~lcpment of thi s ~echnolcgy was

dependent on synchrony in many fields. It is one
"' of the fastest moving fields since its inception and
it dd.lswith a subjectthat society approaches with
great caution artd reverence. ~would only baV.e
been possible fro.m the anima! work :that preceded
it. 1u1 \mder$tanding .ot the origin strengthens an
appre_?ation of toQayis capabilities;

Fl~ 7.3. SA.~ 2004 data.

Anlmal .H)lSbandry . :'<'-:

c . . . - . ..,':.j-"1..,,
. . The .first .animal .~riment -that:e.$.t89J~ed.
the fiel~ of !IlOdern reproductiv bio~gx;.~~
.p lace more than lOO.:yeana ago. ln thda~ pal:t{Qf
the 19u. century; Walter Heape achieved lhc first
.~ccessful transfer ;o(embryosJh~~hed.II:Om, the
oviducts of one specie -.of" rabbits to:r8.b1J.ii$,.of
another species.4 By 1959. -significa,i)t;,ad~eas
. ' r, :, .
'1.
lt

. . and live birth mt.CSw.r':IU'tl had been made in the practice of tissue;.cn,lN,re.,
u!Slngiresh. non~donot~()rembryas, by~ ofworpcn, Chan,g suceessfully n.!rronhed the first IVP.with
1999~ ... .. ., . rabbii sperm$ afid ~ooqitis:~ .Dutiitg th~- ~e~t
. ~----: .,. -~ - ...... .:. . .,....... ---
_, " -"' ..., ...
severaFyears:~ reproaiiCIIVe- -fi[plo 'sta-:~andtlie
...
- -.-- - --;-~- ....... ~- -- -- .. ... : -
.rarm: iiidusfiY-We. re working-~~~ halid: niert;~
was .tremendous. coinmertial value in.the ~bility.
to optimize and manipulate r~production in
animals. Maintaining female.s . in the ~tate .of
permanent lactation, the breeding of offspftn.g tq
select desired traits, and the preservation .of
endangered specie~ were a few examples;
Aca demic reproductive biologists found their
interest overlapping with the n eed s of the cattle.
industry.

Today, most of the techriiques cent:rai to the

practice of ART can trace their origin in the field
of animal husbandry: ..artific;:iaUnsemination, in,:. .
vitro culture, microinjectio.n of sperm,
-t tanscervical em,bryo transfer, cryopr:eservation of
sperm .and
embryos, intraspecies ovum q~tion, .
and the use .of surrogate uterus. M.tcroma-
nipula tion was ~pplied to ~al em_bcy~ mwy
years before b eing u:sed in humans; Jri .tfif! cattle
Figur~ 7 .'1.. CRM Laboratories 2004.data. indus try; the practice of~gg donations a~~ use of

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 114 Si;CilONI: CONCEPTS -QF HUMAN REPRODUCTION
--------~--------------~

:.~~
surrogat~ . tarrier prece.ded llSe i~ hq.mans by b;ahsfer through cvntr-olled ovarian stimulation.
severni de-<f;ade's. . ,.' The Pining of Oocyte collection was .critical and
adlllini~terlng h uman .chorionic gonadotrophiJl
PlONEERi-~b~ ASSI$T:ED -llli~'RGDUCTlVE ~n before the expected time of ov-ula~on was a
-rEClrifo00.GY , . .: ~.-. . . . . novel way to solve this
prot>Iem. Ir1 an influential
_repart of their expeci~n!':e with the first 400 IVF
cycles, the.y.achleved:a 25% pregnancy iatc_ and a
15% cycle pancellation r-ate.6
"' J~:. ~~10, ._ St~pt~e a:nf,i. 'E,dwatd:~..~tn.~de ~-
la.na~k report. They de:ser.ih~ ~-~~~ful Howard and
Geer:geanita Jon~ studied the
'1ap~.$Co'})~~ retrieval Of pr.eov4~ti>.cy. hull1~ pattef'I?.s of re~po~s.e . to .:gonci.dotrophins in tb~ir
o;oeyte ~.ftet pr:indng the ovarie-s wit.h pati-ents. They were fat 'ahea1 of theit t:ime an4
g9~a.?-~P~'$ TheJ. <4'1P~ to a\'~i4. th~ '!lS~~f noted th.ree di:s'tinct re~pqnders cow~ be
~.;A ~~lilil~.ini.:::"'~~.:Sevenil
E>~"~:-:"""K; . .... . .. ~~- .. . . . .. 0 ffier. +;. a:ISQ
., ~~J'a . . _ id-entified. th:is -w ould lead t.9 the further:
-~ w~r}ilirgon .t'J+i.s 'pn>Ject no:t;ahlr: m the desCription of the poor reSPo!lder, <?.ne ofthe mos t
P.D.ited kingdom. United S~es, Aus~it arid petp1e.:cing di.nica:l dilemmas of ART.
Netherlands. The comp.e tition .f~'i.'. t'he .first
pre:gna'ncy was s.nalogous tQ the.spate tace .Qf. the '.
~deca<les. 0 "" " ' . ' :.- ;. 91: . - . .

. . t.~l):e: .:ft:F~t h~a~a;n: ..J>:r~.glf.~e~ .~t!!t' -~on~r

.~&90PY w~s. adv~ted bfS~tQe, 'Which. embt;Yri' transfer,::Wa'S:_ . .:te.P.Qrt<rd... by.Buster in
alloweii~Vi~u~tio~..of the ..~J~~ -~Z:gal:ls :and
1;9.~31~ >J>~:~:u~:r e:;n~iYP~ :W.~re. 'O:bt.a:ii?-ed . qy
~#~~Ji~~~_t,tin'fi~~~~i~the-: ,-:~~m~:u~~@.l~~Y*~-~c.4o:U.%~1i1>J~ts~s: ...,.
the. ad~~nt.bLtrnn$-alfulal. <SQnp~y.;;;yvl.Q.th, ....... t(>:'f.!.tay$taft;.r.Ji)fted :a:t:~ifiei8ltip:Se:~ti<lP. :With .

:;:;;;;;;~~.:"iiii.fiifii%.1,
~n~-~~~f~,til~,ll).'A!e:;~~(~~~,.... ~9~~--~-la~ra~q~~1~~-c;Jl1on~~tea..
13~;-$:~~ te=st:fubr~ey iti-:tb~~o~:pley. ~tJh~ .great .l!laj.o'Iitr, .-Pf.,pr.~~ahcj.es ~c,lii~ed
'4'1d.tirl!'Jn.:~:.~h#~ C~1.~. ~m:.4l. ill m:fP:i:li #ia:fuiet.wciie,,P.tOdli.C?<f.w_!leQ:.an .egbcy:o
m.-o ~tit5~r-::-o-ne."'~e:;nteii':~'rlti;ice bf~lgb:t"t>r'more.cellswasretovered-froto: ..the
wOW.~ slitiw .ffiM p~ -fir;n'ipg P~-r~tl'iffil . u terin:e-cttvity: The~:res-p1ts-su-gge~too-thatl:l:ie:
was o:f critica.l .sjgnifiCfpl:ce. ~~~ :t;i~ded.on timing Of embryo entrance to t4e u terine cavity
the r:.reasuteip.~nt of .1Utein:iiin'g'h6#ri<m.e (t.H) and cellular stage Df !:!ev~1oppaeJ1t .~e important.
'eV:ciy ~ee:ho~, teqUitit}g.a.'24-.:h.~--lrtirllingof vari<,t'b le.s in de~~rin.ining- the -potential for
fuciiend~e:.l~bQra~iy. ~~te 1 timing. of<tht_! ~plap.;tatio~ ~;.~ f(u~:ts wereci>mqille~ With
:;proooure,$as.a.. ,Sj_~t pm1~: i.n~e early . th<!~9.1t~t '}Giio:W.leqg- Jhat:h~tn~;~~s,.are:
:P4~ of.~~ te~evaL :b.ca'si<>mrll.Y, 'll-J>.OOl:of . on~i~al;>i~.:t.o :~~: fer,P,.-}~;etl. .-vffUun .~4 hp,\trs:
:flwd wM:s11~ th,~ -~w. de .~c 's~:ggeWb.~ 'that. Tp~~thr~~~~:Q.~~&:~tt9n~. :- iv~~:'ftw.:ila:riis1Jtal
o~ation. has :Octw:r.ed. co:Jis:~cler:a;tioh~ .for. de.Yel9.:p ihg..th:e GfFT
procedur~.

G~~E:: ~.h~p~:.iun.E X.-~-AN$f~R

Howard -and Geor.geanna .Jones lustit:ute

In the early -198-0, there were three m aj9r E~ - . ..

bariiers to hl:l..IPan IVF: timing .the egg ret:riev~, . . . , , ~ . '

c6llectio:11 ,of adequ:at~ nuinbe:t~ o~f ri~ :OQCYtes,
and .s~ta.ble cultur-e media,.. The .first -successtul
IVF pr.-egn'ancyhad res ulted with. the !ertlijzation
or a .single .o.ocyte in the. natux;al .cyCt. :the
phySicians of the jone~!"lns_tiyute-were.ihe first to
use HMO successfully.. Their experien~.:~howed
th~t the.:pregnancy cite.s were inipro\red ..bY
. lrtcreasing the nu~ber of -embryos f_lvailable for
T~,e .-fJ.rSt:.fYt_IDl~9.'. -~tit ::~~f~r .9'! g~~tes .
-t.o _t'he fallopia.n t'.,tbe~:witl:j.; the' .a~d of'~he
lap~9 sco!>e. \V~ ]n :19~7 ~y T9'8&; the .ot'Fr
ptoe~ut:e':was ~ ~despread use.. ln ili~ t9aos_..
the~ w.ete ,orily..~ -se~ectfew IVF-.'programs.:~:n)liy .
outfitted l~boql.~oty r.equire~ s.Qplij~tica'ted':..:
-eq\i.1prne!:lt andtr.llned personneL this p6ied a:
sign:iilcant barrier to th.o$e .seeking entry into the

Snanned fy: c
 CHAPTER 7: ASSISTED REPRODUCTIVE TECHNOLOGY
field. Our delay in the ent:J:.~:~as also due to this
particular reason.
At that time, in vitro culture techniques for
gamete$ were rather prinrltive ;;md media would
not yet sustain longterm.growth. The advent of
GIFT meant that many centers without a
-functional IVF culture system '"ould offer a
legitimate form of A..'IT. ""
\
In the era :o f laparoscopic egg retrieval, GIFT
made sense . The physician could :co~~ine
diagnost.ic.a nd therapeutic procedures. The advent
.o f c.ffiee laparoscopy would further enable the
adoption of this technique, but the Irtain reason
for the rapid proliferation of QlFT was that it when the mean diarpeter o the lead folliclC.reilChes
.produced better results than IVF at that time.
Gamete in1'ra!a1l<ipian tube transfer h:as .a solid
.foundation in reproductive physiology .. Afte:r . the
IJl ~; ~e .OV\.Ull piCk up by the tube is rapid. in stimulated cycles was made. the.:origmal
Biit.the'oOCyte rem;Uns in the ampulliuy .p ortion
tif the,: :tu~e .ff)t the n .6 xt 72 hour-&. Gamete a full bladder. A lineat :relationshi_(N)e~i:ilie
intitUalltpjan tube transfer effects physiologic follicle diameter and serum estradiC>l-kvcF.'was
plac;ement of-gamete$ so that in vivo .f~tion
-can t:alce~place. It provides a greater degree .of
natu;ta~.SS and for that reason, . a wider
.,aCc:eptallCC''in 5ome religious ciroles, .
~ -. :.. :.:;"";J._J;b--:.. :~. . .- .
Today.-..Wehave a greater understanding of -the
im:portan<:~n>f an attaumatic transt:er Qf embryos
to the uterus. A great deal of success of GIFT is
due-ttril'fe--racnnat efiiOryos eii1er:the-ulerus Iii
rur-:amr-umanc -manrier. - -- - ultrasound guidance was first reported in -1981.7
D.ecllne of GIFT
By the 1990s, IVF pregnancy was improving
and the gap between the two wer:e closing.
Acoo:;di:ig. to the SART registry 1996, there was
no statistical difference l>etween lVF and GIFf. It
. becan'le apparent -that GIFT entailed perfonning a
needles$ :Japaroscopy. The prolonged culture .of IVF
allowed direct obsetvation of gamete inte raction
in the labQratory. GIFT failed to observe
fertilization and a~ a result, cases of male factor
would be untreated. The indications for the
prQGequre were becoming. limited. It was not a
choice for tubal disease or severe male factor
problems.
The int~ntion of controlled .ovc;tdan
hyperstiniulation was to collect m,ore oocytes than
were needed for transfer to the patient. Centers
I .-.
Scanned 8y:
..:.~ . 115
that practiced GIFT withQut a solid IVF-nihoratory
frequently had excess oocy.tes, which were
discarded This $omctimes caused more oocytes
to be implanted. A staggering number of multiple
gestations were generated.in t.~e earlyd~ysoi'GUT
and IVI<'. This created a grave danger from .a n
obstetrical and neonatal.point of view~ Thls acute
medical needs gave rise to selective reduction
procedure. !his Wa:$ a technology that canie into
existence solely to control unwanted asPects of
ART.
SONOGRAPHY
In the natural cycle, .ovulation typically otctus
18 mm to 24 nun. Ultrasound ~hc,wed that the
d9minant follicle under-goes a rapid~QiU
growth in th~ 24. hours }?efore o'iU}at;jon. .In 1979,
ilie (tr.St -r eport cf u!tnis-ound hna~g .of fOilicles .
tec!uliques used transabdomin,al :~'~Pm:oa~~i"th
described. ~-~ ~ ,_.' .._-,"'?-';A' .
The non..~vasive t:nodality-woulctrevo~~
the w-ay patients : ~HhninisterltkHM'd.i'il:te "
monitored. It provided -a means t:?ira~~~~s
ovarian response, allowing more aCcUtaflsing
of Ul.e dication. - ~
.. F.'O.!tl~it~::p:unct:u.r.~ llSing..transabdonlinal.
Soon came a s ignificant innovation. In 1983, the
colle qtion of oocytes was accompli11hed
transvaginally using the guidanee of endovaginal
son-o gr.aphy . ~ Tl):e superior diagno_s tic and
therapeutic 'properties of transvaginal sonography
were recognlzed i.'"l the Illid l98os~ 9
MEDICAL INNOVATIONS
From the moment h ormones were discovered,
efforts to gain control of their commercial
production hli~e been ceaseless. it is difficult to
imagine ART being possible in an era without
-steroid hormones. IVF has evolved from a sw:gical
modality to a medical therapy.
~
One of the most significant dis~eries in
re_p roductive biology was that the ant~riqj.pituit;;uy
controls the male and female repfpductive
systems. The location and source of these human
C
116 . SECriON 1: CONCEPTS OF HUMAN REPRODUCTION
tropWc hormones made them particularly difficult
to $tudy. in 1958, Gemzell, et al. demonstrated
that potent ovarian stimulation was exerted :by
pituitary hormones that they had extracted from
huntan pituitaries The scar.city of cadaver
pituitary g1ands mad~ this a.. impractical .s ource
for treatment. Soon thereafter, follicle stimulating
hormone, luteini~ing honnone and human
...
chorionic gonadot;r(lphic were d.
tscover.ed
..
Oral Contraceptives
Although the o;:al contracept.iv:e pill is more
-~a.n 40 years old, its usc in ART is 'fairl.r~ rece.n t.
Monopha$ie prepal'atiQns have proven to l;)e U$efu~l
before irutiatmgst:Unutatio-nprotoools. They allow
greater flexibility in the .sehc:duling of eyde start
oa~ The.estto.getl CQm:p:Q.nnt i~ NS<> r-eco~
'foe ita ability to suppress 9vulation in ~e tnonth
hefote the ART is:pbiorinett Stitti:uta:tion-cart then
p~ Without the risk -ofreaefivationofa corpus
lq:t eum. :It 'a1so: a$sU,r,e~ tba.t :th:e.;.stiniula'pon is
siaff&fWitliout:afi' eat:~tPtgnancy~ ...- , _.
.a~ id~nopausal Gonadott<l'htns: ...
: . . .
MOiierniKR'r:cam.e Withfcoilllnetclal:ll\'a.il~bility ..
of :HMn1R~-ig' th~:~theta'Pe\tti :p(jt~thd or : Embryos ~ ~eYcOJ:li:pelent .jto ccoltlp~ete :tb:eir
U~G Jeddt<fitseartlijtfoi' :su1tab1~ llQutc:esJrlfiitial ._, . development." in,,.vit-:r.o~~-:A..
~~,S'#.i6fp~-~:t>r11iepituitaty
.g land$..oLanimals. ...lt.s~ta~..(<mnd ..tb~t_ .ffi!mM~
rapidly--proquce antibodi e:s.... to. rtonprhnate
gonadotrQph.inS that l imit their effe.ctiveness.
. Menopausal women woUld. prove .t() be
sourc~ or
HMG. In 1954, po.o led e1tt:racts of
-xnen~pau~ urine were.ttoteel to-contain FSH ~d
LH adi\rity; /4. p~ss. .to. ~ct :gona.dotrophlris
'ft"9.m the Urine ~'f mertopausai V:rcmen was
de~"beq in t9t> L 'the firsfpregpaneies from HMG
were in 1962. 10
Cervical mucus. ferning and seriai pelvic
examination were the only .means available
monitor the response to HMQ.. thenipy initially.
Ovarian hyperstimulation sy-ndrome w:as a
.fr.e quent conaeque nc.e . The introduction of
e$trogen monitoring and ultt:asound brought
safety _a nd effectiveness into this treatment.
T:Oe fact .that HMO would bring ovulation to
those with anovtilation.. was truly. a
miracle, but
the therapy dld not work well when emulating
no.rmal physiolo gy. .l;Iup:lan. men.o pausa l
Scanned By:
gonadotro,p hiri administered in doses that n'lJ,mic
the ster-oid profiles of natural cycles Jed to
disappointing success rates. It became clear-early
that multifollicuiar development was a signific8nt
stra:tgy. An important factor to consider is the .
hlgh cost of medications in ART.
Gonadotrophin- ~leasing .Hormone. Agoni.fots
These agents provide gre.ater flexibility hi
,s tarting bvarlan. stit;nulation cycles witho-ut the
need for pituitary de~ens'itiul:tion and down
reg1llation. Th-ey would provide efficacy in
pr,eventing .pr-etnatute LH .sur-ges equd to ihe
gonad<>~rophin ,releasing h9rmone ag()nists.
Early results support the observation that they
tnay r.e d\lce the :amount of gonadotrophin u$ed
for :ova.rlan stimulation. lf their cost .dreases
they wiU pr!)bably ,replace the gonado.Wophin
relea$itlg honnone agonl~t tha:t a t'e :tUtr~mtly
used.
. .!n vitro Jertiliiation bas tau,gh:t us:that Jhe.3
days :an;~ml;)ryQ:~d~.iQ.the. :fallopjan .tubea~e
n:ot>:eriUcaL:<fp.;Je:t.til~ation ror. i .mplanta#on..
Wide.:variety. o f
=
coi;m:i).e~aUy ~~: eultui'C t1let\ia:su~ the
~:Qfh~~-~c:~~~o~I?U.~~!4e ~~ -~!~-!~:.ru,:td
f~lopja.n..tube.~..
Tissue E;U}ture .procedur~s are larg~ly borrowed
'iD2cjot from existing anjmal i:nodel$ of gameteand embryo
culture. Media used to mainta,ir) groW:th is witliln
a nar:row range of pH and osmolality. th~
envi.tbnment is rigidly controlled with respect to
62cy.ge:n terrsion, tenipel'atu.r e, and air pu,rity.
Quality.control ,stan-dards are roupne incv~ IVF
ART laboratory. T.l)e mouse enibryo toxicity a~say
is used extensivety-for quality,control testing. This
is a clear demonstrq.tioil o! how anim:al mo,dels
to have a ided irt the progress of ART.
One of the major early findings in IVF was the
discovery that sperm .should not be added :to the
oocytes imm.~diately .after retrievaL When
insemination oGCutred .a fter retrieval by 4 to 6
hours, it was noted that the ()oCytes hq.d a :g reater
chance oJ fertilization. 11 Trounson, et al. also
showed that if-the oocytes are less matU:r~.lo~ger
. periods or incubation before 'insemination led to
better fertilization.
C
 CHAPTER 7: ASSISTED REPRODUCTIVE TECHNOLOGY ' 117 .
~

Assisted Hatching by microsurgical sperm aspiration techYiiques.

. This development is likely to make reversal of
One ot the.significant proble~s in ART is the vasectomy a surgery of historic intereSt.
high amount of embryonic loss ~n utero.
Spontaneous hardening of the zona pellucida
occurs both after in v.itro.culture ahd in vivo agi~g.
!t was observed that older patients had. a harder
zona and difficulty in .hatching. Assisted hatching
is a method to improve implantation by .artificially
preparing the cleaved embryo and its zona
pellucida for hatching. The embryologist will drill
sntall b:~cisions in the zona pellucid-a du~ng
cleava,ge. This i~ thought to help the embryo
emuge. AI!SSisted hateh'i ng .i mproves the
implantation rate of e mbryos derlve4 frotn older
patients, thQse with higher day 3 FSH and those
with previous failed IVF attempts. As si~ted
hatching would also demonstrate itnproved res1,1lts
when used irt ccyothawed cycles.
' ""'
mt~cyT()Pt.A:SMl.C SPERM INJECTION ( ICSI)
.,- ......:.:~_:, .
aeroi~'.:: :Al~.T; the i nedical and surgical ~.: . .~.~~::. :... ~iw~~ '.
treat:IJ).ent$ for male ~ertillty had disappointing
ou~meS;..lri. vitro :feitil~don .alone proved to be .. ..
. .. . .: \.""
a -~tis'faclory .treatment fot eertain 'm ale 'tor.:ns of
llifc::rtility~t ~te Jlbt amenable to :intrauterine IntracytoplC~.s~ic sperm irije~ti~ll4allow~~the .
-.in'Se:J.'llimlljo.n:: 1'he:cohceritratihg effect 'Of m vitro useofelectro:ejaculation. ~lectro'ejii:Cti.latiQ'~ti$ed: .
ctil~:,was; sufficient to.overcome some forms of in those with 's pinal cord injurj~~;o~4_;~~e . .
oligospermia~ especially when the.count was over diabetes has resulted in pregnancies'.for oouples
10 million .a.sthenospermia,, . and antisperm that could' not othetwis.e 'c()nceive.
ari~OOdY fon.nat'iQn.

Hr vitro cultufe allows observation of

fel1ilizaUon failure)is\la.UY attributable to male
factor. Befo~ the age of micromanipulation, these
patients were counseled to stop therapy.
'fhe first report of ICSI to establish pregn~cy .
in humans was by Palermo, et al. '1992 ..12 (Figure
7 .4). The possibility of achieving pregnancy with
only a single availa ble spermatozoon launched a
~evolution in the tr~tment ofmaie L.""lfertility.
Intracytoplasmic sperm injection has enabled
virtu~ly eve.ry ma,'n with severe oligospermia and
oligoteratozoosP<;nnia to father his own child. The
method proved . to be. durable in a wide variety of
circumstances. Fresh or frozen specimens worked
equally well. It was not -essential to use ejacuhtted
sperm. 'Success was found with epididymal or '
testic~l~ sperm. One would use sp~nrtatids
instead of' 'spermatozoa. This m eant that
obstructive azoospemi.ia could . be circum~ented
~~:u~~~~~r~~J~s1!~t~~:P.g\~!i ~d
qua"iiHties. Men who banked .s petm before
chemotherapy or radiation will how have a vastly
efficient way to conceive by,lCSI. Finally, combined
with n ew tec;:hniques that allow separatitm of male
and female spermatoZ()a, ICSI coUld be used to
a void children with sex-linked diseases.
Of all semen parameters, morphology turns o ut
t o be the best predictor o f a man's fertilizing
potential. Normal fertilization and pregnancy rates
can be achieved withiCSI in the presence of seve!'e
tera tozoospetmia . Clearly, this shows that
mor-phology is critka l.to conventional fertiliza tion,
yet has no. obvious role once the spennatozo0li
reaches the oop\asm.
Concerns about the health of child:iml born
from this technology are well founded~~ever~l
stag~s of natural seiection: of the individii'rilsper:m
for fertilization are bypassed when fertii.i'Za tion is
a ccomplished by micromanipulation. .

-.

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'.
..~~
.~:
/
I.
118 SECT10N l: CONPEPTS OF HUMAN REPRODUCTION .., ~
------------~--~--------~--------~~~--------~~----~------~------~-- ~

There is a slight increase in the risk for de novo ~hromosomal mosaicism_ The FISH technique
sex chromoso~al and struc~al alt~rs.tions after produces false positive and false negative_ Even
ICSI.uThe in.cid,ence was found to be ~30/o, which in the best of hands, only a selection of
is significantly greater than the 2% incidence ~ chromosomes can be studied_ There is !;till a long
the geP-~ral population. Numerous repor!:s nave way to -go for PGD.
shown the incidence .of cong~oiqu .-m:alfo:rma\:ion
betw.een 1.9% t9 .2:3%, which .is coru~ble to NIC GUIDELINES ART 2004a
the rate in .children born .after natural
~oneeptien.1~ WiUl i-egil.rd$:t::a.. h~ ~o~~:!md 1.10.. Factors affecting the ou::cottie :oi mvitro .
pe~.:ou~P.i~ after the -i$1 p~~~ ~ne fertlliul..tipn treatment
need~ to temo\ie tli~:orifoundm:g \rat:W.ble d:feet 1.10.1 S~getyforhydrosalpinges beforeinv}tro
. of mU!tipaijey. ()$~(Wise,"orte ~wd expect: a fertilization treatment .
b).gh,er ~6~~nce e:r pre~.atunti ~d to~ birth. 1.10.1.1 W9men with hydrosalpinges :ShOUld be
weight !m: t,hi~ .gro.\;lp. Th.re, -is no st~ti$fteally . offere~ salpingectomy~ prefembly by
sigr)#i~t;:iliffete11e~. in .l;!lean -~ :wei:ght or 'laparo.sc{)py, before in vitr-o fett:iHzai:i<>n
incid~n~e :c?f :l>'tem~thre delivery -for .:Singl~t~ns treatm.ent becau~e this .im~wes the
.c-o:n~ived ~~er ..eith:i:.r !CSI or I~.oMti.ral chance Of a live birth: A .
con~ptJ~n~'U~J~ :in. p-lulttpl~ . ~~t~~,X!:s:. the
in~iate~.ot.nrematurlty,arici,i6w.l>irthrate.s 1..10_2 Female ?-ge:
~~-~.ft~ij~t ~-:6rPllilri#l by tbe'.'rijfrl~p~ty
wli!fu. ci>~pated'Vr,iUi n9n-!CSI. gr;-6~ 1.':10;2 Women .should b~ informed that the
chance :of a live 'i)~ 'folloWing ~in :vitro
~-,~~b!i~bl..tion.,~net;:icr.:PJ~im,~;.,,...... .... , ... fe~tW~ .~~tp.l!!~~! :~~;~. ~;th :the
female:agf?::a,D:d:.the:.o:Pt\rp'ai t~ age.
: Preil;nplantatio'n .gen<:ic .Ciiagn~sis~is Qffer:ed t~ ., .. , range is 23::--:.~9 Y~Gllim:sofa:~
itifef#l~~pks ~dcrg(?mgasit~.reyroduction. . b~
.
-~~
. . . ~~f.:went cyek,are:
. 9 ..
~ .

:M .: a i~r:mfi~f ,~~fe,~n'?.J?g<t!f;:.i~!J-~t?,~. -.~s~st~d-. . . .

...U.8~et: ~~2fYl~:~or.:.wom:~-:cageci.
~-
~u~~t~I9~f>~w~:_,~;~:paScif!o~: ... : .
. i

the; ~wo~e~i~ r~~ti-ft:ii<i~.J~o.~~~~.\;t,o~.~~P!~Ye~ ,... 'between 23.:.35 v~"-8 -

su~s,s . rates Of!':AJJ/P;:i:>Y.i;xr~:.j~nting ~Ja~I~.d~-, . iso;'?:ror wonien~gd:l'.between 36"
ini,plan.tif~~n ~f enibeyos. \'4th .ilrtotnq~~in~l to38 ;y~s
cabnotbiiillt~-.'1!.~a.~~-~o..WD~.is...:t<t-dete.ci 10% for women-aged :09 yeru-:s- -
an~~lp~ojdy;cU;SJ,lalty:J:llf~-~t-ec~iq.\le- u$.e.~ ..-is. .~~~~r.Qi.::iP.m~ii:
older.
~i.~ 1?fy~:.Jia
- --
flu~~t in ~iui' ~hyb~tioti {FiSl{},. ~hic;:h
e~~the study of clirom.o~m8 ~ :P.o.P.~ividll;lg
cell;;,i~ lt ~s ~~ptly u:s ed ;in c.a~~ of .advap.ce . The .effectiVenesso f in vitrO :fettilit.atfun
maternal age, .t:ecumnt. imp~~t'a,ti,oh ~~~s :a:ci.ii treat~ent in wci~e'ri young~r ~ 23
ouples-Wi$.;high~geJ;leti~risk-{)(haiq.gan~~ted
chUd.' . .
ye~rs is 'unc e r-.tain: becau~e very few
w om(en in t..l)is agy. r:arige. b;ave ip. y.itro
f:erf:i$;ati9 n. .tie8.tment.
However, ther(! ar.e only ft'w prospective
~do~ studie's and the~ :suidies have so far 1.103 Numxr of:embryos.to be tiansf'eried and
Jailed. tD de~onstrate -s~grUncruit ;hnprovement in multiple pregnancy
live b~rth .per ~timulate4 cycl~ .. How c;:an t:pe
-discre~cy be ~xplain~d .~tw.een the .elegance 1.10.3 .1 Co!iple:s. sjlould b e informed th~t t.9.e
of the. lheory [seleption of n ormal embryos prior c hance of ..multiple pregnancy following
to ;~plantation imp'roves th~. suq::e~s.rate of ART) iri vitro fertilization treapnent depends
and the d,isappointirig .results in P.r ictic:e? Most on ~h.e humber of e'nibljbs transferred
probably, the positive sekcti.on:ofnormalembryos per cycle of treatment. 'To balapce the
in th.e treatment grottp-is.compe.p:~ted ;bY.. a loss cha:nce _of a live b irth .and the risk of
_oi embryos due t~ the biopsy. proctrlure: involved mu1tipie .. pregnancy. and . its
~1:. an'd .bY misdiag!J.os is pr,O:blems. in .~is. group . . c:ron~~qu~nces, . ~o. mor;e t han two
$~. .MiSdiagnosis ~ :b e due b<)~ to 4li~tl:tological; eii,lbry9s .shou~d. .be transterred during .
.}~:: p~blems and biological facto rs in .particula r any one cycle of'in yitro. treat,ment. c

E~:-. -~~,:.;~~
Scanned 8y: ~
 v: ASSISTED REPRODUCTIVE TECHNOLOGY
CHAPTER
------'---------~--~-......------------'--~-------
L 10.4 Number of previous treatment :cycles
'1.10.4.1 Couples should be informed that the
chance of a live birth folloWing in vitr.o
fertilization treatment if ccnsistent fer
the fitst three cycles, but the
effectiveness .a fte r three cyCles is less
certain. . c.
1.10.5 Pregnancy history
L 10.5.1 Women Sb.ou).d be informed that in yitm
. fertilizalicn . treatm~t .is ro::>r:e .em~ctive
in w6men -who have .previously been
pregnant- and had a live birth. C
1.10:6 Aicohol, smokitl.'g and caJfeine
consumftion
........''119
-~ embryos are frozen then -they should be
transferred before the next stimulated
treatment cycle because this will
minimize ovulatbn, induction and egg
collectk>n, both. cf v;b.ich carry riSks to
the woman and use more resour~
1.10 .9 Gc.unete intrafallopian transfer and zygote
intrarallopian t..railsf~r ~
1.}0.9:1 There is. in--s ufficient evidence to
recotn:m.end the use of _gamete
intrafallopi~ tu~ transfer or zygote
intrafallopian transfer. in preference 'to
IVF :it} .cou.ples w ith. unexpiain.ed
infertility .o r male factor infe.rtHty
prob1etil. :.A'

L1Q.6.1 Couples .shoaul:d he informed that Lll ProC<!dur~s used during. ti:~ IVF
.mater;nal a,nd paternal smoki~g can treatment
. .. . l,
~

adverSely atcect;.the -stlccess rate of ART

. .. . . ._' l'rocedu..--e: mmuding ~VF- : c
1..10:6.2 CO\iples shoW,dk itifon;ned.that caffeine
ccnsU.Inpti<m 'bas adver~ ff~ts on the
suc.a -ss tate of aS$isted -c~prod.uction
.:'}_ . .... .~s inClUding "IVF;.' .. C .. . . - .
... ~ -~\ -~- . .
'
T.he:Hmn.an FertiliZation .an<t-'Eili'oi:y~~jA.d:
. 1'9.90requires that .arty fertility cliitic in~~ .UK .
offer:i:O:g :lid;:ns~ treatment ,:servi&'S -~u~ir"BS in
vitrof er;ilizat!on'OFusei:Wnated.-gametes j ust take _
account of tne welfare -of -tl:ie W!enti~ Child ...
. . .
{mclup.ing:ttte . d etern:l,l:IIatif)n
. '- ~of..who~WuJ.t~llave
'1. -~ ~--;;,.,
parental responsibility f.or the cllild)>:an@.~iJany

other existing children who mayZ.}Se. ~ect.ed~- by

th~ birtl;l, b:efore treatme~t. Details. an t)le"issu.es
L 10.-7 . l Ww:nen shoUld 'beinioi"ttied that female or ~_a;ssessmen_!;_q( R~~le ..~-~kiug_Jr.~.at$ent,
. . . c-wa:y:m.as:rmdeXshoUia"nei<ieallj'iii-llie :~~~mfidentiality, inforrila.tio~n~- ~c.o.ns.ent....and
. range I9".:3D)}etorec0iil:ilienci.rig assisted counseliri.g are referred to-the HUman. Fertilization
rep!'OdUction, and fuat: a female body and Embryology Code of Practice.
mass index outside the nmge is likely to
reduce the success .of a :A.R1'. B In 'the Philippi~es, there is .a Prattl.ce
Guideline-s . in . Assisted Reproductive
L 10', 8 Clinical ' et:(ecthr~ness and referral. for :in Technology published py th.e _Philippine Society
vitro fe~tion treatment . of Reproductive Endo~rinology and Infertility
2007.
1.10.8.1 Couples in which the woman is aged 23
to 29 yearsatithe.P.me :.o rtreatment and 1.11.1 Medical assessment and screerung
who have an identified cause of their
fertility .p roblem.. ( such a:s azoospermia 1.1'1.1.1 People undergo4l.g in vitro fertilization
or bilateral tubal occlusion) ~r who have treatment should be offered screening for
infertility of at least 3 years duration HIV, hepatitis B virus and hepatitis C
should be offered up to three stimulated virus, peopl~ found to test positive
cycles of in Yitto fertilization treatment. should .. managed a nd . counseled
GPP . . appropriatelY: B"

1.10.8.2 Embryos transfetted.'duringastimuhi.ted Ll-1.2 . .1 In :considering .the decisio}l to provide

in vitro Iertiliiation :treatriu~nt cycle may . fertility treatment for couples With. HIV,
be suitabl~ for fredng. If two or more hepatitis' B o:, hepatitis.C.infections, the

Scanned 8y: ~

120 SECTION t; CONCEPTS OF .HUMAN REPRODUCTION
impli~ations of these infecti~ns for
potential children. should be taken into
account. . D
11.3. Ovulation induction -du'i"ing IVF
treatm~:1t
1.1 1.3.1 Natural cycle in vi.tto fertilization has a
lowe.r pr~gn.Ancy i7a't e pe.t :ycle of
treatment than gonadotro.p'hin
stimulated IVF and t:s Ulerefore not
recommended .~xccpt in rare
circ\Ulls~ce.-where gonadotrOphin use
is ~ntt:ainditat~-. . A
1.11.3.2 For women w:ho have ~lar. O.Yulatory
cycles, the likelihood of a li~ birth after
a replacement of .ft:'9zen tba~ oemb:ryos
is similar w hether the :en,tbtyo are
replaced du,~_g tb,e .natilt.al :t:ly.cle :or
sfu!iulated .cycl~. .J;l.
-.. i~11~~::3-The:usetpfadJ~t:~o.bC>r#ion,e.~tho':; ,
..gon;adot.JiOP.lltna,., d~ring;; .. :. -*~" v.i.tto.
.fertUiza:i.i'()tt::cyelt. ,:.(j,-~ : ;n~~ i.mptove.
.. .. . pregn~cy ..,raies .~ th?~fote is n()t
..s :. ~min:end\. ..:: A ,,:. .. . ... . . ..
.l.U.4 . Oocyte ..m,atwration,. .!J;uma:n,-.h.orlo'il.ic
:gQnado.tAApbit.>.' ,
1,-tl.4.fCoii-'ies slioiil<rJie imoiilid...Uiat :m
.. > e-rr:t:;:g.~:ttia~~-itiiiVuknt
gonadotrop)l;in , a.chiev.es $~ . r-esults
-to utinaw buman .tbori'Otlic
gonadotrophin l rt tei'.Ins of :pregn6.t;ley
. rafe$ a nd i~eid,enc~-. of ov~Ti~n
hyperstimulat.,ion tsy.n<\rom~ : Conside-
ration :$ hould ~ given'to'Jll.hUin:iiing CO'st
when p~eseril;>ID,g. A
1.11.5 Monitoring of stimu,late4-cycles
1.1 (.5.1 Ultrasound .m.o nitoring of pva,rian
respon~e should fotm. an .in~sr-ai part of
the in-vitro fertll'~tion treatment cycle.
c because this improves pregnancy rates.
1.11.5.2 Monitoring e~:tr.ogen .during ovulation
induction as .a part of JVF treatment is
not r~commended as a meatl$ .. of
hnproving IVF.:zye.a tinent -S'-lccess: rates
. because it ~o-es :not giv:e . ~dditional
informa tion With regards to'live birth or
Scanned By:
>'
'
pregnancy ra~os compared with
ultrasound monitoring. A
1.11.6 Ovarian hypen;timu4ttion
1.11.6.1 Clinics .,providing ovarian .hypersti-
mulation With gonadotrophins should
have protocols in p~ee f~r . pr.e--.'ellting,
dia,gno~ing, and marntging ovarian.
hypetstimulation syndrome. GPP
l.ll.'6.2 Wom~n who .have a .~i_gnificant risk of
developing ova,riat) hyper.stijnulsti~n
syndrome sboilld not ..~ t>ffc;red oocyte
maturation ( ;or luteal support) using
human chorionic gonadotmpb.4L A
1.11.7 OQcyte r.etrie'(?.l
1.11.7 .1 Wom~~ und~ing txan~ xetrieval
.ot~-~-yt~,a .:.;~iu.d.';~,,oft~..~Ol\s .:
sedation b'e'CaU$e it . ls, a safe .a nd .
,aec~:ptJible .m ethod. of. p,ro'ridipg
analgesia. . A : .
1~1.1.1.3 vi.omenwlto-<ha..~~- devel(lped.at' leastc.
three follicles 'before ooey.te retrlenl
should not be o'ffeted follicle 11-q~g
hecau~.the p.mte.d~ d06$ '~9.:t~
tne n.~~>er-tstl:roeyt~~f~r~trieved- or
. pregnancy-rat;S, 9lla 1rmQ"ea&ei the
dqtatio.n .Qf . o.o.c yte retrie'Val and
associilted .pai.n. A
1.:1 L8. Assisted l:latci;ling
1.11,8.1 As~isted 'h atching is not r~.mmended
becau~e it bas .not been ~hown to
improve pr~anty 'rate. A
L 11.9 Embcyo transf~r teclmiq.u~s
1.11 .9 .1 Womenundergoing IVF should be o ffered
ultra sound guided embryo transfer
A
1.11.9. 2 Replacement .o f embryo-;; in:to a U:terlne
cavity with .an endometrium of less than
. 5 mm thickness is uniUcely . to result in .
. pregnancy .and is therefore not .
recommen!fed. B
C
 ' !:': ..
{~HAPTER 7: ASSISTED REPRODUCllVE TECHNOLOGY
1; 1 L 9 .3 T1-ansfer of day 2 or 3 and day 5 or 6
appear to equally effective in terms of
increased pregnancy a nd live birth
rates ~r cycle started. B
1.11.9.4 Women shculd be infoffiled tp.at .b ed
rest of mor~ than 2() in.inu tes duration
;following e~bryc transfer d~s not
improve pregnancy rate .of IVF. A
1;11..10 Luteal Support
1.11.10.1 Womet:. who a.re undergoing IVF
gonadotrophin releasing hormone"':
agonist for . pituitary down regulation
should be informed that luteal support
using human chorionic gonadotrophin
or progesterone improv.e s pregnancy
rates. A
1-'11 . .10.2 The routine u-i?e of chori!)nic
: '~. ga~dotr,ophin, ~or luteal sUoppOrt-is not
-; recommended because of the incr~
: .. likelihc;vd .of. ovarian hyperstimtilaticn
.~drome. A
I~tracytbplasio.ic sperm ~jedion
.I . )...12
.... - -..
- ....- .,, . . .... . .. . ..... . . .
- -
'1~~12:1 .-.:::':llidication;> for ICSI
1.12.2. The recogl).iJ;ed indicat~ons for
tre3,tment by ICSI
. ........ .......,.
. . ~
severe' ~-efi~its . ht se~en qualiif
obstr.uctiv.e azoospermia
non-obstructive 'aZoospermia
in addition, treatment by ICSl
sho~ld be considered in coi.l,ples in
whom previous rn cydes has
resulted in failed or poor
fertilization.
L 12.2 Genetic issues. and counseling
1.12.2. 1 Before cons idering t rea tment with
ICSI, co:q.ples s hould undf!rgo
appropriate investigations, b oth to
establish a diagnosi s and to enable
informed. dis.c ussion about the
implications of treatment. c_
1.'!2/2.2 Before treatment with lC.S_I,
:conside r a tion s hould be given to
r elevant genetic issues. B
Scanned 8y:
.. 121
1.12.2 .3 Where a .specific genetic defect
associated .. with male infertility is
known or sus~cted; couples-;S hould
be offered .appropriate genetiC
counseling ~d ~esting. 13
1, 12.2.4 Where tbe indication.foriCSI is a severe
d e fidt of ~etne n quality or ncn
obstructive azoosp-e r:mia , the man's
katyotype shou1d be establislied. ~
1.12.2.4 Men ~ho arc u.nde~oitig 1auyotype
testing .shoa:ld 'b .e . Qffered ~etic
counseling t.~gardtng the geiletic
. a bnormalities that may be detected..
GPP
1.12.2.5 Testing-for Y chr-omosome micro-
deletion-s . should n o t be r6ga:nbi :as
rou :tine . investigation - . before
in.tr:acytoplasrrlic sperm ib.j~tion ..
.However, -it is ..likely: that:. a>~f?J~t
proportion of u1.ale irrf~tr~ts
from abnornialitb~. org~es i..-i,tb:e' y . .
cfut:imo:wm,e involved ln.the~tion
. qf ~per.tnaiog~nesis -~d .the. couple
. shouldbe~i~ 6.Ftln& 6 <: -
. "!'~.:t~,~ ~.;;'~!:.#
-1.12.3 Intracytoplasmic sp~im inj'e ction
ver:SJ,J.~ :in v;itro -fertilizf}ti~I:l . ~-
................. ,.,, .. .. .. _
~"'" . . -..... .......
'1.12,~."1 QQ!J-P-le_s_sho.uld_Oe..iP.for-med-tbaHGSI
impr~ves fertilization rates compared
to lVF alone; But once f~r:tilizailon is
achieved pr!!gnancy_rate is .n o better
than with IVF.
Li2 . .4. S penD. Retovery
..
1.12.4.1 Su.rgic al sperm recovery before ICSI
may :be performed u .s.ing s everal
different t~chniques ,depending on t:he
pathology and wishes of the patient,
facilities for cr:yopreservation of
spermatowa sho1+ld be available
FUTURE OF ART
Inthe ESHRE meeting in 2006 in :aai-telona, it
wa s noted that the n eed for .ART in helping a
couple .ac h ie ve ,pregnancy p a s become m ore
evident bec~u s e of the changing .tre;n d!; ip.
infertility.
~
..
,.
122 SECTION i:. CONCEPTS OF HUMAN REPRO.DUCTlON
_,.;

These changes include l~ter time th~t present
couples wait to have their children, .the increase
in male .i llfertluty, .t he incr~ased prevalence of
Chlamydia! infection whi~h increase tubal
probl~ms and. the m crea:se in the survivors after
cancer therapy.
Have we
seen th~ erid. of the ART revolution?
Not at.all. There ~e .still opportunities for
irirprov!!ment. All oocjtes are not equal. It has been
'Shpwn tP.at on an average, oniy t .$n 4 'o r 5 .has a
potent.i:al for a pregnancy. ~~rm :~s robe moie
4-ependable. A hiP,Vasive method to identify the
oocyte
. or th:e
. . fertiliZed
. oocyte-with the best
pn!gnapcy potential would greatly improve 'the
sing!etoa pregnancy rate and of course avoid the
complications or' multiple pregnancies.~~ 1
There are other possibilities. Stem ccllcomes
to miilO. . With their pot~ntial by c ontrolled
differentiation of providing cells to produce
insulin for the .diabetics, to produce nerve ctlb
missing in cir-<;umsta,nces in which d.iseaSie or
injury has da:maged the nervous system , to
provide substitute cardiac cells. In .p 2lity:.,
technology cp.n p;!'ovide the solution to th~
prol?lems that b~~ct a woLld With a,::,.. ~g
population.

POINTS 'TO REMEMBf3R ....

.. : .rn~-.era . of a$s~ .r~~uctivetechno.logy :started with the birth of LouiSe :afi:>\Vn ;ir, t97a
. ~ ..... ~ : .:. : _, . ,:~~a~u~~~:qe~~;.:jfits':t~no!Ogy~ha.s r~~ct-.ed.?hiliP.'!'>in~ ,shores .Vfith th~..~i~ -of; the
fifSt..l VFbaby. in fueJ?-~lppitle$ on .September 10;1996.
. . . .
.~oog. pa~n~ w~~er~roale,factOr infertlli1y, tube:! obstruction -and severe endprrret:.Qcsi$,
theusepfARTnav.e: been: ~With successful pregnancieS where-ccnventiot!al ~
h;lv~~ISinal'r.~sUits.:. . _. . . . . . . : .

. "', Jbsllhas:revqllJ~tiiZedtthe-~eatmentrof:maJe-faGtor problems:.lfhas :enabled ~rtuaJty :man

WM.;$evet.~~Oiigosperti}ia antf'teratbs~anialo f?thr hi~ cym child. Even ~mb~!razoosperm~
rnaies;-itis"'7W'.:V~Ss1J)Ieto-obtain ..speri'ns:byTESNwhiCh
. canbeu~ed.fur4GSl:
..

The rapid develop~eht :o! fRT .is rnade possible. because of the advent ol sonography, .
development of T~ri)tiinaht ovulatory drugs, Gr.R!i.agon.ist -and antagonist, together with
the develOpment of:new ff!edia that .allOw the survival Of embr)ros for a longer penod of time
in vitro.

The !'!ffidency and. ~St ~ffective:1ess .of ART caii be :m axlrriite.d by following guidlin~ ,like
the 'NICE :2004 . . . . . . .

The use of ART in the treatment of infertility will further widen because of the lncre~sing
prevalerlce of Chlamy.diai infection, the longer time that coup!es wait to have children, the
increase 'in male infertility ~roblems and the increasing humber of patients s\Jrv!ving .ccrlc:er
. therapy.

The future of ART re!ates ~to the use of embryos which may be dire'Cteo tothe particular
organs. that 'may be involved in
ihju_ries or -dl~ase. In .partiq;lar, ,~ese may :be solutions to
problems. that beset an aging populatiop.

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 CHAPTER 7: ASSISTED REPROOU~TIVE TECHNOLOGY ...._.yt
., 123

10. Lunenfeld B. Historicar'perspectives in gomiCfotrophin

1. Steptoe PC, Edwards RG. Birth after reimplantation of
the human embryo. Lancet 1978; 2: 356-366.
2. Almeda L, Vera T, SamsonG. Firs t test tube baby in
the Philippines. Phil J Obstet G~eco! 1998; 22: 263.
3 . Luke B, Martin J. the rise in multiple births in the
United States: Who, what, when, where, and why. Cl.in
ObStet Gyneco12004; 47(1):118-133.
therapy. Hum Reprod Update 2004; 10: 453467.
11. Downing 80, Mohr CR, TrounsOn AO, Freeman LE,
Wood C. Birth transfer of cryopreserved embry9s. Med
J Aust 1985; 142: 4D94ll.
12. Palermo G, Joris H, Devroey P, Steirtegham AC.
Pregnancies after intracytoplasmic injectiorr 0f single
sperma-tozoon into an oocyte. Lancet 1992; 340: 17-
18. . .

4. Hespe W. Prel.i:miruuy note on the transplantation and
growth of llUI+nmalian ova with the uterine foster
m;rlber.ProcRSoc 1891; 48:451-458. !t:.
5, Chang MC. Fertilization of ova in vitro. Nature 19.59;
184; 4q5-467. .
6. Jones HM Jr, Jones GS, Andrews MC, et al. . The
program for in vitro ferti.li.z.ation at Norfolk. FU"til Steril
1982; 38: 14-21.
7. i\sch Ra Ellsworth CR, Balmaceda JP, Wong Pc. Birth.
'i~.noliowin_a gamete int.rafallopian tube transfe-r. Lancet
- ~ ; 1985;:2: H53.
. :
13. Bonduelle M, Van Assche E, Joris H, et al. Prenatal
testing in ICSI pregnancies of chromosom.al anomalies
b 1:586 k.aryotypes and relation to sperm parameters.
Hum Reprod 2002; 17:2600-2614.
14. Bonduelle M, Winne:-hoJm U, Loft A, et al. A
multicc:nter cohort study of t;he phys!.C!ll h~th of 5
year old ch.i ldren conceived aftu intracytoplasmic
~perm injection in vitro fe rtilization :and natural
conceptiort. Hum Reprod 2095: 20:413-419.
. .. ..
15. Hansen M, Kurinezuk J, Bov:erC, Webb S. The.risk of
. major defects after ICSI in IVF. W~~.-:J-Me~99~2;
346: 725-730. . . ~ ;,.:;: . .
.)< .. ~ .. J

8. unz S ...t.!.Lresonically
guided aspiration of human . . .
~.1J1J;rasound Me.d _Bio1 '1984; 10: 625-628. 16. Dev.-oey P, Van Steirtegham. A review of 10y._e~s
exp.e ric:nce with ICSI. HUm. -R eprod Updat e 2C04; 10:
! ....!.:~
.;,. . ~
19-28. . ...
'1'g_:~yee "B;:Bames RB, V.argyas JM; Ma.rrs_RP. COrrelation
..:.of t:ransabdcminal and transvaginal ultrasound , ......
. - . ~ ' '
.. .;., .
0'
:. ..:
( ''t
' ,#o '

rileasuretn:erit' offolli<:ie size s.nd ~u~be~ with 17. Munne 'S, Magli C, Cohen J, Morton P, ~tal. Positive
" '-'.,~ laparostopicfindin.gs for IVF. FertilS~eri11987; 47: 828- outcome after preimplantation di.agn'oS).,so~an~U,P.~bidy
832.. inhuman ec::.bryos. HumReprod 1999;14: 2198-2199.

'
-~

:~7'-

:~
....,-.;.,.
~,

~
...
.1

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.

,.

r-..
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 8
,.

PSYCHOLOGY OF PREGNANCY

Th~ Maternal Role

Tr~ AttitUdina:J-Spkitual Aspect
The Psychological As~ .
Pi~ Trimester Phase -of.Adjustrnent
Second Trimester Phase of Adjustment
Third Trimester Phase cf Adjustment
Intrapartum Phase of Adjustment
Postpartum Phase of Adjustment

Maternal Behavior Aff~ng the .Fet-Js

:Preconception Behavior -: . - .
Advef$e Matemal-P$0atal-Behavior
Ne-al 'Potentially Risky Behavior
Supportive Maternal 'Behavior

Th~_.Ee.tal.:Role.. _
F-etai~P.sychology -
Prenatal bevetopmentfrom a Personal Viewpoint
The Paternal Role
Motiv~n for Pregnancy.
Paternal Psychological Adjustment
First Trimeste Paternal Adjustment
Second Trimester Patemal Adjustment
Third Trimester Paternal Adjwstment
_Intrapartum P3ternal Adjustment
Postpartum Paternal Adjustmer~t

The Role of the Environment

N?tural Environmental Factors
CulturaVMan-made/Environmental Factors_

--.-.

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 -------~--S-E:-.C-n~O-N_t_BA- G_O_N_CE.,.-P_T_S_O_F_H~U-M-A-.N~.-R~EP_R_O_D_U_C_T_'IO_N~-----~- .. .
1
. -S-IC
__ l '

------~----------_._:_-----'---:----------------- __ .,.,_ ~

~
. ~ - ~~4

INTRODUCTION particular, and of l;>ehavior in generaL" l3u,t he .:.~ .

preferred the term "behavior" because, .. _ mind :~.;
-
The obstetri$n. is also .a practical psychologist is .abs:mct, and without the physical_ co.mpom:nt t.,'
Who deals with human behavior, especially that by which mental processes are manifested fu., ';
:_or:a~partieuiar person ~ho happens tqbe pregnant. by behaVior) the term has no valid utility :except ~:
The obstetrician who is compassionate, shares in a limited hypothetical sense. ""l t~
4:.; '
- ~tl?. .the patient's _cone~ about the physical
~ges .and somatic sensations o cclirrirtg within We now have a deeper insight into the effect~! . _
;: .
h :et Pody; h~r thougl;lts and f~e~gs aoout.her of pregnancy on maternal behavior. ~e psychlc g;
,p~n.t CQp.dition; a:P.d :~e mcatiing, v:alu~ and . dimensions of'f~tallife, 1;he supportive rol~ of~ -~:~
~1\i~ -prq.~~- o:f:tlie. nW h~ ~. sne -is f~~er, f~y m~bers _QT oth~ ~e-:gi~ .Biid <~.
. -.~b:o~g:Wirun -~~r. bOdy._ ~s . ~ncep~ is . th~ infi:u.~nd~ of. natJ;h-:M ~irdj;or Iiinn;.made -:fi,
. . ' ~ :(m 4.(-
:tt :~ m:fhe"acco - ilhi$trii&.n., Fi . . eovirorune:nta.t-factOr8. . Futthetmot:e .. ~_;,:-
.--_ .- .a~j}:_:_ . . .: __ . -.:.~~ ,:. .-~- : .. ~ evidence of
~ ~ -
~Jl .fu)-Q.ip:gs; we_el$oha't'C .-~ reeent .

. , th~ . op~rtunity to . -~FPlY ;.more :-.t~tlo~al ...~

~.

interventions ~a _trea:tm'erit'. efforts d~ to

........... ..-,a eliminate or .m.inim.b:'e - the. n~ga1J.ve effe:cts of
........
~;

........ ~-.
maladapti~e or ..mtS.dir~~t~d ~haviors '(m the
-~-<~~CHOLOOtC -._,_ h~thofmotheni.a!id-ehii:dreD;. l:>efore, durini$.~ --~-
,,. sELF . - ~ter
childbi."'tb
~-
.:,.
..THE MA~'ERli.AL
. . . . ROLE ..
: .
. . . '"
:.~i

Pregn_a nt- v,ro:ai~n u_n4rgo .~Ii:l:ked bio~: ~.~ .

. :
physi~logicat and,p$ycliolqgial~ha:pges fuel~ . -~. ' .
.alte~tioJ:lS _in,~eit::~~w4~ t9!'fa.rd~ .p~cy: -':-~ :
which ren~_deepzy'felti~4~-.~ut'reProdli~ . ::-:~ '.
.~dp~Y./ _'.'fhia.F..~t.~p~r sbarr;f~s.- ..-.;~~
m~?~lx .9!!th~~~~l?-~~c:~~-:the.:ati:i~~-- :--:-
spiritiui.J.'ti.s'Pe;c-~s.~- Tl:U;s fust aspect sha~l-be .;..
discussed fir.St beCause :hf it:S ~portant:e. . .;> '
~: :i::~ .
-~ .
.. :=~ .

'The mother':S attitu,des towards 'pr~C:y

. . :~-,8.~. I4agram of,fue pregnant Wo~ari ,,owing .her
. . ' :~:~pects of personality: .physical, ,psychological
. ~tUal.
The -caring obstetrician need not be dismeyed
:Qy tlie pro~pect of having to deal with .something
. ~elu~ive and intangible, :such as the hum;p1 mind.
~o't:the mind. c an be represented by something
o~servable, measurable and expla.inable, like,
h\np.an behavior. This is what pcychologists and
: psychiatrists study and work with as they manage
ffidr patients. AJil eminent -pioneer Filipino
neuropsychiatrist, teacher and prae:fitioher,: Dr.
J.~imeC. Zaguir.re had leftas a l~gaty, the 'following
reassuring words to medical -students and
:physicians alike. "Esychology is Uiestuciy cif t he
. ,:$.tril:~tur.e and the function o~ the mind, in
a re of crucial -imfm.r :tap.ce beca.u:se tl'!.ey ..
determine matemal behaVior -a nd influence .the
and ccurse of pr!!~~Y- .An ~tutud:e m<Jfbe d~~ .
.
as -~ rela~:i.v~ly _fLXed.- .pr_e~isp{fsitli:>n or ten~cy : :
to ~haye or .r.~ct j...J. a :c~fi way to pe(>pl.,
event!! or issue~s,_ either positively or negativeiy..-4
Attitudes, expresseaill a .s ystem or s et of values
(worth or excellence of something dee'inc.d
desirable) whi-ch repre:s ent t}Te i:ntarigib1~
-sphitual a~pct .of perso~ty, are identifiable.
a nd measurable. The'se a re convenient fe~tu'res
for the obstetrician-coun selor .who needs 'to
assess the m 9ther:'s a.i:'titudes tow~rds
pregnancy.
In general, "most w 9 men u~detgo ,- _ .
p sychological a da,pta,tion to pregnancy and : .' .
develop.coping mechanisms to deal wi:f:4 .ihe.-_-: . . ..
routine as weH as the unanticipated. :This

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 CHAPTER 8: PSYCHOLOGY OF PREGNANCY ., 127

px:egn1mcy-spedfic adaptation is _g reatly affected The 1s: Trimester Phase of Adjustment

by .a wolri<ih's beliefs, 4esires and culture.s
Normally, ~omen find pregn~cy a means of
affirmation of.theirfemi.-rllne identity, that they can
function as wotnen in the most basic .s:ense- .Giving
birth .to a child fulfills a woman's need to create
andnurture life. 3 '
However, some .women have a negative view~
'fheymay fear .'pr~cy or ieeHnadequat-e abo:1,1t
moth~. Their b eliefs about their competence
ate affec;t~ by their experience with their own
a
. m.ot:htt: It her tn.t~ther was~ poor role model, a
The early Jl1onths of pregnancy ~e ~enced
in different way s by different women. Some ~ve
a s trong sense of energy, wel.lbeing ..1).nd
anticipa tory excitement. Mila levels o f anxiety
associated with m.inor.symptoms of fatigq~ and
loss of:appeti.te.a.re, nevertheless, To~d corilfort:iLg
as they~rve to.reassure that.pregnancy .iS normaL
NausP..aand vomiting, although romm.on, ~mild
.in nature, do 'not impair health nor :re;strict 'the
no:rmal activities ofwomen. 7
;-
Other women.e~pecially tho~. with ~.mplanne4 . ~

w.omans sense Qf maten'lal coml.)etence may be
ini~ and .she ma:~ lack .oonfidence before 'and
~'her baby's Qirth..s
. :r:h e -..manifoid -psychological irepact of
~cj ieqU~-a period Q(fune for emotional
.a;n4 :m:~~lJ.~al adjustments during gestation,
~eli nlily be divided int~: the 1 trimster, 2Dd
.t..,-hn:eat~r~ .3r<~ :t+im.e'S'ter, intrap.artuni and
or unwanted pregnmcies, may inani.fest .greater
degrees .()f arodeiy !iue to worry. a bout hm"l the.
.b abywo\Ud-affe.ct her.i.ife, job, ~e orsa life,
in a dditiqn ~- a .strbng fe<;rr ofthe p<rin of childbirth.
Most or -ti;1:ese w omen : respoi,id ravop1;oly.. to
coun~ ir\,:fue for;m of $iti.lple ins~~tipii ~n
.reproductive phy~~logy an'd: th~ :re::.a~ of
contm\J.ed support. ~ouShoui: pregn.a:nCy;>~
... . .~ ,. . : : .-~ f!.~:.:.. .
The zVt Trimes~ .Phi:l$e .~jA.~ ' ~~~~?;: ':
' .!~ !"~
. , ... . J

. .~~~ phases
,........... .
of adjustment. For .mps t women, the Z"" trinles~r is:~ tifue-of
peace: tf:l:Wqllty ilnd ;increasing conli&~ce..
.:.., . "
. . .. -; .. .
. :<~~.";i~-P:~:~fl.\IC~a\ions,; repr~sented .l:;y c;h~gin,g oc~u~g-nr .~~. 4.th,.. mo.~~:f.e..~ /m.o~em~t. .
.leyets ''Ot:arunety~. mruii.fested ;b y vita,l -sigils a.."1d (qUlckenm.g) 1s Vlewed a s.asignal tha.tfue,liaby.ts
' . ' ' ..,_, .: >-\ '
" ' ' I ;

olher indicatOci, oompaioo to -the usual range of alive and well. Previouszy rej~g:women,J~cq:tne
en1otlori81 tcnsion.or~equanirnity lev:el~ iri. th~ non- . resigned 'to the ..riality of p:r:egnancy7 ere: abk to
p~~ - " . - , .. .m
. ' .. - - -. matrbe illustrate& . rire~cusly
-tlie
. . ~- - . .. .. .
~~n tth'en- r~_ anii n<%atiVe ~t:a:sieJi~~-.to
pro~hypoili~tical~...emotion.m-'tensi:Qn-. curve .exiJerlence-re"'dticea-tevets::-or:.anXi~ty-;a:s iliey
-qf-pregn:ancy'"~--s-htnvtr-in-trre~a::ectfrl:i:j'fa.lryfng a 1ffi'lJ-weicome..tlieir-eondtnori~p<)'SLtiYelj:~- ' .. ~-.
~ Figure 8.2.6 .

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12.8 SECTION J: 9ASJC'CONCEPTS OF HUMAN REPROOUCTfON

Marital relations often improve during this epidimll) are preferred because they are '"the most
period. "Heightened Snsuality at t his time is .o ften flexible, eff~tive and least depressing to the
a p.lea~t bonus; it is not 1,musual for some -central nervous system allowing for an alert
Women to first exp~nence orgasm in the middle .participating woxp.an ;md -an alert neop.ate. 111
. . . . . 8 .
m.quths of _pre~cy".

1'b1s is ~ed- by the ..pi'~gilancy effect''. a

phenom~oii assqciated 'w itb pr~cy.where an
.lfi~)tt,fue amount (?fvasc~ tissue. in the
pdv.:ic .:r:~gioti.: etihances th:e .capacity -o f' sexual
tension ,sine there i's -mc>re
. ~
enfS'-'1 1!>-"'"" d. u. g S"'"""al
--m '-""... -.cn..-...usaJ'"
u.'-'.
. The 3'* t:i'im.e'ster is. lna.tk~a ~y .'iiJ..~asm:g
di~tnfort :an.4 pres:s ute :sy:inp~.ttis aue to ah
Postpartum adjustment requires a c~ in .
self-:i!nage from that -c>f a pregnant woman to that_
of a new -mother. A sen-se o.f acliie~~~e.nt.
tl_s$ue t.O ~me satisfacti01'i,a;$htitipati.9n tnaY ~be ~-v.ith ;a
.
9- sense of.sadnesS -a.I)..d re~tment for tbelOss:ofa
simple- ~ style mtd husba,fid..wife rel~ -t:b
a :~ C9inPlicated parenthQOd :stYl~ <>f -~"'
child and father..$bemu.st-adjust -~:the~
loss of the baby :s he h(:l.d carri~ and-d>pt'Yiith.
the deniands of the newinfan:t -~ tb.~ nevv ~ther.

-~~=~:;~ ~~:!~;;;;:!t~ki.~ ..
healtlt;lieraiSto~stm.pe and:het:~~:k>Ss b~ues... Tl;lis.phenomenon fdfeets about ..50-80
--o!-8tir~~:-:slie:%Qf.:~~0~J:ne.d,;witlHier~ percem--~f new ~o$~. a~g. tQ a ~.nt .
t>a$'~ilipdrtg)mdr~~vetw~~bJ.!m..Of.. --:repoFt!.= 1 $ympto~s-.)hcltIe;"~il~m~,~ .. . -
(he,patn. ot~.~.-she~yQe.~ttoul$1ea.)vith.. ' sleep:'<UfikultiS''~ _:irritability~ . :Tb~-~en .
~ty a~u.t -~padty her :to
~::@.tl are. . us\Uilly 4o ;J icl reqUire ;pmfesSional a~tiOU.~d -
'fc~ :clilld.Jtt '~~n~tO"hQu~o:ll:l-u~~s; ~ sym-ptom.s .~to subSide'Within-two~n.
. . :. , ::~:y~; ~~~~~. _r ;~ . . ." .: :. . . . . : . . . . . . . . .
: ..-.Qri"'tlie"'offiei'tha~(t;~'n:i6st'Wb.Jin:en:~e:.aqle,~, :. . .: How~~. ;it- is ~~t.:d"or .-o~ to -.
~:wtti(~Chiilleb;g~"tiG?Sr.e'$edWidi:hoi>e..,,. ':.identifji ~onier;iWi!tr:~tpai;tiu:nsbhi~.--~~, ....

-~~4!f~=:,~:: ~~~~~~;:~~~:.~:;.~~ .
SJ;l up.derstiirianig~<ilis~effia:a:n:~-so'Dfes:ort~or ottheSe-wom:::n~evel.op'.aior~dep~-
~tionf9r CliH<io-tFtn wurt>e 'liapml' ~-uus tlie-nr.st~pm;itiat.a-yeat;-:ior~n;ich~~~:
phase or ~dNstm.erit: interven aon .'is indicate_d .. Wpll):~n ~t -~ fo'r
~posfpart-..un b~es .are iq~n~. by an.y or the
The .lnt:rqp(mum PhaSe of Adju$tment following: ~~or famizy .bistocy 'ofde~.
preme-ns~a1 _ d ysphoria,. rec~nt stressful. life
The lev~l of srot trimester .aruliety ta~ .off -~s: ._cv:e.nt:S 9't ..~r s.~ .'fi~j'ustnient. depr,~il. qr
the .parturient resolutely !aces the' challenge of amcief.y d~g p~.e.gcancy; :~ssive .fear oflabor .
J.abdr. SheisJoeu~d o~ adequ.a~e ~oD:t;rol_ t)f.W-in . Oi' '~ ~~'Y 9'/:~cy as :~otiottiilly,~(;\J.lt, ap:d
ana the safety and condition ~'?!'her' clll,l.d. . The .
ain1)1va:lente tdward ~cy: 11 .
relax~ ca:tm demeanor of women intrapartum is
tile. hallmark ofp.reparation 'for dllldbfrth training r.futema:l Behavio-r .A .ffee;ting the Fetus
like hyP-nosis, Lama,ze or similar ant:e.p artum
.programs. . Certain aspeCts of pare(lW behavjor, notably
that of the mother , both before or aft~ coneeptlo~
. Accor.d ing to the Americ~n CoHege of can affe_~;t the fet:us, pro!iucing- Hfe-long
Obstetricians an.d Gynecologists, 'Pain consequences. 12
. management should be provided whenever
me9itallyindicated.'" Tp,i~.advi<:e-wasfollowed:by, Some .behaviors pr:odu-ce .adverse effects,
."Mlitema,l reque~t is ..~~:fficient iriaicatlon .fdr pain cYthers ate indifferent unles3 done under certain
. reliefinthea,bsence-ofa,-rneQ1Cal eon:trairt<ij~tion. .. . ~nditions, w4ile otl).ers have ~sitlveeffects on
Neurax:ial.analgesic .te.c hniques '(spinai ."~d./or : IX?~~tal w~lfare. .. j

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~
 CHAPTER 8: psYCHOL6GY. OF PREGNANCY
--.......,----~------~----....,--------------------~~;.
Preconception Behavior
Because of known dangers from ter:atogens,
ob'stetricians s~ould counsel women planning
pregr...ancy to take th~ :follov.ring precautions: Um.it
n on-emergency x-mys to the first 2 weeks after
menses; have vaccination against roMlla 3..:6
months btfo~ gettin~_pregn.ap.t; stop taking birth
contr~l pills at least 3 months before t.ryjng to
co.nceive.ll
Adverse J,fatemal Prenatal Behavior {for detiills on
this. please refer to 'Chap~r 16: P,rep.atal Caje of
tbe fi~thy Wo~ ,under Prenatal COunseUng)
...a. Drinking Alcoholic Beverages12
b. Maternal Smoking12
c .. ~terilal Drug Use 12
. ~havior
Ne:utr:trl Potent:W1191?isky
. during,the pr~nat.al ~ri. manifest:iilg cvn~ous
. ..
'\ '
:- (:;,...fu . :CS:ffdrte !ntake13
;:.~:3)~ ,Use:of cAM. (Complementary .arid .
;~ : :' '' ;'!1\ltem.ative Medicine) 15
. .:'_. c': Air Travei16 : . . ..
,.
........,.......:-
...~~~~:~~~:~W>.~ ..
~.;;;:.o.:!~feerlai.i:t m.&.t'e:r:n.al bebaVioi-3 promote optimum
'1iehlfu ofthe motbe.r .a na her unborn :child.
xru:riples are :re;'ular intake of well-balanced
:rit.e~~s ~~a aileqrrt:t.te exejcise approprhite ror
pregnancy~
Intake of a Weil-balt:!nced Diet
A wom.ari's 'nutritional status before, during
~d .after pregr~cy contributes to a)arg~ degree
:t o th~ well-l:.emg of.both the 'Ihother.and the infant.
,A varied wet, h igh in nutrients i ea:ds to fewer
:.tqmplioitions q~g pregnancy, ande~ey la~r
8.?-d .a hehlthy baby.
ObstetricW.llS should. coUnsel t..'1eii- pa.tien.t s to
foUow recommended dietary allowances oT' RDA
to in.s ure levels of intake of ener;gy and.e~sential
nutrie~ts considered p.de_q uate for pregnant
,w9men and their ~bie;:;. 13 .,
. .
.Maintenance
. . . . of,Regular
. Ef(ercis
. .e
Re~iar exercise .during pregnancy keeps the
mother phjs.iciilly fit and. optimizes the pr'(friatal
: environm~!nt. The goal of exercise. during
Scanned 8y: ~
' -129
pr:egns,mcy is to,!maintain th.e highestf:.l.~yel of
physical fitness consistent with maximum safety
for both mother and child.
The obstetrician should screen for obstetrical
anq . ~edical complications befor~- prescribing an
exercise. Absolute contraindications include:
heart dise~se, IUGR, 'sever.e hyper:-teri.si~n.
~p~ed me~brane~, uterine .bleeding. and risk
of premature labor. -.A mong the relative_
cont:,raindi_cati!):ns are_: essen,tial hypertet;ls.iori,.
SJ!.emia, thyroid disease, breech presentation, last
tdmester:r 'excessive obesity and extre.m e'
underweight~ 13 . .
'TltE FETAL ROL.E
The fetus may be considered as an active
participant in its own growth and d evelcpm ent
awa,rene~s,.of.~d.willful.coowratio!l.with.~t;h~
physi~al~ . ,psycholqg~_ca.l - ~.n.d ._psy~R.l_f;t~P~~~~
. .. . .
.occ\.J.Tl:!.l1g))ef?r~;.d:uPfig::and:ro~-er _q~," ~#<
.
... :;;'?..'~'fri!..::....:~~~~~;.~ .
; : :'I ~ t:;';
.~etal. pSyGhq1ogy_ starts when .h~~-jife
.
begln~ ~s ~;:one-:~ellef,i in,diviqual_; o~~~~~!!
~y~o~ HUmat1-~havior has ~n d~~i~..~
m.divtdual ormmt~m's respon~ to ..enviroqme:g.tal
stimuli. both external and internaL ",-2 : . .Aceoidi.n.g
.to t:fii~ .. . ... .... .... .. fu:ei.yg
....... udniinori - . <:>t.e
. . i~ m' iili.ii;i!~
..fu11\\}.
g . man
'lett.a'Vi<ir-~tm'til:i'g-fro'"P:r:na.y-pp.e: -otiffiig.ifS.~:fir.St
2:-t'~ours~--qi.- "f:tsponse. rogerienc an< Cmafe"'$:al
st:imculi,-_it ~bi.ts t.'1.e capacity for' .growth. and
. reproduction;. i.t .Pa~ !'epr:oduced. .its.elf: 'i:nto a
2-celled. organism~ . T4en: i~conti.."1Ues developing
i..J.to a.4~elled, i3;.cell, 16::-celled living being, 9-
soon, until it- bec9mes a,. multi-cell~ fetus.
it is not difficult for a rational person to
conce.ive the existence of a dynamic intangible
mind, while bei.;-~g sustained by an- J-nfused life~
giving Spirit, is i4 charge. of coon;l inaling the
behavioral respon~s of a complete human, _being,
composed . of somatic; mental and spiritual
aspects, 9-l:lririg th~ -p.e riod .of prenatal
.development. rn
;9ther words, the unborn child,
fr.orp.. zygote. to e!-';lbryo to (etus, is a1re3:dy fully
human, .a .p.etson who possess~s Cj_ij'),SC~ou:s
awareness, free;dom of choi~ an.d the ~acity to
for.m. m~a.I?-ingful r elationships.'.. TheJ~.l~o.wi.I}g
statein~nt by an .eininent !IJ.or.al tbeologi~ wot,1ld
have. compe~ling .validity -to a conscientious
.13"0 SECTION 1: BASIC coNCEPTS OF HUMAN REPRODUCTION

obstetrici,an,-.to wit, bne must:a1ways treat a 'living infonnation which provide evidence that ba~
. fertilir.-ed ovum as ~ human person, whatever its are sensitive, co~itive and affected by their:b irtb
stage of development, With all the rights of a experience. These sources are: personal reports
h~nian bein~. I? contributed by parents; revelations arl$Ulg ftODi
therapeutic wc,rk~ and formal experimentS:.u
The physical -and physio!ogical changes
undergone by the developirtg ccinceptus are ~'1own The first source, personal repPrts of parents,
to health profession~$ mtere$'ted in:perinatology. touch on a common phenomenon found in.tfuoei"se
What Is not known .mucli leslJ conside're4, 'except cultures~ Many mothers and fathers claim to have
by soD1e mental hc:alth dlnieians~ are the commUJlicated with their unborn .children and are
p~cllolbgical~hanges . md .tt1earillldul .behaviots <X>nviheed that a baby is a person havin$ #1hld.
Of the unborn child. M.o st .PAysi-clans, he~lth soul and body, with tin:derst:apding, wil>m and
professionals and laymen. often ign9re, disregard purpose. ~use these reports are aneCdotal and
and,evendeny the pos.$ 1"bilitythatthe .unborn child intuitive; better exp).a.ined in psychic -tetm.a .and
has. the eapa.city tQ think,feel, act, .remember and .not .in word-l;lased lang-Jage, these da~ 'Wf:te
leat;illike a r ea! .p etJlon. The pten.ate is eonsidered considered inv.alid, s~lf..setrlj:\g, ims:giruuy and
.:s.,.b-human, not~J~et-fully-human and is treatec:l unscientific by some dj.rtician$. Howeve.T. an
as s\leh. increasing numb~r . of . 1nesti.gator and
practitionen have becom-e mo.re ope~ . and
For "e>..~mple, the"prctllite .is ass~gn.e4 a purely recepti\i'e to the n\UJlerous -~nat ~timcnies
pa-~iv~ :tel~ bi l1re. ~a c>f..p t egnancy and" c ontributed b y parents. tt . .
.childbirtp~_-'lts ~vowth ' and -- dev.elop~ent- is . . . . . .. . .. , ,_
dete~ediriAfnJY.-'byrlta:'genetitr-potentfitt~tmtt-bY' "' ., - ~~~~mg::tcti_~~~~a.~thora~!~~~::t:~~-on .
CQn~t-:Dls;te~1, support;.... ~g,:labor;: the'... . Cliriicai ..~yn~ologt::E~PCrin~Jogy~ana,ertility, :
actlve role:.o fexpulsion i~ per(Qrroed'bythemptb.er .. communu:.a tlllg :w1th our un'Qp~ cb.lldren is
~d~:biftha~~~t$; tbemsl$~fQrcescome e_v.ery?~e..s b~tthright and easily wi~ our
~~.;~c:~~~~.and~efe~a~assign.ed ... . ca~b~ty.:. We ~e born,with_th~abili1;y,to~.
the ~-,'-~k~<>f.~P,~,;"Diirlht-Ue~~: to.~tuit,. a.n<t:...o ~ wl1a!.:HJ;,'QD~.. :~- :add:. . ' ,

the~~bly'ittsensate~fepts"is 76fte8: ~dled : . tha4:~:e- ~e:::iilliOO~~:w;thYa~p;n~ ~~,Ule ..

in:a profes$10riafo~~nve~ei ' Witll't'Oncetns physiC:al suuetute w~chcorrespontt.a to ~lion
'f~~ !IOlelY on 'ltsilnitieaiate' ;b. eat vat and clairYoyi.Ulce.- -clear...seei.ng ;and. ~ It
. ... , ' . . . -~- ~-< -~ .:; . .! : ~Sl ~.. $~~ -- . ~ Se'r.ltt:S~aa:a,~.pttWe~6ur.pl,i~jd~.~JaiQd
. Fol'tUnllt e'lyt ;tn .nt:brtt y e!it s, wt:r -b-av-e our. .innet .knowmg:,_? .
witne~ a revetsal (;( this trend ,in the field :of The s econd source of. e:idde.nce for fetal
pe_tinatbl.Og)rtilaiked by an..m~sing.interest in consciousness arise Jroin wO'rk do~e by ronn&ny
the I'$Ycl1~~e~land spirlt:ual'fe.itur.eS ofthe early edu~ted, ~ed .an:d li~nse.4 ,pe~ns. wbo .au-c
sta~'ofhuman:llfe'. N'eweviden~ indicating that exper:ts 'i.ri, tbeir Ji~l~. Most t;>1' thcdnt~tion
. Pttl>ies =a,re.$ehti~t h~.Unan; bemgS ha~ :exne~ged cames Jtpw .vi~d, r<:co,U~cno:n O.r earlY' ~tal,
.from :t he work of 'behaviora1 $eie rit is ts and 'and neorta:~ :experle.n ees or cli~tS
intljtpitfun;t
cl~rti~s who have expl!>ti~d the psychological underhypnorlc 4.@c~ .admiriistered iii th~ ~mse
dini~nsions of perinatal life. of psychothera;py .for various conditit;>ns. Many of
these client testimonies ofiiifant intelligence were
.ff nqta'ble representative cf this new group of confin.n~<;l by hospi.t al records and eyewit,ness
birth p~ychalogy pidneets is David. B. reperts,ts
Chamberlain, Ph.:'D., a California.-based clinical
psycho.logi~t. author of numerous .p ublications, This prese nt author cah attest to witnessirtg
on~ of the founders and past president ofAPPAH instances when rebellious arttisoc.Ud adolescents,
:{Association for Pre- and-Perinatal Psycholog y artd who were induced by hypnosis to regress .t o early
Health). presenL'y serving in the editorial :boa;rd pretratal life, would have clear recollection of
of the AssQciation joumat and: fQund.ing .editor -of. exi>eriencing prenatal trauma.. like repeated
~lrthpsychology:eom (the APPAH 'gateway tothe attempt~ at abortion by their own parents.
. . . . .
Internet). Dr. Chamberlain,' 1n S\l.mll;la riZing his .
.,
pioneering work and: that of his like~mirided . .. . Ttte third source of evidence; ~ost compelling
coUeagties, has identified three m a in sources of of all, was derived from recent experiments and

Seanned lly: c
', 1
CHAPTER 8: PSYCHOLOGY OF PREGNANCY
--------~----------"-------,---~------..
scientific observations u t ilizing breakthrough
technolpgie s . They deal with. three areas of
investigation, pamely: prenatal dev'elopment of
physicil.sen.ses; ~y movements on ultrasound;
and mOdem kaming experinlentsY
Early Development -? fthe P~ysical Senses
Prenatal ability for Sensation .and -perception
of s'timuli.starts with 'the i:i:p~ce ofthe speCial
organs of sensation which has been determ~~
by numerous investigators to occur at ~he
following weeks of gestation: fGr touch (7-12
ween); pai!('{l2 weekS); ta:ste a.:nd smell (14
w.eekS); heariJ:ig {1.~24wee~s); sight; even with
eyelids .fused H~26weeks}. ia
Body. Mov~ent~ Viewed In-~teto Usmg
fJl.trasound
: J?re~t~:l ability to' m~nifest . reic tion or
re-@n~.t~ -stiinulation U.nde;r dir:ect vieWing has
~ :made possible 'by utilizing recent advances
in~~uhd technology. Graceful, spontail.eous
and .p~~-(ul vol.JIDia...""j IDC?V~m!!pts have been'
n~,~gat 8--low~ks: gesta.tion. ..A cbmplete
. :r4ixiQ1ie~:of bod,y lrol.guage hhs. ~n obseived
-~)0::12 w:eelq! upward whic~l'grants theability:
forJ.~-eX:PressiOn 'df person~ty, as exemplified
by: con~oUSAess of danger. and self-defense like
s:t:ri'lPng o~. avoi~g an amniccentesis needle or
an ~a-ggrcs stve :tWin; distinct reactions to
ci:intrestmg ,sfim.Uli,li:Re louanoise'or soffinuslc",
o~gbt .O! oiffi)lgat;;: ~~for.: oit.ter-fiiS1ecfaiiiruoti~
fluid. due :t o .~other's diet; preference for gentle
matet:nal motion against sudden jolting
m~:veme~ts. an.d so on. 13
.Mode~ ~g EXperiments
...
Mo9em learning experiments show a wide
range of fetallearclng abilitit;s, _like: recognltion
of mu_sical passages-; l a nguage. o.cqti.i s ition
demonstrated by, reaction -~0 m other's voice, and
l~arning mothers native tongue by l)l.j.micking her
rhythm and int,6n~t,ion shown .on spectrographic
. analysis postpartUm; and h~ter confirm_ation of
early. prenatal' experiences a.n,d remembrance of
bir.th.e vents'. 18
After reviewing .the above information, the
pracP,cing .Q_b stetrician would perhaps be'ready to
believe that the upborn child is a sentient human
bei.I).g, and to agree with the conclus ion that, "The
Scanned By:
131
:::.
ran~e of evidence now avc:)ll~ble in t he fg.rm of
knowledge.ofthe,fetal system, observations offetal
behavior in the womb; and eXperimental proof of
learning and memory- allof this evidence verifies
what some mothe~ and fathers had senscl from
time immemorial, that .a baby is real perso-q: ta
'Pr,~na.t::.l . b.evc;l<:>pment from. a Pers_ona.l
VIewpoint
. 'The -inter ested reader is now mvi ted to review
the earliest prenatal biologic changes augmented
by the p~ychological and psychic- spiritUal
dimensions. :A3 a guide, i..\e reader may ~fe_,r. to
any-standard.te:xt.book of Opstetrics like the recent
edition .:o f the Philippine.'Textbock o( Obs tetrics.'20
lnor_der to acquh:e a new .p er'spective and
to d.e,ep_ly
apprecia te the 'f ullness of e~1Y Pt:enatallife, ycu,
the r ea:der,-. may s tretCh your imagination, 14e!l.tify.
~fu th~.deyelopmg con~eptti.s and go .f urOlfg}i ~
sim.iliir experi~ce- vicariously. You migb.t ,~yen .
enjoy itt ........
. . . . . . . . . . . .. -:-'__:_:~ ..~~~;. . .
As a.$rt, ima~e. the ~t-~w~~~~~ ?..~~- .
.a ne1'7 su;rgle-celled liY!J;lg prgarusm.- a,zygo~~ou
wonder ~t .th.e strge of creative powerwit:lllQ... a s .
.you. imm.edia~:dy .g row-. and multiply..:in ~n.~
to.the:drivin.g'force
. of.your.heredit<hY.;en;:i<)'wm~~t-
. ' .. ...
Wlth the s-u'pport. of your mothers.Jissuemllieu.'.
)~ ~ ~'
.. t,~ \.~ '.Jif IJ
...
You witness a rapid transformation in:to~a 2~lled.,
4-<:elled., 8-celled., l~elled. orgo.r.ism, ~s:o. on
evchfi~.ally be&rillr:ig a. I~rlllti.:C'elluliir f~~.i; , '
YC"u:-begffi"Yoiir :rou.m-ey-.through.. metn ili:e
tubal passage. of your mother. As your c ells
mul.tiply,_you fl pat alpng ~e n~ringtubalfluid,
gently propciled by the wav_elike m otion of tub8.1
epithelial -.c ilia towards the ut~ri~e cayity where
you a:rrive on-the third dayc;.s a 16-ceu soUd ball,
-~morUla. A!J .a morula \vifuin the immense uterine
cavity! you feel like a spaceship lost.in space.'
Aw.are of possessing a limited food supply, an
urgent sens e: of self-.p reservation impelS ~you to
seek a hospitable haven ~pable of sustaining life.
hi. res,ponse t o -some -inner prompting, you
embark on a purposeful structural re-or.iarllzati<;>n.
'Nithin. the next' 4-5 days , yo.u convert intO a hollow
fluid- filled s phere, a blastOcyst, >vith.an outer shell
of trophoblast and an inner cell ~-jls . The
trophoblas t is de stin~d to form a placeata while
the inner cell mass would become the erX{,P.ryq. and
the extra:-embryonic tissues. YouenEiow your
tro phob lastic cells with ad hesive,. invasi~e ,
~
132 SECTION 1: BASIC CONCEPTSOF HUMAN REPRODUCTION

proteolytic and hemophilic properties necessary notochoFdal process. At this point~ you have the
for implantation into the prepar-ed endometrium. building materials needed to. construct the
physical .edifice.:of a human bemg. The ectoderm
Qri the Sib to :t he 6u. day, you give the .g o-signal will give ri!)e to the nervous system, the skin
for implantation. the sutrou..11ding :rona pellucida
-.:
including its appendages and the special organs
i~ removed and the blastocyst a~..acbes to a 6hOSen of sensation; the endoderm will form the gastro-
-landing spot on the endometrium, _.u $ually at "the intestine! tract structures, and from the mesoderm
midportion of the 1.1terlne fundus. bnplantation Will arise au other tissues,and organ systems. The .
.begins .on the 71b day after (:Onception. Primitive notOChord. a nidm~ t~.romiu which the vertebr&l
ch.b r ionic villi begin to form from the outer oolrunn an,d base of the ~kull develops, will~
tro:Phobb.$tiCcdlJayer. tbe$C ~ ccl}s_.m~g as the cr.anjo,.:~~ud'al axis of embryonie
in.humber, continue. in their Uiwsi~ ad~ance . developme-nt.
d~per mto ctld()metrial territoryUntil ~ntact i~ .
maa~ cwith -matem~ blOOd ves~$. - l3y '~! D:~ri~g the ~ext 4 weeks of your npid
the ~e!ls1-WtUls :sOme matemalblOo.d ~~into oembryotii~ evolution, you demonstrate rematbb1e
eJttJ"ava$cuJ.ar ~Pe.ces, ;fcirmlngblpbd,.fillt(l:la6;mae virtuosiey in undergoing (\ramaU:c sequential
or ~es<in whieh tl).e primitive~ are (Uspersed changes "in form and funcUoti~ from a. flat
~~~them tOobt;ab,.:nutiie.nt:a :{()r'tt'i;U1t~rt :tO -e mbryonic disc. -to a straight n~ural tUbe fonrtation
the m:ner~ . ~ass wnieh -l$ in .th.e pt~ of stag~ tg an -elongated soinites ela)>omtion ~.
tt~~fonrung into an embryo.1'hc:: .hl~.,:filled . . to a final C-shaped cuiv~t! fotm With attachedmm
lacunae:furiherCQ81e-see into ~ intet~v.illous - .and JitnJ:>.b~d.~. i). pulsating, .e bty,Qmc heart and
~Pt.\~.:kWhile,.th~-:p.riDUti.e_ ~.:cntfete~~~ -~~ -, a _ fu,l ly_~~tiated ~bUi.~ wt.d. ' Then in~
tbeiiefiiiifr~;pla~tal~.;!f"nu!fi.l~.i~-.:- .P*t..li;:;_m~~~,Y.0.\1 J~~ "$~ .~n .ot-&ll tl;le:
p~$t;~you:bl;lv:ci:~~~~~rith -: -:~tt;~tU.~e.l "4e"$ led . .~o 'h~::,:pt~~~:rit af'birtii~ .
~o:tir.-c!; df tltJtcitivf! sup:port-)';onr~~Q.th~t.'s; foHowini ll dl!.f itl:lte n~e sequene:e : fof the.
~l;Oatoty .-~tem. Atisb~ y.pu rt9w ~Q\inqe, t'!i . appear-~ee ~a;n.<l ,9itrere~ti~_don: .o_ r _e~h 1).-pn .
~<~"J'tied~~soltl< -"a.i:t198.1:.=by,.~~@D\\:.:cst~o~ _ :aya~~~. .By ~l_i~ :eii4::9f ~h,t : 1:lt)l .. ~-1( aft~r .
p~rltaf. gon~d(;)ti'<>pbie ~.1\~ni:ton(t,,Jlie~g~r~ 1 .. '.fe~tf:~n,. 'P.JlY9P.,r,~d~rp'ent\aity' organ ~$' '
cfrCU]atblg~m:t}i~;l.lia~~~!.;bldod.l.~~:,:,: .;'. -~: . ' . are m .p}4~_. 8.I)d:~tio~: :Ttie ~tribty(),~ :Of : '
ot.ga:no.gene$is is oomplete..
As agrpw.ing t:On~pws ., you~~~~$bed.
~ci m8mtai~d -;a-iiieamngf"Ul~~~e-mlibJtsbip-with Of.-utmost-ltnp<>r-tance.-to.:re~ J>syc;h()togy
yolir mot'her.-- vou-hi.ve :oomm\UlJ~ea- wiUt- -ner comi:ng-fr.Qn.t; ~~."bty9genesis .- i!l--the :. development
in.;'$()zne non-Y.etbal intuitive Ifia.I;Uler -a nd abe has .of -the _physical.phys"iolqgic ba$i s o'f .human
fttitiured :you all along>asjtQU _made Y.OUr 'Vlay conitnunlcatio.p: the -special organs of sensa~
through her tubal passages, .u~e <:4Vity at}d and per~epti'on the . n 'e r\ro'us . systetn for
endotiletrlalnrtil)g~ Shebas :allc-N.ed yow:-il\vasive transtiii$siori, evalu~tion. integration, and s~e
tt~phobt~st~ to :br-ea~ .her _ clo$eCil ,cir~latory of .infpn:nauon; and the m~eh~sm::J fot motor,
$YStem ata-tettrun $pot; wJ;i{le at the ~e .ttme .secretor;~ and ling>.1:i stic eXptes$ioil bC inc:fuidual
sh~(has erected an itn~~tr;a;ble. w$1J;. $.0l4'ld th behavioral -r espanses. Aside from the intuitive or
itnplantati<m 'Site~ thUS lin'liti~.{~ your essentially psychic )node of .communication you are now
_para$itic ~ctiviQes to a weU~de(in:ed a,rea. She w.iU capaQJe ~?f interacting with your m~>ther ~d
cb.nd.inle -harbo):ing and s:Upporting .you llntil .s ignifiqmt others in the us~al manner. You can
childbirth and the post-natalperiod. sense; feel, listen, smell; taste. see light. mo-ve
voluritafily. _learn i:$d r~$ember, just like any
Assured.oftnatemal support, you proceed with other:sentient human being. Thru1ks to the latest
yo~ developmental plan. ~y the 21>4 week ~;liter advance$ in medical technology, y(lur intra-
fertm,zatio'n, the inner cell mas!J has differentiated uterine l;>~havior can be detected; .monitpred~
. into a two-layered elise {bilamlnar embryo .With recorded and evaluated, which will Setve as a :guide
. ectoderm 1ind endoderml-with rudirne ntary to person~ .c;oncemed with you a nd yow motheJi'S
:a nuiiotic.Quid cavity and -a.dill'erentiate&body stalk welfare during the prenatal period..
(future umbilical cord) . . By th~ . third week,,Ule
ein~bryonic disc has acquir~d .a :third laver, the During. the
remaiping 2ri4 artd 3r4 trirneste~s of
mesoderm, forming a tri-laminar embryo with a the prenatal period, your time is dedi.c ated towards

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 I
CHAPTER 8: PSYCHOLOGY OF PREGNANCY
f\l.rther development and maturation of all your
organ systems which will enable you to c ope with
the rigors of birth and the .s truggle for existence
in an extra-uterine. environment. When that time
eomes, you are expected to sigi)~ your successful
arrival by taking a <Jeep breath -of satisfaction and
then emitting, .as loud as possible, your first cry
at birth- the.,ictory cry of a true champion!
This is the end of the section . on prenatal
development from a personal viewpoint. It is
hoped that the reader, after experienCing
~ouly the above events._would have acq"\lired
a newperspeetiva e.nd a d~p. appteciation of the
genuine hullUUlity offetal life.
THE PATERNAL ROLF;
Pregnancy is th~. cooperative. project of a
couple, a man and a wotnan. joirit,ly undertaken .
fr<m;~. ~~ jni~tion through its.gx:c>wth, development
ari,d -li:Ul,tiici"uon and successful ~lmihation in a
h~:Al.Y J;llc;>~er and a healthy childsharing with
a ba:ppy rather in the fortnatlon of agroviingJamily.
Botli partnerS ~e jointly responsible fc~ carrying-
o~t tb,~,P.f-9Ject with the.woman playi.~g the major
ow.t~inQ.l Mie whiJe the man plays ~e lesser fulftllrnent from. children..s a~cc;>J;J;i~US!w~nts;
.surindfti'v.ematemal
...~~\~-.:. :.; ~b . ,: . . .
role.
.- . .
Although he is not subject to the physical
buclen bnposed on women, the man is obliged to
pro~:jiuVide"for.and.s~pport the woman in their
jO"iln-talitc or pef?et'Uiitinfllie-nu'man specfes.-
Acc of'ai!f((to- a ~gro\ip of' num'iiii' sex\i"a1Hy
profe8Sionrus, Inability to experle:nce pregnancy
does not eXclude .the faQler's partiCipation. The
nians inv'olvement will be higtuy individualiZed
depending in part en his self-j>erceptionof his role
.as father. log
A popular authoritative textbook on Psychiatry
recom.tllends, fuat due to pregnancy, a couple
nee<\ to redefme their roles of husband and wife
to that of father and mother; to a dju s t their
relaponship With friends and relatives; arid to deal
witb new r~sponsibiliUes as caretakers to the
newborn and to each other."3
Motivation for Pregnancy
Ideally, tl}.e decision for parenthood must be
agreed upori before i.ts initlatiori, . aJ least by
implication if not explicitly expre ssed . The
motivation to b ecome parents , is infh,tenced by
Scanned 8y:
'1 33
two sources: the cultural value system ind the
personal value system.
Cultural influences may include: the common
view that pregnancy is an extension of the Self.
as an avenue to inunortality; the sense of moral
or religious duty; to have children; parental
pressure; peer pressure; and Other .sc...-io-<:'.lltural
factors. 9 "'
Self-~rving .e lements in the decision .include
tra,ditional expectations: that children will provide
companionship and support for ~ ]larenta;
that they will maintain a family busiuess Or-term;
t.llat having children is the sociaJ norm.21
Personal value$ are crucialiy important. these
may _include: the wish to experi~ce the
eJ~Ccitement _ and wonder of witnus~g and
parJcips.ting'in a baby's birt..h and dtv'eiopn:)ent.
to a:n' autonomous adult; the :perception.:tliat .
children ere so1,uces of d_eli~t~ . joy~1\nd .
imineasumble e:uichn~ent; 'an urge t!i:}xo;eiiiility
or fertility; as a means to fix-up a .rdaQor#.lifP?..
. . . : : - =-:;; ~ -- T~.
Other .personal. eXpectations ..rn.entioDed ,.~:
. satisfaction.Jrom-:seeing them: ~ni~~i-arici"
enjoyment from forging a cloSe bond; witlt;:t:heir
youngsters.21
. - . . ....Psych~logical
Paternal .. . -- '.
Adjustment
.. .. .. .. .. . .----... ---"' .. -..
. ._
Faihere.. ~un<le~go pror~1i~d p~ycbo~~~~~
ch:mges which panillel the mothers reaction .to
pregnancy, following the d'ifferent stages of
gestation; before, during arid after birth.
1st Trimester J>ater-ncl Ad}ustm.eni
. .
Men are often ambivalent '-lpon learning about
the pregnancy. Th<::ir initial ~ctioil of surprise;
elation c;mdjoy may be replaced by uncertainty or
concem. They may manifest physical signs of
anxiety about the wife's well-being and the
developing .baby's health. They may be worned
about additional financial and emotional
responsibilities. About one-fourth (23o/o) of fathers.
may e~hibit the "couvade syndrome"', where
husbands experience physical sympto~-related
to their Wives pregnancy, not explain~ other
medic~l factors: As a!} example, arious
"morning sickness" is perhaps a sign of anxiety
cr a vrish to share in the pregnancy experiencel 22
~
 134 SECTION t: 8AS1C CONCEPtS OF HUMAN REPRODl:.lCTH)N

J2"d Trimester-Paternal Adjustment In.trapa:rt:t.im Patem.al Acijustment .

At this time, fathers are .more likely to be drawn The onset of labor can be a time of confused,
more closely to th~ experie~ce .of pregnancy.. Tb.e frantic acti.Vityfo.r m;m.y unpr-epa:red,couples.. Most
ability tO -see olrvious changesin.-Ais ~er'alxxiy. of the hassle can -be eliminated by ad~uate
_gratlu,ally, giv.e s him time to adjust. ..Feel.U:tg _the p~para~(m, ;rehear-Sal and simple instruction o~
baby,-ldck or. turn gi,ves a greater s ense of eon.~t the evidence.of true labor to w~.tCh -out :(or and
and proof of the ba:Oy's eXist;nce. Father--child the timing .o f adll?lssion to the hO?pital SU.pplied
pr-enatal bonding $ay ~ started. His patillei's by the obstetrician ~r other birth attendant..,..
renewed energy is reassurihg. gives fu.e couple
mbte.tim.e together fur a p leasant inte'd.u~ bef~te Unless -h ome d~liv.ery is planned. the f~1fher is
the ~oil.of.ad~ced -pregnancy-an<;I$Qdpitth. usu~y:eneoliraged to be prestnt:in the iabQr room
:Earlier arudeti~ a,OOut the ~by~s t~gilit;y .er.e arid St_ltnefunes in th~ .del.ivezy room. depe:n.Qing
g:ben.illY p~t t~ rest.22 on. hcspiW. policy. . Hi3 pte~~ :~s ~
for the 1ciJUoW:ing reasan~; ~~that .h'e~cati..~ in
Measures -to tdieve mnch -yf :ili .m.ystetf and the bJrth e;xper-ie:nl;;e, 'so that he giv.e
fear.Qf cliildlfu:th~Y be availed of l~y .fu1:-c:O~ple encouragement at:i,d s~port; .and~ so that he can
at this time. in addition to-~urate i!lforJ:Qation help ~e the ~tient col:Qfortable.~ .
~btalfi~ from ~rea,dit)._g8 'fr!ld ftom. ~scu~ ~
'~ -~e piijtSician; .the tX?liplt cbl,itd .ii' tfend ti:>g~er. Post .P~m. _ i>atet:U.U A-~jt..t.Stmeht
. child:.o.ii;th c~ dffei-:ed. 1n sotil~ hbsp~tals --and . .
.
~~it Jhe:::cl.Pl<,l~~,.~~fl:f.atiMt .::P~~. Th~ -~~:~Jl;l,:t>1~~. :i~ .~ time of:i,Ipti an.d
- offe~~ip., ~:lQca:f:~osp1W,;;is.1!l~~~~-.Qt.>.... do:wp.s,.~e~~e"Q.~~J\1lsU;ati..im~- ii:Qd.jey-; It :.
:ie~ to . :the-~p~~P.t. ,,ifi:s<::~~i<?n:;A~i~e).. is aisc>. : a ~iitriefot- ma:kmi::~y._.-psy4b;~gieal.
o~ -fonuD; o# .the :R.b1e otTailfex- - ~d Ja:inil.f in adju~tzn~p.ts:f-or the ~~.'f~t:th~-r.: .. .
. y~cy" is -~eluded ,in tQ P.~~ . . :
. . . _. l~--~a.'dffitf~n~ :t<> tn~!>It}'s~al adJustinentS.
-~.-3-i~P~A.d.~t:- -~ .' =:, requir-ed.-.m'~~vecy~:f't:Oma:~ -~:tb:e'
nioiliei:,must .at~ ~ake. si~t; psjcilO~
At this period of the wif~~ pro~~gjJhy~~ change_s;t~ether-witli-~h\1.~~ - ~
discomfort and inco:asl;ng 'depende~cy 'il~ '~ c}l~gM. , r~qltix;ed. :()I -~~J1i- -.p~ren.ta: :4.1-q_lu~~: .
'husbani:l-Df:ten..- e:iq)eiiell.ces...:a._cci:fte$~p-aing. .~jJi.~rlii~nUQia:R~-~:i!tfu!stiD:ex!t,b~til;.
ln.crease-:in-the,feeling" of..;belli.g:...w~~and-u,~ . role~-and.:,new-re~ponsil.>ili?.es;.~~:.iP..:(<I.n.WY
...a.jp.~tification .o f his role pf P.r.Ovi4e:r_.and;p~r. re~atio;~~Ai;,s; loo;tdpg :ah~_~ii f9r t;he rutu,re.
a.
M9st :m_en;feel strp.ng sense of,lo~ty.~ss .Adjusti,n.g: .to paiei\t4o9d i:s .not easy; Wi$. its
and::gratimd-e :tow~ th~ir-.v~cy p~gnant.1~er;. restris:tJo11 . pn :.rr.i~aom, . priv~~Y .an.d,se'lf-
Th.ey ~re u:Su~l.Jl:Y .gl~d n-ot to' b~ ,p itrtn aut indu~g.en,ce. Paxeti;t~ .n:e~ time to gain ,a .Qew
themselves and are con~erned about rp.~g :t heir per:s~ve aP9. ~;ti.~pt ~e teitr .'tlul.t ?ooooy
]J.a,rlr~er cpmfc~...able.22 can a.chleve ,Py t.OO?/o 1 :the st:S:tus o f !!. peifed
parent.~
on. the negative side, .t:P.e.3r:! ttifnt!:Ster ~Y -~
a .time -of tribulation te the lli:cile :partn::r~. His The fl.r:st dttys..aft;d:d e)iverr 'C?l;l_play ~:.CritiCal
partn'er's tha.J?:ging sh~pe arid physical. :di.5comlo~ role in the <ievelo.pnient -of an emotional link
-~Y lead to Jos~ of his se..m al.desire 'for her-bt.hi'S betwe-e n..p~ent and c~d, dilled ~<patent-child
continued interest may not be .matchect: 'bj.h~t8. bonding". fu.ysic~lcontact. cuddlihg, .cooing and
Some:. men may.e ven see k out e~~mariqli' sex.:i2 eye ~ilntact iri ;this pt!riod -or'.the infa:nt~s "iife h as a
Th.~ hu.sband -may_f eel "le:ft-ouf wh~ the -..yi:fe major impa~t on t:l).:e .chitd's -~ter behavior arid
~m~-s cicser to her mother_, ~el4ug:~v.ice ~d psychological heaJth~n .Some' bonding, initiated
speFlqing ;~ore time together. And. -the W.ife'.s during the prenatal :p erlqi in~y facilitate definitive.
profe~sional .~lationsh.ip wi~ her phy~icla,n~Y .p ost-natal parent-child .b onding.
'also be a sou~ of feeling left--out. Alteration i.h
;attendirig . s'o cial .events,. recreat~on ,and ..~t...;.er Resumpt~on of mari.tal s~x-relations ~s an
~etails. :Of ~v_eiy day livmg mar.vrov.~ :sties~ful?? .individualmatter with its exact:timi.b,g,:in:fluenced

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~

--------~------~------------------------~~--~---------------------------
by: the rate -of involution and restoration of
puerperal genital .structures; medica,! factors like
persistent bleeding and fatiguei and piychological
. considerations like post-pa,rtum depression. It
should be noted that by 34 weeks post-'partum,
most~omen find their sexual .desire retuming and
can comfortably resum-e .ae:xual activity. "In cases
w~?re .1nterc6urse is still unc.omfortable,
alternative means of sexual expression may be
used UJitit full recovery ta},<:es place. Jr2:l
THE :R,)tE OF THE BNVIRONMENT
'Theenvironment is an ~s$ential feature of
human' behavior, for it is that. to which h:uman
beingS respond to. The environment composed Df
nat:u.ral ~d cultural nian:-rila:de components may
e~a 4ired i.niluence on parental heha:\.ior,
wbi~may:in tti.m, a!fectfetal behavi~:>r. However,
environmental factors often: induce beh-avioral
res_ponses without the ilidividuais co~~dous
a~n~s~f.r volition iio'r delibetate .choice. .
0 .. ~
=-4.
.
Na~til~on.ilienW Factors
4~~-'Fqerm;il Age
... I .. . . . . J ~
. , ."?ottt~:'g~pphysieal fQ.rGes ~n~ ;_n~t~ral : po~~~ti()n I?':-Y -~:-unintenqec~:yet,~~ye:.~ro,I~:W,l4
' P.~:~g uP-on the weli-bd.n:g of mankind
m :genernl, wme have a direct bearing on maternal
andfetal health~ One that may be m entioned is
:a4van$i ~nW.. age. . -
..\. ...,:.. .! : " .. . . . ..
:A-gi:n:g;~~evi~bi:e--rr~turalpr6C<!ifs,-ma.ytrav.e
.deleterious. effects o n the fetus, wh~n pregnancy
occurs towards 'the end of a woman's reproductiv~
period. Advanced: matemal.age increases the risk
of having a live box:n infant with a uto$.<;>mal
trisomies21,18, or 13, orwith thesexchrom:>ome
an'e uploides 47 XXY or 47XXX. Genetic . pills; food and dairy products ; pesticides and
counseling is offered when a woman will. be 35
years
.. -or older as of her estimated delivery
. date.:24
Advancin-g pa ter.nal age may also affect
pregnancy outcome, altho~gh effects on genetic
disease rare are less completely understood .
:rhere is gen:etal agr eern.ent tP,at .advancing
paternal age predisposes the fetus to mutations
in autosomal dominant P.iseases such as
neutofit>omato's is, achondroplasia, Ap~rt
syndrome and Marfan .synd:i:-tJ~e.~
The "grandfather effect", a-phenomenon found. damage was done d':lflng the, prenatal PeriOd :when
with incr~sing patemal .ag~. ~~Y be ass oq.ated
CHAPTER 8:-PSYCHOLOGY;OF PREGNANCY - 135
"""-
with mutations in X-.linked gene~ th:at ,are
to
transmitted through carrier daughters affected
gtandsons. Examples include hemophilia A :and
Duchenne mus8u~ar dystrophy. Howevei;", t4e
exact risk for any. specific disorder is small; ;and
counseling on an individual basis is
r-ecommended for couples if advancing paternal
2~
age 1s .an 1ssue. .
Cultu.ra! Man-Made E.tivfrorunental Facto~
. Man-made ~dvance~ in modem civiUzation.
-
~- cultural _practkes, myths of sodety, and the
subculture into which both paien:tswer.e bom
exercise a major influence on par~ntal-~vior
a.."ld fetal viell-being.
.Environment-al Pollutants
.. Unhealthy .featUr'eS of the 'mo'dern .
environment reach people tho(ough,.JJ:le ,
atm.9sphere, ..foo<i crops and tp.e wa~er ~~ERi?.it.; .
through chemicals fqr medical tr~tiJ).'en~mia
d iagnostic -purposes. All of ' t;hese~.thi:'flte.ii
r~pr9d~ctive health and the wen-befu'g. oFilie: .
.chil;a..It s,houlci be not_ed. however: tha(parent$:
effects 0~ their. offs'p!hJ.g. . . . .,;':::~,:-. .,
........
.., . ' ..;...\"';;.'
;.,-;
.
The most recent threat to reprodt;J.ctive.li.duth
is
t~~ .a:ctugult~tlqn ()l abnortn.aify' 'liigb. .
!X>'n~trattotts-;.o'f"e""sttog~t:ric"':-"compo'Un~s.m.-t:lle
p:0.1JliC"'en:vlron:men r:TJ,i:ese ..~cotnpo.uni:Is . m~:Y
produ(;e serious eff-ects on human semality~
fertility; speri:n morphology and.S-einen:pl"'4uctio:I.l
~d.may contribute to. caneer of the .Sexuai organs.
Sourc,es of estrogenic co:mpounds.. inclu!le:
prescriptions of syn-etic estrqgens; contraCeptive
pollutants .in air, food and water:; estrogetl3 in
detergents; coating of cans, bottle tops and water
pipes.25
In a study of fou~-year-olds who were exposed
prenatally to the environmental toxin.
"polychlorinated biphenylsn [PCB), .tests of their
cognitive abilities in visual discrimi.p:ation and
short term memory, revealed lessened ~fficiency.
Greater postnatal exposure via,. brea.St milk than
4
in prenatal placental transfer was unrelated to
cognitive ,performance. This indi~ted that th~
the brain is unde~ constructio_n,u
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 136 .SECTION 1: BASIC CONCEPTS.OF HUMAN REPRODUCTION

;);::

Paternal Occupation During Conception unintended pregnancy, communication barriers,

.Paternal occupation. at the tiine of conception
was found related v.q th the risks of p irlh defects
1n the offspring in a recentstudy of6;000 .father$.
Occupation~ a.~sociated with numerous types bf
'b irth defecti'inclucie; printers, for gau.:blad.der and
liver anomalies probably due to exposur~ to lead
and sol~ents; foo(l proces~rs for'braln. anomalies
like hydrocephalus and niere><:eph?lu;J pro~bly
due pesticides or pr-eservatives.; .electronic
-equipnr~~t <lpetators for a.:rm ~nd ~pln~
.defotmlties du~ to .~sui"e to eleetrom..ngn~tic
'(t~ds ~d ya(iio,-frequency radiat?o~ ~d vehicle
m1.nuf~cturer!l, po~itively identi.:fie<J_ with 10
defects, esp&ially anencephal':ls.; . r~ctum and
anus deformities and deft lips, ws:Sibly due to
:exposure to solVents and :m~t:als.n
P.sYdwsoCia.!Risic.Fcctor:s
. ... . . :
~;
nutrition, tob.acco US;e, substanee u~, d~preSsion,.
safety,
.
intimate partner viole!lce.
.
and
f
stress..~
Obstetricians concerned w ith psy~ological
problem~ in pregnancy .should identify ~en
under stress (state or condition of strain whither
phy~ical or psy'chologica,l). s tress 'associatcl wifu
pr~gnancy itself, COI.fCer:ns. about lB:oo:r ~d
deliv.ery and fears abbut pare~thood .are .ofteti .
reduced by couns~ling, in~truction and social
support during t'}ie :cotir-seof prenatal:care:. 4Ck
of support. which refers to the.rewurces and aid
fr()m social relationships,. .fui.3 J>een ~ted G
with motbidi~ and .mo~ty. A pasitive'effct cf
~'upp.ort may be . of. :neuroen~o.~Ii.':l.e or
neuro4Imune in .pri~. :r11e "'Quffering e{fecfo 9f
sOcial. ~uppvrt may be ther~sllit of an in~
of hea:lth-Jlt'O~oting behavior.s' PT a tlect;'iaSe in .
risk
.
behaVior
....... . or .b. o~,.

. .. .;P..~cli~:~s~~~~:1fr:wpme~ and-1heir SUMM:AaY ~ CO~CWS.IC?N

.... ~farilli.ies"<iciiligfu:e;cl:l:ild~:~:Yea:r.s:,ate:tiienon.-. . "
bi9,lct;~~ctoi:s:that:ttif~~ incii~r~~d:;pb:ysidl. . . . . The vario.u s ; r:ole~ !J'layed.; qy~.t.4e. -:.x;uiin . :
~;.~g--: .~riing:f9T: pcyhc8&$U 'r i.skfat:Ors. . participantsm . the :cl.i:a.D:ia~ofliumari p~cy m:.
h~:P.~a. ~o~~~.~~t,i~~~~s~ .t'o ~~ desoibed with empP:asis ,on.t4e .psy~ok>gicai
~:~tt~'p~t.~H~ ;"Clf:-P'r.ep.f,l.'~{s:ci::Vjces. ;ft;l . aspects.:D~sc;uss~d :oin scin~ detail. are:.t!J.e .
h-ealth/status ofheroffsPJ-iifg::IS. mateinal~iob; t4e f~tal rote;;th~.~terila{r61e:and.
-the .roie of ;fue. ~tqn~ll' ~d :cuitubi;::n:.n;mri.ciaii
.A n impoi+..ant port,i~~n of' ~ses of adverse
p~g'~u~m.estiot'qu~to.bi<:llrieprc~;ilfaetors . it:is hoped.th~~ this ~~ion .~l ');~~-the
:{re.~'p_i:>'nsible~i"or":o.n6-"haif. of. cases) ...may. -be. o bs tetrician-U:nderstand...ana...appftcif!.t~: ..Jh~
'i.:tttributable"':txrp:sycho~~-str:css~'~.t.fany Of the psychology. of.p;-~gnailcy:a.ni:Lfurther_cn.hao(:e.the
.psychosoda.J.':is~\}.es that mcrease .the risk oi guid'l:l,::i).ce-co~:m.seli:t:lg funtio.ns pF~sc:,ntly
p1egnartcy .als<) affect 't}le :heru.th and w.elfare of un.d ertake.n; .cohsd.ously or ofue~, in dinicaJ
the . ~~wb<>rn. Icknti'fi.cat:lon._.of <signiflfip-t pr.a:c:tice - g~ar::td . to~*rds pr.:o:moting and
p~ytho.soci'al risk Jacfors sho-q1i1 include main~g physiGal, mental '!ll<i ~.irj~al weU-
assessm~Iitof: . qa:rri:er.s 'to ~e. unstablehousmg, being.of mothers and fueii: inf<mts.
: .

POINTS TO REMEMBER

The obstetridan.is also .apractiealpsycholog.ist who provides guidance and GQuilseling to a

pregnant woman and her family.

The :CbstetriGian shoutda.tso:be aware of the patient's main concerns about her pregnancy,
namely: the':sensatibns an.a .(:;fianges in'her body.; her'current thoughts and feelings; fjnd 'the
me<ming :and 'value:of,h.~r ~rdition to ~erse lf and to othe.rs, i.e., .the physical, p,sychological
and -spiiitual -dimensions. of her personality. t

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~
 CHAPTER 8: PSYCHOLOGY OF PREGNANCY

'Human behavior which manifests ar)d represents the intangible human mind is qbservable,.
measurable and explainable; and is used by psychologists and psychiatrists in handling their
patients. The obstetrician, as a physician used to objectlve.signs and symptoms, can do the
same, 'fetl competent.and :adequate in dealing with psycholo9y of pregnancy.

The mother's .attitudes towards pre9n?ncy .a re of crucial importance because they determine
maternal behavior. a~d influenCe the course of pregnancy.

The rn9ther's behavioral responses to pregnancy, representing her emotional and intellectual
adjustments, varx am6ng differ.ent women .and change accorditlg to the stage .of pregnancy.

Fathers may also undergo profound psythOiogical chang~wt:Jictrparailel the mother's reactions
fo1iowih9 -tOO -different stages cf. geSta~n before, during :and after birth.

Certain 3.spects of parental behavior, n otably that of li--te mother, both before and after conception
can affect the fetUs, producing life-long consequences: Certain behaviors produce -adverse
effectS, oth_
e rs .are indifferent. While -some have positive effects on fetal welfar-e:

Theenvlronment, whether natura! or ctiliural marH'nade_. may-jnfluence diracti]i'parental behaVior

.. . an!findirect!_y, fetalbehaVior. However, .environmentat.factois'oiien in.puce behaviorafres_ponses
-without the 1ndjviduar.s cpnscious awareness r.or -deliberate:choiCe. - .; !i,; . ::;~~3,;f.
.. . :. . . ,...;:..._-::.{\

At present, new information is avBilable Whi:;h indicates that the developing conc~tui.:.~om the:~~~:
. start,. as .a ::ane-celled :zygot8; until birth as a rn ulti~llular neonat~ .jsa ser.~ent human be~g.-;:;.1.' " . . .-
......
'f .
~:. . ~e~itiYe,~p.ffiv~ an_d!.pffected by !ts birth eXJ)eriel)ce. -The new evldence.comes.frorripe:rsonal
. ~~r--.:- . r eportsconttlbuted by parents: r.evel_ a,tions -a rising from ,the therapeutic wqrk. (:.~~i~~~}..~-i
, '---..
.. "'" ~.:.:- pr0fe5$ionals;.and re6.mt.-5cientifrc observ'atioos .utilizing brea'kthrough te9hn016_Qie.s.:: . ;.:!. . . -.~.;::..{-:: -~
:. !!..;:~t. . :.. ,-;
This nev/eVldence:urg~ the 'coos2ientious obStetrician to agr.ee wTth the r%Qmmen9ation.of an:.~_
emif1ent-rnoral theolOgian, "-One myst ?!ways treat a)iyjOg fertilized bvum as a human person.~:
- ____
wnateyetits s1age ofoevelopri')ent..with all the rights .o f 'a human being::
..-............... ... _.---- ------- __.., ........ . _ _.. ---- .
-~- ~ , ~ . - ~ -- ....
~... .... .. .. .. .
-
-

. 5.-American.~llege of Oqstcricians and Gynec6lot:ist3.

' 1. EsguerraAB. Pcyology Ofpre~cy~.Ifi: Sumpaico
WS, Villanuev.a-Guticrrez R, Pagtakhan-Luna L, Negre-
Pareja M, Ramos MM Jr., Baja-Panlilio H (eds):
Textbook of Obstetrics. 2"" ed.Quezon City: A.:;~ation
of Writers of Philippine Te:ctbooks of Obstetrics and
Gynecology, :;!002; 730 .
2.- Zaguirre JC. Integrated Medical Psychology. QueU>n
City: Private Publication, 1977; 1-6.
:psychosocial risk factors: per{natal screen.in ami
intcrventicn, In: Compendium ofSclectcdPublications.
Washington DC: 2007. ACOG Committee Opinion No.
343, Arigu~t 2006 .
6. Esguerra AB: P:;ychology of pregnancy. In; Sumpaico
WS, Vill.anueva-Gu ti errez R, Pagt.akh.an-Lun.a L, Negre-
Parga M, Ramos MU Jr., 3aja-Panlilio H (cds): Tcxlbook
of Obstetrics, 2n4 ed. Quezon City: Association ofWriters
of Philippine Textbooks of Obstetrics and Gynecology,
2002; Fig. 66.3, 734 .

7. Lee IA. Gastrointestinal abnormalities. J:l: ~umpa.ico

3. Kaplan HI, Sadock BJ. Synopsis of Psychiatry, 8tb ed.
New Jersey: Williams and Wilkins , 1988; 19-22.
4. ChJ!.p~ J'J". Dictionary of Psychology. New -;r:ork: D el,l
Publishing C., 196'8 .
WW, Villan.ueva-Gutierrez R, P:agtakhan-Luna.'L, Ncgr.e- .
Parcja M, Ramos MM Jr., Ekja-.Panilio H (ed~lfT~k
of Obstetrics. 2....s ed. Quezon'City: AssociationtbfWriters
of Philippine Te.: ttbooks ~f Obstcrics and cynccology,
2002; 648. . . :< .

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~~\.-:- .
~:~ .

138 SECllON .1: BASIC BONCEPTS OF HUMAN REPRODUCTION

.e,. Masters WH, Johnson VE, Kolodny RC. Human
ilc:ruality, 3!'lcl,.Genvicw, Illinois; Scott, Foresm(Uland
Company, 1988; 115-118.
.'
9 . Sandler j, Myerson M, .Kinder BN. ~.Sexuat.itY:
'Current Perspectives. Florida: M'Btine=- P'J:bliSbing CO.,
1980; 90-100. . Villanueva-(iutierr~ R, Pagta.khan-Luna L, Neire-
10. tuneriean Cc:!!!ege of Oh~tetiicians and:Qyi-J.~s.ts.
Pain reu~ <!uring labor. In: 'Compendium of~clecte4
Publ,.icati~s, Washington, oo 2007, -ACOG ~ttee
Opiriii>n, o:o. 295, Jwy'2004.
11. AmerieaJi College of Ohst1.~-s and 'Qytieeo16tti~ts.
Depreiswn du~g pr$ancy.afid fbi .~i:u
peri6<L In:: J>recia: .an ~p4a~~ ~ O~i:rlCa and.
~logy. Qbstetrl~. 3rded.. Wa~ DC: ACOG
2005; 181-183.
19. Speroff L, Glass R, and Kase N. Clinical Gynecologic
EndOcrinology and Fer:tilitY. Baltimore: Willi.Bln:s and
. Wilkit:ls, 1989.
20. Clement~-Chua L.R. y, et al. Morphological and
. physiologic~! ttevelopment. In: Sumpaico ws,
Pareja M, Ramos ;MM Jr., Beja-Panlilio H {~s):
TeXtbook of 0 bstetriC3. 2oo~ ed. Quewn City! A.ssociarion
of Writers of Phili.pPin~ Textb;)ok.s and GYn~logy,
200.2.; 75-.96. .
2L Fel'dmanRS. Dpvelopment:ACI"?ss -!:p..e We Span. New
Je.rtst:y: Prentice..:H.iill, 199(; 4~5 .
22. tfa&:tet:s .I:lM, J-9hnson: VE, K.Qtooni 'RC.Jiuman
&xu.ati'ti=:3,. '1:1. Glenview,' Illinoi~: ~tt, Foresman !
. an.d'C0 7 :199~; 11~-~:30. .

12.. Feldma:n RS. De\':pqpm,e:nt~~ thellie Span. New .23. Esgudra AI3 ..Rol~ .of faUle:r and .family in-~C'.i
Jeney: Prentiee.HaU. 'l:9,97;-f)9~74. lh: 'total~F~y~th.care Program.~ ~ :City:ost.
'Wk~~ .M edicai Cdlter, '2.007.
13. Sing~n--.Md.ay A:.. Prenatal ~ ~- :Si.).m~ 'Vis,
vmul\im;Guiier!ez .Ro~J;i:ma L, .N~gre.- . . 24. Amerl.a,n Colle~ -cifC)bs'tetriqa:Ds anP, Gyn~cgists. -
Par~.U..~oHIMdr.; ~~P~ilicSll{ed#j:;z""'.ea. A~~~eep pateri;la.l s.Lge; tisks to lhe fetus. In:
Q~l:;iop:CUj: :..A~~on -iO:f..:Wi:il'm:of-~pptp.e.: 0mp,:diUDi~~e~;t~LP:tiblkati6ns....W:~gtonDC: . .
Tbo:DOO)(S~&~~~~;Y.:r>~&Y;~-13Wi'40;~ - : 2007-:A0a:.cQ:up;nittet Op:I'nion no,.':i89; '.Octoi>l::t"~
. .. :-. . . . .. .. ; . . . .. . . . . '1~7.. . . . . .
lL American'Colie~:o! <;)~tetiicia'u~:~;,1J':~~-
Smo~ ~n ~~1 lhi-CQm.~ . 25. J<_.-:ll~id s:~.- ~~t;z DM, Cp~ B~l)lo.nied~~. Guillete
. -~r~~--.:.;~?U
vv
_- .4~
~!'':"".._.
......., -~1 """"=uc;"'~ ..
-. :~. .:o~:~. .t~
~ -':~.L
... .,...
.:.j.:.n_:ie~i_~~---~~
.....
. _
::_::.~.:.CbG
_ . _. . : w .:an:\1.' ~ciachl.S:n, :~k :Stnergisti:aUvatioc. of ...
~e.O.;itte,P.to:r.s:Wi.~:~mb"'~tK>~;i>.t.en.Vin>nm-entB.i .. .-
.-. .. dt~iciils.::Scienee:. 27.a 'f7.;June),~t4~9:t4'9:2; :
15~ AmeriCac.C<)~e;. of :o~st~:.an<::.-cyn~bgists~- ,. .
Com;pliui~n:tary :id:~:W~tna~lve<~tcHciq,e. "in: . - :26. J~b~n~'L~ j!!..eobsOn.SW, ~gettR, ilnunitt.'G, et
COm~~pf.~.~~~-)~~OC: e,l. ltif~u _
ot ,jl,:ena~ -P-CB ,~~ :<Jn <:e~!ivy
2007, ACOO 'Committee PP.P:ii9nno. 2111, November proce3'si.ng ~fficiency :and !nl. Stillned. attention.
r9'9'9: .... - .. ... .. ---' ::'.. ... .... . .. ... ..:.... -?.~9P.~~~~1~'ii ~:992i'~a @'~ 2.9,7;~; ~ .
10 .. Americari College of. O_b.atetP~~- and, Gyp.~lqsJ.sts. 27. Sclm.JtzerPG, Obhan:AF, andEritksonJD. Patcmhl
Air travel durillg :p.regil:~cy. ~n: CoJnpehdiitin of ~cupation a..,_d risk .o f birth defects in offspring.
Select.ed.P,ublicatWns.. 'W~O:. DC; 70()1, ACOG Epidtmicilogy6 (Q): S77~Si}3. .
Committee6piniori, no-; '2M, ~'lx:r-20:01.
28. American College o.f O.bst.~trieii..~ and .Qynecologists.
W. Peschke I a. Cbristian Etbi~. Mtuiila: -bivlrie Word Psychosocial :rlsk .fact<;>i:!': perinatal sc:reening and
. Publicaf;i~n~
.. . ....i:w:~k-316.
. . .. intervent?on. In: Co!!lpen~wn ofS~leded,Pub)ications.
W.asliin'g ton I)~: ~2.007: AC0.G :(;:ommittee Opinion no .
.10: Chal::Oberlain.E>B.. Ba.ble~ R~em'Qer'B'iith.NewYprk: 343, ?>-ugust :2006.'
Diillantine.BoolCs, .1990.

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 9

BIOETHICS

JOSEPinN.E M. Li:!MJTAO, MD, MJIPE~

Moral status of the 'Embryo

J::thical. Principles
. in
'-..
Obstetrics

-~-~~Principle cf Beneficence
.:: .. ::.-.?rindpte of Non~mai ef)ce nce
of
. . ' .- :P rinciple. Autof')omy . ...
~

.. Principle of Human Dignity

.. . ..Principle of Free and Informed Consent
:.' - "Principle of Weil-lnformed Conscience
1:.: ' ..~.Principle of ProfesSiqnal Communication :and Ccnfidentia1ity
of
.. .Principte Totality
Principle of Double Effect
. PrinCiple of stewardship

alrect--and ~lndirect A bortion

Maternal-Fetal Conflict- Situations and Principle of Double Effect

Prenatal.Diagnosis

Special Cases

Ectopic Pregnancy
Pregnancies. with Anencephaly and Congenitally-deformed Fetuses
. Pregnancies with Genetic Defects

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~~~;.~.::. ......
:~t.

SECTION 1: BASIC CONCEPTS OF HUMAN REPRODUCTION

INtRODUCTION These attempts to confer increasing mor.al .

-: The.phy.si~-;patient relationship is based on
:mil-$~ respect and trust. The patient comes to
th-e _physician with a health <::are need and trusts
.. that the physician will provide her competent care
. ':that wi..ll restore or maintain her health, The
phY8ician trusts that the patient villl provide him
W!th.all rekvant information neeQed to atriv -at. a
, .. " ;41~gncsi~ an4 will. C9t:llQcy- :w.i~h . the ~:((dtca:1
. .. ~~apn:~n,t .pr.e,scdoe~. t~.. a.#ld~v~- 'lle'~'lhig.
. R~s~n$ibilit:y.fu promctJ,rig ~r maiJi-t~iclng hea!Ui . O.t} its.~q?ni:
'-':' is :eq'tiall: Shared b .
__ , y . . . Y.. .'b<)th th ..ih.v '
. ~-P ... ~ ....: :. 'and th
--~
. . . . .
, .. J>ati~nt. :~~ilir:;~n~ act$ i~d~i>nd~)it}yor the Th~;r,~:~ <lt- ~g9te~~ill.tiug-Jro:ri.,e .
o~but bOth. parti~ipate-a:.divciyi.~. the.~teajmg unionOf the mate and.fe'rriale ~ete~ !Soot}Ust .
':J}.~()Cess.
, . :. :. !p,0t~e fieldofob~t~tric3, theJ>hysi~-:pa:tient
:.re@tirlhship 'is a unique one. the -obstet:rl.Cian
-t~;~~ of two patients; the rnpthet- and tl':-~
:. .: :fet'.1s~fu-;most cases, providjng .benefi.Cent 'healt..'1.
careifur.themother v;illen.sure.-ben~ rerefot
..... _:; =clte,~fetus:-.;r~e:reareob.st:itri'ca:l>- cohditiohs~ .
status at different stage's of development of the
product of;gestation based on characteristics like
viability, sentience, relational capacity, conscrous
awareness of self are -based on an errone.oua
determinativn ofparameters for person..l-J.ood with
its full moral standing. Attentibn is focused {)n .
the_ structural differentiation wit.'l its extetnril.
fupcti.o~ manifC?tations with total disrt;ga'rd.bf
th<!. iiihe~t lif~ force that enabled the zygo~ to
. :.:go.-.fi?Iougli th~~ ~er~t stag.~s qf de-~~~t . .
' . . , .
:':. . ..
a '"blob bf j)rotopw.srn"; it "is a complete un:ifie.d :.
str'Jct'..lre that- contains all-the information and .
all the a~ti~e potentiaUey ~f self development>
essen:t:4U to ;live its 'Yllo~e :Pi~hy of inte~O;ri. . .
"iVit:h its en~n:rilenL This Wbn:llati6n is -oin its : ..
-e>wn U:Iiique gene~c-~e-:pp._n'citb,er fue:rilOfu~ii : ,..
.or the rath~s, :but ~a :unique a;>mbination -alid
in~gnllgi:Of;tli>:par~nts~f}N~~~fu,fue,;'\1IIiort';.h_:. ~ n

. ~ ' :however. where the best interests~ of the two'. of !he Jriale and'fen:j.aleproi:mde:iiatrertiliza~n..
.. :pati~tsc:onfl.i;,.t with .each other. A~~te. topic : U:ft{)n'its~ 6'wtl Wl:thjust, th~ provi~oh.ofare2ePtlve .' ~ . ,
_- .. : 1s.~eV<it&l.toi:h~ uniqu~-prcblen;ul in ObStetric's .. gro.l lnd. I or; -:~mplan:tdioi:i>:~nd:h;e matd;n~-. ,: .: :
. undd. the heading ;ofi MB.tfiina!JF~tal:Co;nflicts. . cild<mie~um.;,fuis .gentk str'tic~e .dicta~_,_fue; ;,.: '
::.A ' . ..;.1 .. r. ,:-'.\. : ... .Wliole:dev;~o~ep.t:~~ss~from~the~bf. bf:~-;~-.,. .
.. The'<'moral''status-of--t:h~':::statusof'the'.embt:Yo mitotic;:..dhdsions,.:(,c!p,t.Yag,c:) ~:.:which: .sta:ts.~~: . . .' .
: . . ~-~~ .;~S<;usSed. fu"'establisli. hi~'/he:i cWrn' 1{) immediately :a,f'ti ~er:tilization to Jorination o( a : . . .
:~ .....'beh...~p1ea1~~~~}.._1..d~~~-~~-;tha~ of l?~~_stocy.st rii~,de up :cet ~n._, inner cell }lla'ss~'<'.
the IDQ..ther This will be followed by the relevant feililiryol5Iast)"'anir o~ter .carnras~ '(troj:J):ffioli.fStl' ::'
. .-~-~ --~ .: ______ ....____..,_..... .:..____:._~--- ..._ _, __ .__.~--
. .- :~thie<U-prin.ples applicable in .clinic situ~tions.
Wl
-.-fu. :-- b--,:;:~-::_-~---_-::_.,-~-.;;,_;.;:;ty-
- .a
l.i:l.:>.VJ\.AJC.lC ............
-.,::-on . .==~--._. .
.. -1.-ts own.-, ;:c-::-e~_=-c-_
lilt: v.J<J..lH"--J _

... ':The ethical issues 'in .prenatal diagnosis :will also
:. ~. :4iscussed, separately..La~tly. ~specialfupi~ll+
.dd~ling with. ethical i~:~ues in. abnortna1
p~cies Will aiso be eluqidated'.
... . .
MQ~:U. STATUS OF THE Eli-I:BRYO
.
The rapid advances 1n the field of :reproductive
. t~ ~h!lo logy inc;:luding c1oniag and stem cell
research has created. an .intense debate on the
. ill:gPJ status of the embryo. Ju{ ~H:empt has bee~ coruerrt:d b'i,Jly-,on 'the ...;ial!le fe.tUs or ori the -ernbcyo ~ .: ..:.
~i,de to simplify the is sue by terms like "pre-
.. ~tnl?ryo l-referring t,o the gametic union from
:fettilization to the appearapce of the embryonic
:-a,_xj~ knpwn a.s the primitive streak at
approximately 14 days aft~r fertilization) and
. ~embr-yo ( refers to the produ~t of.g<ir;netic union
.. f;i:-om the beginning of the third week to the end of
~-.. :th seventh week after fertil~tibn) to draw a
~- : . :dividing line ih conferring moral status t o. the
.:~~~~-, developing product of gestation.
..~:t: ---
. ... .. .
~i.~ .:~.
Seanned 8y:
implants between 6-:81h day after fertilization. : ..
SU:bsequ~n:tly after implantation, the thr:ee. :_
priri:j.ary g~i:m. layer.s are. fornied- from .'tp:e~ . ,. ':
embrjoblast; these eventually give rise :to -the~ > .. :
diff~rent brg:f!?s an? ~stems of tl;ie bapy. !,Jn. it-S . . _: .
own, the trophnblast, evolves to form the place~ta.-. .: ;
with its chorioruc villi-essential to slJ.Pply czygen\:. ;
and nutqents and for the excretion of the waste .;... .: .
prod'l;lcts of the developing product .of gestation. If:. . :
perso!fhood with' its fu'U rrior:il status can be:.
.after implantation, what force ~nabled the :embryo :_ ,
to implant.or to evoLve its organs and become
viable? Can. hmn<m life/personhood evolve .from ,
somethingib.a..Tlimate or.subhuman? Im planta:tlon
a.t"ld other milestones of development are 'the: ..
functional evidence of.hu.man life.already p:r~sen~-~-:- .
from its 'inception. Human life (human per~qh) .. .. ..
begins at th~ mQment .of fertilization with .the'
1;1.nion of the egg and the sperm resulti.ng .fu.:_ the.. . : .~
fonnation of a new indiVidual,. wit h a _unique
C
 CHAPTER 9: BIOETHICS . . 141

genetic composition that dictates all
developmental stages that ensue. Hence, the
fertilized egg or the zygote .should be given 'full
moral status; he f she is a unique individual with
his/her own rights that should be respected.
ETlJICAL PRINCIPLES
1. Principle pfB~eficence ~ thh> principle is the
source of the ;J)hysician's obligation to giye
.h ighest priority to hi's.. Patlent~s welfare and
provide competcnt.healtb care th~t rn~s
.he&lth benefi~. for the patient. It requires that
physicians roniliiuauyupdate. hiriise!f With
evidenct..based tteattnent mbdaliti~s that .are
be~enciat for l;Us patients.
2. Principle of Non-maleficence - this principle
requires the pby$ician to pmertt or minimize
hahn .to patientsin the coUrse. of physician-
,. ~fjerit~teia.ction. No ~attnent,.proc~dure is
Jisk;~;n'isthe dutyof a:physician to choose
.ruid-''~:tnmepd a 'kee.tlnent option . w.hich
hann
poses :Jiilii:itnai or no to his .patients.
Fresqib!n.g a.."'l~biotic~ to Whi~h the patient
respecting the. j:>atient's autonomy. Efhic;ally
guided health ~e decisions are only possible
if the essential fea,tures of an informed consent
process are present. These elements are:
competence of patient, adequate information,
coinp rehension and understanding of
information presented and a fre~. voluntary
consent.
The informatkm th11t should be included in
re-commending a dhignostic/ therapeutic
procedure for a patient are:
a. Complete "'description of the procedure
b. Reas.i).n for the proposed diagnostic/
therapeutic pr~edure
c. Benefit/s of the diagnostic/therapeutic
procedure:
d. Risk/ s.. of . the diagnosticj therapeutic
procedure including expenses ,
e . . Who :will :perform the diagnosticfthe..-a~upc
procedure . . :z . . ,:,,,;;.:~.;:~
f. Alteq1ative diagnostic/ therapeutic-~ptioils ~~;...
g. .Freedom .to ask .questions ~' - . .~.;< ..~~r.ffi?'~!~
i ..: ; ' .' ~ ' :

~S' po-Jmown allergy or doing sensitivity tests - These L.-,f'l)r~ation should be prc:sented in
J Pr~()t>.\;To : .j:u\r*nteral . antimicrobial simple . terms understood by .th~:"natient,Jor ~ .
.;, adi!WliStration' areconcrete"mertifestalions of . adequate rom:prehension. Efforts sb6Uld:be;made :
. .:: prmci~l~ iof non-Iiialeficeric.e. . to ascertain whether the. patient. ttuly~~~ds
. . . . . . .,,.._, . .
the presented information_ A w titten''COnsentJis
3. Pri~~,9f ~"lltopomy- thia,p~c~pl~ .~:equires rC?quired-fo.r inva$ive diagno$ticjtherap~~tic
uiit).h~.JD~~_speettbe.rlghts.:.of,.patients . pr:.oc.edur.es. to.. signify .the..-ffee- and-..voluntary
.- to_ nuike.:..ind.ep.Cnd.ent -decisiqns . .as .. an. character--of-the-cpnsent- process-; -For:--sur:gical
expression of their self- dete~Uon. this procedures, it is ideal that there should be a
respect is rooted in t.,;,e ihherentdignity of each separate consent for the anesth~tic and surgical
peroon .a s 't -reate41n the 'iniage of -God. Health procedures. Although the nurses can Secure the
care decbions, enli~tened by the physician's signature of patients to sigriify th~ir eonsent, the
competent recOID.nleridat.ions, .a se ultimately responsibility for the informed consent process lies
based on the indiVidual p atient's values. This with the attending physician.
should be respected in so far a:s .it does . not
conflic~ With beneficent h ealth care a nd the In cas es of incompetent patients who cannot
physici.art~s oWn values. provide needed consent, .p roxy decision-makers
(husbarid, parent, relative, guardian) should make
4: Priricipl~ of Hunia n Dignity - this principle the decJsion accorcling to the patient's b est
require.s that all health care decisions must interest. In emergency situations where no prox:y
aim to.promote human dignity and result n ot or substitute decision-maker can provide consent,
onlj in physital health but also satisfy the the physician can invoke "therajx:utic privilege"
patient's psychological, social, spiritual and and give consent based on his obligation to provide
cultural ri-eeds as an individual and as a beneficent' he'alth care i.e. ruptured ectopic
member of the larger community to which h e pregnancy or placenta previa 'patients: l~shock
belongs. with no available relatives .:~

5 . Prmciple of Free a nd Informed Consen.t - this 6. Principle of a .Well Formed Conscience - this
principle is the concre te expre ss ion of p ril1ciple requires tha t physicians as

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142 SECTION .I: BASIC CONCEPTS OF HUMAN REPRODUCTION .

responsible health care providers, when faced Obstetrics, because of the maternal-fetal
with ethi~ questiops i.ncluding health car.e relationship is replete with situations w:here this
decisions, have the follo'Win.g .obligations: principle is applicable. The four conditions that
must he fulfilled for this principle to be allowed
a. Infonn themselves au ft~ll}' as pos~ible are the following:
about evidence-based medical fads and
ethic8.1 honns a . The action must not :b e intrinsically
b. For.m a morally certa-in. judgm.:nt of contradictory to one's fundamental
cohscience basett en above itUQI1Jlation CO!llimit:nlent to God and nc:ighbpt; the action
c. Makehealth eai'e dec.ision~ according to ~ust he.'g oot\ :or at least ind44'ferent
this.ftilly ih.f9nned eo,nsclen~ b. The i:p.tention C!f .t he agent must be directed
d. Aeeept resnsibi1ity for thir actiot);S .towa;rds the ~e1icialeffeet, the harmful.tffect
is otlly allow<!, ncvei dirc;ctly intended . . .
7. ~ciple of. Tgtality.. this 'J)thleiple teql,li,re!l - c. Thl; foreseen :beneficialeffects must. be equal
that a ll .persons :sho.u ld de\tel~p. use .~ . for to or gater ~ the hE.i:rml\11 eff~ts
arid pte,erve all "his phy~i'eal and psychic d . the benefiCial effect' mus~ prc>ceed from the
function$ in $Uch .a way that lOwer f\Ulctiorts action ~ead or simultaneous with the hannful
are nev~t sacrl.fic~d exce-pt f-or the better tffect
fAD.ctio~.ofthe.~dle pet~n. or to.p~~erve
life. l"ot ~pl~ ptt>filSe.lY l;?leeding a tonie 1O...Pri."lcipl~ ofStewatf;lst.t,ip- frJs prinCiple refers
l.lteTU$ ~y:~ re;n1oved .tQ pi'~serve theJife Of .. .. to m11il's ..limit~ do.min:icn .cv~:r ria~ and
t\-patient. . bl,:~ own !,ire-= Th~ -things -w~e en.trosted. to
,hir:ir.to.02,!"'e fQr.and :inlP.l'QWna~. ,~pqnsible
:a. . PQnclp1e9rPiotes'sio-Q:al~.~~liC;:1itioii..~this (., . .. sr~'w.~c,l~ .'l\h~ :.heaith.!pf)fe$sron~.. has.. the
prlniple :tequir~s- th"~t h~i;dth .j)tofe$sio-na.ls .. . . eth~clil . .responsibility :to :u.-s.e hi~ . reati\'e .'
bave ,'the:folltiWin~vie.s.Pc>~~ibUity:.: . intelJig~.n~e3,arid a~ailab!e. .t-eqlu'lolC>gy to .
. .
p~v~n't':~d ic'Ufe.dj~;s .'~ 14~ . gi:eatest
.

.a; ... ~E:J:titb~i:jh : and'tc;flte$e~~-~trust';:in:th~ir, -~ :,.re~~~.for, ,~e ,t(ii~t'hQf...tbe.:b\ll:IUQl .=~n ..: .

. patints'H-' r. .:- .";-: : .': .....; ..:.: ;:-.~ .-: , ::.::.:. -. ,_ . . TI1ete. .shot.ild ne.:.caliti6nJn:s:q~b.lng;.to)he ..
. b .<: .s~ -m~~::facts~tb:~y -~sess:~t are - technQl~,gical im~tive that ifitqm be.d one, .
it. must-be
- . . . . .do .. .n' c! ~ Thts o.,t.;;;. .:..re ~u,ha .,. ts .
,. -~=~~~~:y .~u~llts to ~~e an .: .. . p,~.;w.CJ!" w~ . ~-
S:ppli~ltt,fpn-~"r--th-e ~-1>t teclffiolrigrt<lr--sat--
c. . }(e;f:t~w'f:ro:-iii lirnr - ot p:rovJding ~~~tion; .ror.:gen.etic:~l:iliaiieem~nt.p~lii'es
niiaiilformation . i.e~ de~igne.r babies.
d.- _Keep .seere~ , it1J.ortnatil)n .no~ '.~e&.titnately . ..
needed"byothet"$ -t:l'lat <ifte~~ed :will:hann D:QmCT AND INDIRECT
. . -ABORTION
.. .
'

patie11ts or destroy patient$' trtt~t.

This last dement of . :p.totessjo~al
'co:tilmunic.a tioll . enil>:o11li~;$ tP:e .P.rin:ci pte o.f
Confidentiality which re:quir:e~ the ;physician to
keep the prlvacy of.patietlts . l;i.'Po.Ut those ~spects .
of lif~ wl'Uch .do not dir~~Uy affct .o:th.ers ..'t bis
principle,. however, i~ not .absolute P.liJt t;nQ.Y Q.e
broken by the need to ptoree.l thepati~n't ~r others
(rom.harm. The statUS Of a n urv (+) l?a:tient can
be .r,ev.ealed to her ~exu~l partner-s beause they
~directly aff~d or banned by :thi s irif.ormation.
Breaking .confidentiQ.lit,Y should .be limited only
to those who l~gi~atety need the infQrma1ion Le...
those in direct harm.
9. frlnciple of Double Effect '-r efers -1:9 ac::tipns
which both have good and bad effects.
.. Abd.Iti~n:is the termi:na~on .of'pregnancy Vlith
the re sulting de,~f;h of the :p roduct o f gestation, A
dire~t :a\).o rtion is one in. wh'ieh the .d irect,
immecliate pur:pf>se of the prooe_dure :is to destroy
the human fetus a:t any ~ tage after its conc~ption
or to expel it when it is rtot yet viable. lh~ct
aoo.r tion is one in which the direct, bnme.4 iate
purpose .<:>f the pmce:dure is t~ tr~t Jhe mother~
the. death of the fetus is an incidental and
secon<fary result that would h~ye been avoided if
p<:>ssible. Therape~t.ic al::>ortion is termination of
pregnancy done to save .the life of the mother.
Direct abortion is unethicalb,ecause.it violates
the sanctity of human life which be~ns from
fertiliz;:~.tion. Indirect abortion is ethically justified
if the four conditions of the principle of double

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 CHAPTE.R .9: B10El1UCS f43

effect are fulftlled.. ~e mpr:ality of therapeutic The fo~r conditions of the principle of do~ effect
ab<)rtion <iepends on whether.it is a p!rect abortion are fulfilled and therefore doing mastectnmy with
and th~fore unethi~al or if -it is e.~ indirect or wi.thout chemotherapy, in a pregna,nt patient
abortion that fulfills the principle of double effect with breast cancer .is ethicaJJ:y allowed.
a,Tld therefore etbictill.y allb~.
.P IWriATAL DIAP.NOSIS
~~J;Ui.AL-FliT~ CON:fL.ICT ,$ITTJATIO.N S
The purpose of prenatal diaino.sis :U to rule
Mate~-fetal conflict .situatior..~ refer....to the out the presen.ce in the fetus .of a particular
p~ct. of ~edi~ an4 s~cal . 90inplications m~ie&l condition ~or wq.ich the pregn~ is at
:during pr~cy.<~~t rquir.e ?iagno~tic an4 an increased risk. 'This information i3 'U'!>Vided
.th~rapeutic ptQc.edure.s which p-roduce dtJ.al to .th~ cauple to ~ssist in th~ir 4eci~io;.making
dfec~ they iU''e -b enefieiai to the mo.ther but PX:Oc~.:_~.e r~gar.dirt g :the avaih~.bi~ options.
d~~t::tatbe btiby. ~que iila~~feful
The lnfon:ftatiori about the ;p urposes, bendif!i. and
relationship. provides the. perfect .set~u:p for t..~e limitatiqns oftests li.k e Jiltrasou.nd. .a nd-.temal
oecu:ITence Of materr~-fetal
.. .
~
conilict
' . situations .s~ru'm biocheoikai scr.~enirtg mus~ k :given
which create ethical issues that .cannot be. wh~:u. offering the test, ind~diitg th~:folict .t hat
a:nsw:~ byth:e,\isuiU.ptinciples app)i~qle in~ -any ::a:hno-.rma,l scr.ecning result ~ need
clinicaJ ~tting.Tbe prin#ple;s.of.beneficen~. and cooFlrmatocy te-s tii=\g..by -in~.aslVe .,W-Ql.atal
noo-I:fiilkP~iite . b.ave -vdy .l.i.rriited use in :these <!iagnosis which, may increase the risks :kr fetal
clirik:al 'Bittlati<>ns ~usellie:t.e aretwo patients :v.nd matemi;J.l coreplications -like sp6nbrle<>u~
wh,'Qse ~#i;~ :conrucq.~e mother .and t4e !~ms. a1y.:lrtion. . -
Wliat isbe~ficlalJor .o'n.e is detrimen:tal :t o the "'- _:.. . . . ~: !~. )':,:

othei ~((~~versa. hi .the~ sih.tations; the The . foi:towin.g ~thi.c.a:'l g{r1nel:lli:~:S~.;::.i'l,~.e.:.

prlrfcip~O:f,4~~b~ effeelalSP I~~ is the direct~ recommended for health ptofessicr'~s~~in .
iliffi.r.ect: ...,,:_.pile i3 a~plkable.. . . . . prer..atal dia,gl).ostic procedures: '
., : . ~ ' .. >Y- . . ' .. .. . ' ' . .. \ . .'
. : . . ...

: - -~ .;~~)-o ~~~~ 'a p~~t.Jmti~nt With .bff6.~t '1. tf p~natai' .dia.gnbsis is 'medi&ilyn.-5}E\iEa.t
c#~ ~ :ap:vised ~ 'flierapeutic .Pr:otedute .o f there Should be a free and infoimM-tD~nt
~st~to~w?.th or without chemotherapy; in this about tb,eproeedure. .The intohpail.~n~ed:
~.: .TW~9l1l.Y:with~r ~thPut,chetno,thetapy :to.the coli.Pile .e::..r.e:
. . .at'Om-lete'<!~::i
. P . -~~.~ - of '
mn...tttaOhe..b~st.:cao~u.Ut::t~the.$<rihe~t:irlle the-prooedl:l:l'e;reason-wh.rthls~p~-i's
ma.y~.cause:.:.snigioal,-arie-st:qetie--r-iJ>-k:s-.~;t-nd needed;:its~l>enefitsforoofunrotlrer.atiCJbaoy~
ch~motbera~uti,c risks :!dr abortiori, .pr~mature its risk.s for ~th mother and ba:J)y., l.:OIIt of the
labor a:nd s~birth. {:Tsit1g t4e four c<inditi<>ns o( procedure, the -ciltem.ative ~gnostic;opti.ons
the principle of douBle e'ffect to deter:roine the and fredom tG ask questions. '$Mo-rts to
motiility ~r this -action: .detemrine .comprehen;sion of the.itiixmation
given shof1ld be done. A free and "Uhmtar:Y
1. Mastectqmy with .o r mthoui: ch.emptherapy is wrjlten cons~nt should be .g iv.e n for .the
an indiffer~nt...act . . invasive prenatal diagn<:>stic procedure$.

2. ~~ iD.te~tiqn is to treq.t the breast c ancer and
the det:iimeri tal ~ffets . on. 'the Jetus although
fore~:ri are uitint~nded .
3. Ther~ 1s propor:tiortality between, the . good
effect (tteating the'bteast canter) intended and
the_ had eff~ c.t (abortion, pr~maturity or
stillbirth) allowed to ~happen
4. The'good effect (treatn;ent 9f breast cancer}
proceeds frorp. the at;:tion ahep.d Qr
:;imultaneou,s '\vlth the bad dfect (a bortion;
pr~maturity and stillbirth)
2. There should be;counsding before :thprel;latal
.diagnostic procedure done by another health
prcife~si:onal independent frorp. the.one who
v:m.perform the prenatal diagnostiqirocedure.
3. Prenatal diagnosis is carried out onl]' to give
pareJ.].ts anp physicians:informatiot),:.~ut the
health of' the fetus. -The use of pi:enatal
Qiagnosis for pa.ternig testing, except.in cases
()[rape o r ince~t, or for gender selection, apart
from sex-linked disorders, is not .ru:ttptable.
Its use does n ot necessarily mean 'that the
physician will pursue abortion in .cases
. . when

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 SECllON 1: BASIC CONC~PT.S {lF HUMAN REPRODUCTION

tlv:l.re .is . a IX>sitive .fiilcUng of a severe genetic/ embryo to its mother_, causing miscarriage.
congenital disorder. S\U,pingostomy is a surgical procedure that
directly removes the embryo .thrOugh an
4. Physicians should disclose all clinically incision in the fallopian tube wall The
relevant fmdings to the woinan .or couple, majority of Catholic tno.r alist! reject MTX
including the full range -of varl~billty in th:e and salpingostomy on the basis that .th~
manifestations of the condition under . two amount to no le$s than a direct
discussion. Infomi:ation abOUt the incidence abortio,l~ - In both cas es, the embcyo is
offalse ~sitiveand fai# nc:ga~ 're~Ult$ .w ith directly attacked, so the death of the
the testa :.should alao be di$Clbse4 for .a more emb.ryo is not the unintended-evil effect,
info.I'Jlled ,g uided .d~~~n-making. .but rather the very .means used to bring
about the intended good .cl!ect. Yet. for an
s. 'Qlc WQtnan'a al.ld/Q'r 'th.e P~>uple'a -cllt?ice.s Jn'a act to ~ morany licit, not .oniy must the
pregnancy with ,$\ .arret.t~ tetus ~b.i)Uld -~ intended effect be g<:l, but also the act
t~spec::ted and-proti!e.tc(l. withlnUl.e ~evrork itself must be _ good. Forth.i$ reason. JnOSt
of the f8,li)i}y and p( 't ll.C c;ultura), .$ocial :M~ motaii.sts . agree that MTX . Pd .
rellgious valil~s ,()f. the <:P.Up~ If however. a salpingostomy do n~t with~tand the
d~to:purwe a.lxn-t.Um:~ii:Ulde, th~health application of the principle p( double effect.
pro'~$!~ ~U;ld:adviseegtiinlt lhi$~e
of .fiction and o!ter 2. Pregn(ltlcy with a:neneeplw.lic .fetuses and
.a)~m2.t~e ~nipJ)Qttive
measures. congenitally mairortned !e~sea it is iessential.
ths.f there is ~--_co~pt~t~ -.dlilclosw-e Qf all
, o~ Noitholic:heruth'.ptp"f~onU.i:hoW"eve~ ,should,~ . .. ..,. :releV:~nt;-.. --.i~or:~~ti9n..-. ,.reg~r.4.ing. .' .tile:.
protect t.be. ligh~. ud. 4\~tY-- 9f.. the fetus. implie(:lpori$ of the CC>n.~ta).~oimatiOns
.!"~gatd'le$S of the :p~ee~ce of ge.netjcf. on ~uriiVai. aiid Jupetion&l.-impairtneni'ifth~
.. congenitalllbnQtm:.B:liti~~ malfo~tion is cowpati~1e -~th'life~.DeQsiOna
to >j)ursue. or-.withPold: -~e treatment .is
i\ll~Jc;>J.UUJ, .P~SAN-emB . made joi~t~Y. . by the~ ._p}\yslcian,. (b()th .
. obstetrlci~:-~d neQ~Wl~~t) ,~d the. coqple
1: . ~ba.lPregnan.cy- .the CUrrent .there,:peutic a!terdi~$$ionof~vailablb treatmentbenefits
.~~ t;mpiQy.ed.-fotjllbtli ~giuUiC:y will an:d but~. i)'s . :!fJte' :p~~~~~~~ .:of 'a:eyere
be-~ined--msblg-th~-:-p~eiple .-Qf'double conge.nitat~ma1fcrnnation-$nould--n~be-a
~ff~- - - grotinc:t-ror-a~ttio'ir'"~Y-ft!~bll :Cjf
pregnancy. Approprl~t~ ~fertal to units/
a. . :s~pU1ge(lto'$y ,-, qaing the principle -of su.ppptt grO\!ps . equipped .to h~dle such
do~ble ~'ff~c4 thl.s pt.Oo~q.~i-e 'for tubal situations ~ho.Uld be nuide~
. pregna-ncy is c:ttcal .because . of the
foll6\ving: :~pln,g.~rtJ.YiJ .,~ . i,ndUI'd:ent 3. Pregnancy with Genetic neT.eets
. .J act; th'e b.ltentio!lts :to'tre9-t U1,e mothti' by
remo~g th~ ~Uio.lo.tlcal tube With :'t he When ~ diagilasis of a :.g enetic .ll.bnOt'intility is
resulthj:g dea'th :Of baby f:Qt.e seen but made, there shouid be a ro,mplete disclosure
un-inten<:fed.. there is :p ropqrtiona1ity of ~11 relevant inforroatioJI re.ga.tding the
b~tween the _gaod efi~(oftr~_ati.Ag the genetic abrtormality : mode of inheritance,
or
in.<>ther ,and.the b .a,C:l,etret;t of <t~atp baby prognosis for . surv'i.va) or functional
~d - lasUy~ -t he td ~ffeet ()f treating the impairment&, treattn~nt options, if available,
. mother by removaloftubeis simultru1eous implications for future pregnancies,
with the de~th of.'the baby. implication!; ot the di$orderfor other .cl:iild:ren.
There should.likewise be genetic -Counseling
b. Salpingostomy and Methotrexate before and after the genetic testing to ensure
administr.a tion ... Metho~texate -(MTX} respect for th.e patient's and her family's ,
attacks the tissu~ celJs th!it connect the autonomy and values.

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 CHAPT~R 9: 'BIOETHICS. '145

POINTS TO REMEMBER

The patient-physician relaticnship is based on mutual trust and respect; responsibility for
promoting health is shared equa!!y by both.

The patient-physician interaction is governed by a healthy balanced betvve.en the principle of

beneficence and respect tor patient's autonomy.

All invasive diagnostic and therapeutic procedures require a formal consent which should be
informed and voluntary.
. .
The fertilized egg or zygote has a unique genetic complement essential in :the development of
a new individual; hence, he/she has full moral status.

Therapeutic abortion .Is unethical because it is a direct~ttack on the product of-gestation even
if done for maternal reasons.

- .The principle of double effect 1s a very useful ethiCal prinCiple in determining the morality of
indirect abortion a nd matemal-fetai cchfllct ~ful~S. "'-.
~ "Iii.. fubal pregnancy Y,lith signs of cai'diac ac;;tivity, most ethicists agree that salpingectomy is: .
~'morally justified V~.'hile salpingotomy/salpingostomy and methotrexate admjnistratio~-violate: .;;;;/~
:I '~e principle of double effect : " . ... . :i .o: .
~ .. -;.:. . . ..~ .
.I
:"'Oecision to .perform .prenatal {:Jiagnostic procedures ~nd on an adequate assessment of
- ~~oiiinefitlrisk ratiQ ~nd must have an informed arid free consent

~:,ne :presence of ~vere congenital malformati!;>n is-never an indication for .abortion. - . . ,:. -

2 . . Pkkenson, DL (Ed): Editor Ethicallssuea in )date.m.al

Fetal Medicine. Cambridge University~ 2002
' .
1. Ashley OP, Benedict M, O'Rourke OP, Kevin D. Ethics
of Health Care. Third edition. Georgetown.University 3. Ethics and Medics February 2004; Z9 (02).
Press 2002
4. Catholics United to.r the Faith.!tun

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 10

ENDOMETRIUM
AND DECIDUA

Maternal Tissues of the Fetal Maternal Communication System

Overv!ew of Endometrial Function

Endometrial Products
Cytckine family
Grov.1h Factors
Va$oactNe Agents
Vaso13ctive Peptides
Oiher Products .

Honnonai Regulation of the Endometrium

Estrogen Action
Proges~arone Action

The Endom.e:.triaLCycle
Dating of the Endometrium
Five Main Stages o.f the Endometrial Cycle

Endometrial Histol~y

Clinical Aspects cf Menstruation

. The Decidua

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 1
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-=:P:-:HY::::S:':'IO:::-L:-:0:-:: -: :0-=:F-:P: R: E: G~N:-:-A:-:-NC: :Y:. :--~--------- ~~
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_ ____,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _........_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .
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!
~
'.~
<~ . :~:
T1u:- ~rufometrium. the mucosal lining <>f the cytokines and growth factors. Like the
uterine .cavity, is the most dynamic component interleukins, UF : is most abundant during the t~~ .
of {he. uterus. It not only responds ~d changes secretorJ ph8.se and early decidua and may hS.ve :li.. . .
in a seJi$tive fashion to classic hormonal signrus a role in embryo implantation.. 1\tmor necrosis .~{! .
. (the mdccrine events of the menstrual cyde) but . faCtor- u('r.NF-a) gene. expression is pre~ent it{ ~ -
i~ a lso composed of complex tissues, with endometrium, and its activity is increased during .~; .
iin~~ autocriile and pa:racrine functions that the proliferative phase, decreased early in the .
.~t;.()t:only tile utetusbut also the cOntiguous secretory phase, and in-creased again in the
thsue~ of the fetoplacental un:it :dutlng midsecretory phase. r NF-a exerts multiple . ...
~ f!.om U.JWQlUtiQ~per~tlve, ~e
1
.influences on cellular growth. 1 :.;
. 1J.~.:~rid()f4ettjutil ~ :~gtlly 9~#'1-l?P~ . to
...:~~~()~odat~ ~t~r~:~ltl(il . lbl:p)~~tif'li, ~d .: a Growth ;:factqtk arc peptide$ .that: biliou to
..,Jt~~ ~ ;f;1f p~J!~h. ~ti~~metrla.l specific tell i'Jl~b~e . re~eptoi$ .and .ihitia:te .
.. de~e,nt~~e,<t~~:~!!itb ~~ 'il~ li1~~)$i-~$~gl)at)i~; . the pioiiterative
..(Qt..t:oiUPg) :an:ene....;.is re$tt1eted to orily a few ae!:Mty or the endotn~tium 18 lllAtked ~ :~atic
~tet, suCh .as humans. treat a~.t and 'Old a,lte~tions 'in growth :f actors. Estrogen stimulates .
W.W.~onkeys. ~pbQb.lasts C>f th-e b~b)cyst gene exprSsion for epil~n.nal growth factor{EGF) ....
hit.4ll: :. tb~se ertdo mettb\1 a rteries during {and-its .receptot:') and .-in.sulinlikegrowthfador1IGF) . .
.. iJ#J)j~~tj'Qn and pla~e.ntath>n to establish production. . In ~. ,EGF elicits .estrQgen-J.ike :
:u-~~ ves$els .'these primates tire !he actions by intera:c~g with estt~~en receptor
<>ri'l.Y' ~8roJ'Da1s,;Jhat 'ill~st;t\late.With nonfertile., mechanism. Transforrni1J.!J1Ywth /(lCtor-:a(TGF-a)
. QR:~~~rx.;~~es,m~st::nt~tioh efT~~ an.d EG~ work thf9ugh$he ~e rtept.Or-and ~e
:,d--lJ.tijati:c>#i()(~th:~tehd.Gme~\U.'no.Thet1-Jhe,cyle.. ... .important. ltledij.tot!i :of.'~trt>.,gen.;~~ueed grilWtl} .: .
b~,iChi~.'.;yntl,l n.e'P ~ndomet~a~ ..gr.ow..fh . e.;nd of the endometri:Um. :;r.aF,:a lev~ls .ptak ~t :.
:4~C.ent and :inatlifation tlt~t corresponds midcycle, in contrast: t1> ...EGF lev.dS.' which are
. Wi.<~(be ne-X.~ pr~en-a~y (i~pla-ntati'on) relatiYely stap1e ~d':no~..cycll~ Platelet-4erived
' Q'J)~~nitr! :T:hJ$. w...ttJ,dQW. ..t>f. elido't netria1 gr.Ov."th facto.-.is a pote,n~. ri:tito~n.:lQCalized 'tp .
. .. r.~p~~ty.; to. blastocyst.:l)lant~tion. occur.s stromal:- cells.1 .
~P.~~ly~op~Y.~~ ~ay:; ,20 '.~ 24.~
The IGFs pt~znot~ cellul~i :D;iitosia an:d .
;~RIAl. :P.Ron.ucrs . differentiation. The.)' ~.:~n:'ssed in a. ~~. . .
controlled.':by. estf.t}gen:and. pwgestet:one .IGi~L. .
:.- --~eFJ,i~omelrium~~ :l iumy substances, ispredomin~t..in prolifer-<;~.tive.~d~ear:ly-secretory.
t~~... (li~ctions. of whl~h .r e;present a ma:j9r phase, while IGF-l~ app~ars in 't he mid to tate
... In.~etl#tive cha)len.g~.3 In lldditi<>.n to producing secretory ph~e 'iind persis'ts in :early pregnan,ey
.. ai.i~~g. su~portiv~. envinm:m~nt :for the early. decidua~ :This suggests that IGF..l synthesis is
. em..~.the endometrium pl,ays .an important role regulated ~y estrogen and med~tes estrogen-
:ii\::~n.lj)pressing the untnune response Within the induCed growUt of the endqm.~tri~ and IGF...tl.
,p .nt,.uterus. Themet;hanisms controlling the is involved in the tlffferenthl.tion in ~~ponse Jo. . -
itt.t-un~ response in deci'dual cells are not progesterone.
unde~$tood, . but hormonal influence .is
UAdo\lbtedly
. ..
importiltlt.1 Gonadotr.opin r eleasing . hormone(GnRH) is
.: present in endometrium and in increased amounts
. :. ;11le presence ()fthe cytokine f~ily, involved in secretory endometrium and decidua. In h\lllla..'l
. . dn: tnnammation and iinmupe tesponses, is not decidual cells, Gn:RH increase~ the expression of
sUQ>H~ing in a tissue that undergoes cyclic matrix metalloproteinases, suggesting a role for ..
. f.~S~lJ.etation. Th~ interleukin.s stimulate the GnRH in the regulation of enzymes involved in.
prot;l\fttionof prostaglandins and other cytokines. implantation. 5
.CQtoiiy: stimulating fa'ctor-1 is a cytokine that
.infiij~ces cellular proliferation and the presence Human myometrial smooth muscle and . : .
AI:"~~tophages. Inte.rferon-a. 'is .p.rod,.u ced by endometrial stromal cells express mRNA for. : ,
. aCtivated T lyrophocytes !Uld inhibits endometrial parathyroid hormone-like protein, the functio.~ of-
:.eptthetial prolifer~.tion. Leukemia~inhibiting Jag.or which is unlmown. Transfo.n ning growth factor-..
.{LJF).is expressed in resp0nse. to a varie!:jT of other . 'a(TGF-a) stimulates the production Of parathyroid-

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 Cl:-tAPTER 10: ENDOM~RIUM AND DECIDUA ;:~:.. '151
~----------------~----~~~----------------------------------~

hormone-like protein. TGF~u ptodud:ion is Wo)nen with''~excessive :menstruai 'blh'eding

greatest in the secretory phase and may inhibit
cellular proliferation by increasing lGF.BP-3
syntheSis: 1
throtnboxane is synthesized by uterine
.tissues. Gen expression fot the .thrbmb0~al'l~
synthase and for the thrombo~e receptor C
be identified in endometrial glands, stromal cells.
my6:netria.I smooth muscle, and :uteriJ;l~ b lood
. J . .
vessel~. :
have. a1terations in the normal rates of
prostaglandin production. For this reason,
effective reductions in menstrual blood loss can
be achieved with ti"eatment utilizing ;;;ne of the
n onsteroidal .ariti-inflam:m.atory agents that inhibit
pro~taglandin .~thesis. These agents are also
effective the treatment of prostaglandfu~mediated
.dysmen:orrpea. 1
Vuoactlve Peptldes. and M~.J1Strnatipn

Thromboxan:e A2 is' a PQtent vaspconstt5ctor The actiol),s. of a number of peptides may

a:hd stim,ulator of smooth 'nl.li~~e celle.. 1
Fibronectin: and laminin.are ~acellular
~trix $Ubstance~ :that are.s ecreted. by stromal
ce11s of tl'i.'e .endometrium. in ' resp.cmse to
progesterone. 'fhe$e pr6teiiis .are important
ad~e~i,on molec:qt~s dut ing 'impla~tion.
Jn~ ID:e a f.iim.ily :Cl(glycop~teinsthat fu:P:~n
~i'~f~fit~rs fo.r protein..$ such :a:s c~'l~agen,
~~and 'la;miriin. T hey ~ jrnpartant for
&1ii~i{and cell-t6-matrbt interactions)
Vi(.Sol.ct'fVe.A~;:-nu'Pri>du~d hi tile
:i'ffitb~~~ . . . .. . .
. .'Blood:flowin the endo.metrlum.(spiralarteries)
appears to be ~by ~ steroid hon:n<;>.ne
iifduced moiEfieati9n's t>f a 'local .(I>arg~tiP.e-
m~~f~l V;~~~ct:i-f~ft>et>.uae .~y~t'e'ffi.. .the-s e . ?.~ _EE.~g~~t~r~ . .~~);._Qooation .. ....:the..s~e.
hioactive4lssue'""'aiitacoias are moSf.'CQmrrlEiily . ~tctivitY._C2L:~.n..ke.phalinase-in..endometrium-is-
syntlre-s'i'Zeam-:tnesame-peffsm 'Which the;~ highest during the midluteal phase of the ov~
substances act or in :neruby cells~<~
Pr"<?$taglandi.n.s are .produced ~i both
epithelial and ~tt~mal cells, an:d the
proatagtandi'n content in the eh.d ometriJ.?.in
reaches . a :pe-ak level in: the late seeretory
endometrium. 1 A .t.ole fol' .p rostaglandin,
es~aJ]y pros taglandin .F2tt(PGF2(1) ' ~hich is. a
vasoconstrictor, i n the initiatiqn Of:ple nstruation
has been ~u,ggested. L~rge amounts of
prqstagiandiris -are pres~t .in men~truill blood.
The adniini$tration of:PG:f':2q to wpmen givesrise
to ~ymptbm~ tha t mi-mic..dy-smenorrhea, which
. is commonly: associated With n o r.tnalmenses .a nd
likeiy eaused by tn.yome~al contractiori.s and
uterine ischemia. The ?..dffiinl$tratlon :of PGF2a
to nonpreg nant women wilt' a l so cau.se
menstruatio.n.-' This response ts b:elie~ted .to .b~
mediated b.y PGF2o:-ind.uced vasoconstriction of . pituitary gland tha:t control and r~gtilate .li.~rmone
the endometrial s.pir'al :ateries.12
explain a :honnohe~r~sponsive par:a~e system.'
in the eh.P.9m..etriUm to r~late ~pir.al::artery blood
flow. One is the en:dothelin-enk~phalinase
system. The endoilielin~ET;_l, .ET~2. M-dET-3.
are .sm.~: :i ~~airuno ~cld peptides. . Endn:th.eljn::-
1 i~ a potent v:9;sQ~9~~_tiictor tb:~t -w.aa ~flrs.t
ideiltilied: as a product of .:YaStul~ .endG-melliu
cells.-2 'It .is at J~sto~e agent :=tespori.Sipl~.~':(C':r
v.as.oco.nstrktlon. that sh~ts <i'ff~;nieii'St)rua't'
a
ble:edfn.~. It. i:~ aHro potent =s~m~Y>:;,<if:
. roy.ometP~ :con~-ctions .a nd can:M"Afriii~fa:;to
dysmenorrhea, and a .:o:iito~n that,,.can .p:if';;bte: : .
the .'healing...a~d r.eepith'eJi<~.liZation of :the
endomytrium/'J.~~. endo~ell,nsar~.~~grad~~j:Jy .
th~ e~e: eljkephafuiase:. .-Enkepf1alii5);_~'{is :
1ocaliied 'in :endometrial strom?J cells/ab"tf:1fi
specificactivil;Jinthese CellS merea.3esst:rililit:gly
~d in p~el with :ihe W~$e in:bloocl:1evers
cycie.am! declines thereafter a:s t:be plasma levels
of progesterone decrea~e with: re.gression 9f the
corpus 1Uteum.2 .
HO:lW:OtjAL REGULA;'IOi{OF T.m
END'O.M'F/rR IUM
Thefluctua ting levels .of ovarian stero.i ds are
the direct cau~e offue endomet.ria:l.-cy~le. 2 During
th~ first h.a lf ,of the menstrual cycle, all the
components of the .endometrium, including the
glands, stroma:, and blood vessels.proliferate under
the influence of estrogen; during the latter half,
these elements respond to progesterone by the
production of glandular secretions, and .stromal
and: vasc ular alteratiqns nee. ess~ fo r ...
implantation of a fertilized ovwn:6 The f~r.s in
the ,hypotha::lamU;s an:d anterior l.o'b~of the
production it1. the ovary are discussed iidmother

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 152 SECTION II: .PHYSIOLOGY OF P'f~I;GNANCY

chapter {Physiology of the Normal Menstrual proges~rone receptors is d~pendent, however, on ':{;'.
Cyde). pr.evious estrogen action. There are 2 di$tinct ..,
isoforms of ;human .progesterone receptori Yiz, the ~
-:
~trogen Action progesterone receptor type A (PR-A) and type B{PR-. .!:<
..:: .
B). When th~ PRA and PR-B receptors are
~strogen is the essential hormonal signal on co-expressed. it ~ppears that the PRA c an aet as
which most events in -t he nonnal menstrualcycl~ inhibitor of PR-B .ger.e regulation. Th~ repressor
depend. 17~-estradlol, the most biologically effect of PRA'. may extend to other steroid
potent naturelly-<X;Curring estrogen~ .secreted by reeeptors, i.."lcl~dirlg estrogen receptQrs.= Thus,
the granulosa cells :Of the:d:otninarttovarl.an follic1e prb~esterone is believed tQ llinit the gr,owth <>f the
and lut~in-ized ~ulo~a cell~ oftbe .c 4rpus endometrium during the aer:eto:ry ~se of
lutewn: ~nten the endometrial ceil from blood by the cycle by its intederence with est.to_gen ~ptor
simple <Wfus~on, ls se.que$tered -lUltl t:ntnsloea~ e~pression ~nd its stimulation of
tc) t be nu:Ct~u:a where it is oound to -e -tt(lgen l7.J)~bydro~ysteroid d~hydroge4Jt~ and
receptotmnk.cUles. Eatt-codiol ac~n iS (l(mtplele sutfotransfera~e. which .c onvert estra,diol to
e.nd appeal'$ .t o involve two cla~sieal .nu!-ea:r estrone sl:ilfate (which is rapidly exer.~ted fr:om the
bo.rmo~~ ~~~~ptors., <4es~sn.11ted ~s cstr~ge,p cell).l7 Pt'Qgestet.one .m ay also act by .receptor-
reeptor ~ (lt~}: and.esta.gen iceptor -~ ~). inde~riddlt .nw~gep:omic mechanisms.2
Th~s~ !'~cep~onf cail .<Cxm'\Jit .dlstincf flu~
Q.iftem..~a ,iri :~lativ ~ion. ac>th ~~- The differences in the nw:llber and ectivity of
~poor ~pl~~ - ~ . p.s b'ell~ptio!UlUaelrirs steroid r.eceptora in tbe various parts of th-e
the:t'~Ple:~te.d-Witb~We;C$.~~~~=- endo~etijunrma:Y, .e,xp]ain, their :!V,~tions in.
eletg:ent~(>fs~c.~-.s~-~~~~~cell,,,.,,_ ~:nlorPh~J~-~~P.9A~;to bQ~OJi~~~ Th~:bigp.est.'
h) th~ :biild,ing_..c).f...othet. :eatt-o~.--~ ;these.
..concentra:uones. of.estrogen . P.a(l .pJ1>geaterone
rccep,tot:~~. .t~:rgd~ . _Jpr s~!~(<tive , et:*tog~n dlirlng-the midpn>Jiferative ~eptora are found
.rnO<httatora.. 'fhe-m~p:Witb ~t$id ~.<!a pha.se.of the eye~.~ .~ tin;le 'W~en:es~olin the. .
b$.p~~!ce~~~~fic:~~.#a#~tio.n p~is~g<~dntitotit;'actiVit;'ln,.~
'that~ts:~m :tlie:qn.~ot-~c~er('.-: .cells : J.S;maxun~. -
:RN:As ~d $pecific PI'QteilU.: Pm.tdils ~th~
fu te.~P9tt~;to.;e~tWS~4 ;a~i)P.'.in~ n4,Qtnetril.Uil ~~on b:4In\U10hl~tocpetnistry te:nllt.$,the
~~ll!!!~;._ . _. .. . . .. ... .. . erid:oiiie.ti.itd ~rim. ~t~~!J ~UJ.~Iffimi hi.the.
' ... .. .. .. - - - . . - - - -- ---"---- . - - . - - PfC$1Uerab"ve-jtnt~:~e$ting-~t~tb~tors
. .1. additional estrogen ~p~rs a.re-mvoTv~'Witli --subliv.~-~~-fo~tion.
~. pro.g~~t~rPn.e ~ptor.s ~t -~'1.\U~tior~, the glap4s -co~tmue to ~ss
PR-Bthmug..~ the :~dlut~:Ph9.~, ~~that
The ability of es.t radiol to Work i n.t he ,ceU glandular secretion seen dUring. th:e luteal phase
nuCleus and -a t the ~ell sur:ta.ee to cause rapid is PR~B regl)lated. In .eontrast. th.e ~ma and
changes . in :cell ..s-igrtalin.g molecule>$ 1~ one prede_cldua1 eeUs ~'xpre.ss..oniy PR--' ~ughout
e:xpiaila.tion ~ror tl):cotJ:l'p1~ ~pcn~s '!Seen as :a the:: mens~~e. ~p.~stib.g that p~ne
re.s utt r;;t .est:rQgen thata.pie~. . s~~~ted eve~tsWithiri :t he ~J:troma are media,ted
by th~s receptor. ~
It is -~ely that ,e~tnad.ioJ ~d oijler hioactive
esq-Qgenseau_s e ~plication :of ~e eu(lom.etrium THE ENDOMETRIAL CYCLE
lndireetly .(thrQu.~ actions .em stromal cells) .
.Based onJmm~obl!jt9bemistrY results, ERa is Dating of theendomet.'illm refers to the classic
expressed 'in gland~ .sttQma,, ~ood vascttlar eeU~ of 28-day cycle, in which ovulation is assumed to
th.e endometrium and ieveis .p eak duripg the occur on day 14. Since the :postovulatory phase
. pfe>liferative phase of t..'le cycle.2 is constant (14 days :t35 hours), it is appropriate
to designate .the thir.d posto.vulatory day for
Progesterone Action .example, as day 17.

. Progesterone enters cells. .~y diffusion 1;111d in The day i.nimedi~tely preceding .m enstruation
responsive tissues becomes assoCiated. .with . is day 28, an(\ :the. f1.rst-day bleeding is day 1. of
progesterone receptors. The concer.ttration .of Becau se Uie range th~ normal ~enstrual cycle of

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 CHAPTER 10: ENDOMETRIUM AND DECIDUA 153
-----~---------~-,-----~-~~---~--------:;..

is from 21 to 35 days, the pre-oyulatorJ p"iiase may and stratum spongiosum. The superfic~narrow
vary in length from 7 to 21 days. Because of this stratum cornpactum. consists of the :n ecks ,Of the
variation, it is "inappropria~ to designate the days glands and densely populated stromal cells. The
of the pr~vulatory phase of the cycie by numbers. underlying, broader stratum spongiosum-consists
lnstead, the terms "early,. mid", aq.d. tate"" prlT11arily of .glailc,is. with les$ densely populated
proliferative are Used. For example, in a 28-day stroma and large amounts of interstiticl 'tissue.
cycle with a 14~day preovulatoty phase, days 1-4 The functionalis layer gro;v~ during the cycl,e, and
would coincide with the menstrual period; (lays a portion of it desquamate_s at the time of menses.9
5-7 we>Uk\ be early proliferative; days 8-10 would .
be midproliferative; and days ll-14 would be late
proliferati~~ ov:ulation occurring on or very near
day 14. .In the secretory phas~. progres$ive ~ -

c,hanges :o ccur fl.:~m qey to di;ty _thl\\t the

endometrium can be -dated" accUr11tely by
histologic criteria. bay-by-~y dating is difficult
in the proliferative phase because -o f the
considerab~ variation ainong women .in the length
of U'lls. P~ .or the cycle.2
. ..
The S.n'i~ stages of the.ei)dometrial cycle "
in;:1:_~$pdft~ to ~e ovarian sex-steroid hormone
~eti~~:~~: .:. -
1: Men~ttualjpost menstrual..~pithelialization .
. ~ : ~. :~.
2. E;nd~nnetr.ial -proliferation ~ response to ..
: :~'I :~;etU.:ri~tro.n {directly or indjrectly) .by estradiol
a:. i:~b)lilifa:nfgl~dular secretk>P..Jri r esponse tO
.:' the i:(iombined : action o f :estrog~n and
progesterone
4. Premen.s trual ischemia. the result -of
e:M~mtri.Ql tissue v91un:u~involution; ;which
ca~tasiscOf-blood,.:in~:thi.spital..arleljes
5. -Mens"tr-uat.ionf . ~whic-h is --:pree.eded--and
accom.panied.by severe va~oconstrictlon of the Figure 10.1. Patterns of histologic changes- throutbout
endometrial spiral arteries and collapse and menstru&.l cyCle.
desquamation of the functionalis layer of the
endometrium. 89
These zones or stra,ta can be distixlguished .
durfug the second half of .the secretory pha$e of
the endometrial cycle. 2
Huma.'"l endometrium is made up of two basic
layers: the basalis layer, which lies above the Early Prollfera~ive Phase
myom,etrium, and the functio nalis layer, lying
between the basalis layer and the uterine lumen. 9 After menstruation~ the endometrip.m is only
The purpose of the functionalis layer is to prepare 1 to 2 mm thick and consists mainly of the basalis
for the implantation of the blastocyst. The purpose layer fu1d a portion of the spongiosum. Under the
-of the basalis layer is to pr.ovide the regenerative influence of estrogen, 'the .runctionaiis layer
endometium following menstrual loss of the proliferates gre.atly by multiplication of bOth.
functionalis. 1 The basalis layer consists of glandular._a nq stromal cells. The .glandsare small,
primordial glands and densely cellular stroma, tubular and s hort a nd appear s.pherl~c;rpss~
which changes little during the menstrual cycle section. The lining epithelium is cti~idal . to
and d9es not desquamate at the time of columnar and the nuclei ate ovoid.at:ld~sany or
menstruation. The functionalis layer is divided centrally loca ted. Mitotic figures are a"l!>nndant.9
into 2 strata or zones, the stratum conipactum Mitotic activity in both epithelium a.n d stroma

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154 SECTION U: PHYSIOLOGY OF PREGNANGY

~p-
per~i">ts until da,y 16 to 17 {2 to 3 -d.ays aiter
O!Jn'la:tion) . By the f+!th day of the c ycle, the
~~pithcl.iai ..surf.aee of the endo.~etrium ~s been
re.s tored and rev.ascciariz8.tion ofthe endometriUm
is In progtes~ . Reepi.tbelializ.ati.o n a:nd
ap.giogenesis ere :ir.nporta..."lt to the cess~tion of
en~om.etrial p leeding at the e-c.d of menstruation,_
ant i' these processes .a re dep~ni:knt on tissue
Te-~.i (Rig-ares 10~2& 10.3) Estracl:iol appears
to -act by ihducing gro-wth facto~ gene.expr:ession
:in stromal .:cells. ~st;rogens also increase l0".._3l
pr.oduetion ot .vasCular endotheUW .growth factpr
which qip.se~ angiog~n.esis thrOugh-the elongation
of v~.a-~s ln. :the Qasalis.2
Late Proliferative Phase . :~.
..
i:;>urin:g late proliferative phas ~ . the
eadomet:dum - thick~ns due to glandular.
hyper'plasia and an inereaS in stromal groU.nd
substance (edema and proteinaceous material). In
the fu:nctionalis la.y~r. the strcma .iS loose .a tld the
glands ar(? wi:d:ely separated, whereas in th~
basalis layer., th.e sq-oma is denser Q!ld .the glands
are t1;1ore crowded: -At midcycle.; as the time or
ovy.lation i.s approached. the surface -~pi:th~lial
cells a9qllire hulnerous microvilli -E.Uld' cilia, whlch
aid L.-i the movement of endomdriru ~tions in
t..~e .seci-etoty phase. 2 ~.Fig\lres l;!f-4 & lO._S~ .

.'
Ff.iun: l~A.f.atet>t:olifurativ::.

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 CHAPTER 10: ENDOMETRIUM AND DECIDUA
Early . ~ectetory Phase
Dating of the endometriUm during this phase
is based on the histology of t})e glandular
epithelium. After ovo.!laticn, th~. e8trcgen-pritned
endometrium responds to tising levels of
progesterone in a highly predictable manner.' By
day 17, just after ovulation, _glycogen-rich
subnuclearvacuoles:appear i."l the base ofthe>eells
lining the glands. 9 (Figures 10.6 & 10.7) This is
the fJist sign of ovulation that is renected in
histologicalchangesand Ukelythe resuli: ofdi.r.~ct
prpgesterop.e action through the progest~rone.
receptdf$in ihe' glandul.a!-cellS~2 As proges~e
levels rise in th'! ~ly luteal"phase, the glycogen.-
containing vacuoles ascend toWard the gland
lulllinil(day l8).. Soon thereafter, the contents of
the ghinds tit~ -rdeased into the ~ndom~trial
cavity.(day 19). The gtyC(lgen_.Provides energy to
the ttet~AoatUig blaStocyst, whic}l ieaclles the
ut-~~e ~~vity 3 % da,ys after fertiliZation.
InipliUltatiort~ occ'Urs .o ne week after fertllization. 9
Glaitdttlart;cell mitosis ceaSes on d~y 19 due to
riShlg teJcl:i((jrprogesterone, .whih antagor..iU the
m!tbtic elfects ~fe~i:rogen. Estradiol action is al$o
d~~.:~uee ,or the g}andlilar expression of
th~': t_ype" 2': form of . 17 .tl-:hydroJty~steroid
.d$y~ge:iiase~ whi):1 CQ:nverts ..estradiol to -the
~ -aeti\re : est:rOgen, estrone~~
Figure 10..6. Early secretory.
Scanned 8y:
155
Mid to Late Secretory Phase .,.....;
' :
:;.1
The dating of the cycle in t..'Usph.&se relies on '
changes ~een in the endometrial stroma. On cycle
days 21 to 24, the stroma becemea edematous.
On days 22 to 2-5, stromal cells surrounding the
arterioles begin to enlarge, and st.:-omal mitosis
becomes apparent. Days 2~ to 28.arc cha."'acterized
by the presence of predecidual cells, whkh
surround the spiral arterioles. On cycle days 2 2
to 25) the glands" exhibi~ ensive coiling and . '
secretions become visible within the. lumen,
striking changes a$sociated with prestecidual .
transfom'latton of the Up~r ~o thiids or'1be --
. fuhctioruilis layer. On days20 to 24 (the .so-:<:alled
window of implantation). the surfaee epithelial
cells show a decrease. iri inictovilli and ciiia on
cell surl~es .1;1.$ w1111.~ Pl9tr\!~~9J).S QfllPPl ~11
surface bito th~ l~en~ th~ Ptotr~~-:~Uled
pinopo4s. ~ i!n_portant event in p~tiOn for
?Iastocys.~im~~tatjti~u~n~roiitcldewiffi~.
mUle surface gly~yx that alloy,;~'ce
of .a blastocyst.2. (Fig'!l~s 10.8 & 10,9}! lii'~~il~ .
an important chara-ct~stie orthe ~j'ij~se
end.o mettium is the $triking ~ groWth~.. and
development ofthe cpiled orspiral ~~ries ~ch
becoxne.mucb~ret(>r:tu~u$-atthis~:~l. .
endometr'ialcycle-specific;inodiij~tiop'ifm.t;pC~_i-ate
of blood ..flow in the spiral arteries .~ ~tial
. . . .' ..
Figure .10..7. Early s ecretory.
pcaii
~
156 SECllON II: PHYSIOLOGY OF PREGNANCY
for the initiation of men$truation or, should
fertilization occur, implantation. The developmept
of t:Pe spiral arteries represents ~ extraordinary
induction of an.g io.g enesis, consist.ing of
wide'spread sprouting and extension of blood
vesstls;2
Post9~tory .. Endometrium
In the catarrhine primates, the midluteal- .
sect~tory pha$C of the e.nd.:)metria:l cytle is the ...
. proau~e~:,blter.leUldn'fB~ .{I'k.:8}~:;.a}'epem<ltac.tic,.-,.
. to .:mens~a~on. . f4.qn~e :ch~W..Qta~ ~e--
- : 1 (MP,.,;l}:i$ ,~p~~;factprl:hat qan:l?e~the~
Fliure 10.9 Late Eecreto.ry.
Scanned 8y:
eritical branch point in the development and
differentiation of t he endometrium. With rescue
of the corpus luteum and continued .progesterone
secretion, decidu'alization conti-nues. with
luteolysis however, })fOgesterone production drops
and L'le events leading to menstruation will be
initiated.2
This occupies 2 to 3 d~ys before menstruation
durlrt~ L'l.eregression of corpus hiteum and rapid
decline in estrogen and progesterone se:cn:tion.
There is m~ked reductipn i n thickn.eSs.of the
endometril);m and -'C911apse of the glarids due to
lo$S of tissue. fluid, aad intense coiling of spiral
arteries.
Nota~ly, .t bere.i$ inflltl"ation o ffue strotna ltv
pol}tmQrphonu cl.ear l<mkocyte;s. giving a
pseudoihfi~ma:tpry . ap~a:pce t6. the tissue~
t.h~ end6thettlal- $trQ~~ ~d epitheliai cells .
actiyatiilg=.factor :=for .':pe\itrophil$~ T:hi~ ,Jtiay ~ to .
r:ecruit:~eu~rihll! ~ t,he :endQJI\etr:i,~ .N St: p~or: .
.
by $ti:'OhlalicCll~. 'fhis,-is a.poterit't;he.'iloattra,ctant,'' -
for mono.;.""'}'tes. . The raie~ ~f ~1;lie-si:. of.!L-:8 and ..
MCP-l may be PJ.odulated by~ -steroid hormones
8ll4 'fGF... Jh2
-~e-infil~tion.,of:leukoGytes .i s conside(Cdkey.
to the initia.tio.n -of exttacell;ular Il'latrix breakdo.w n
of the futictionalb.l<J,y~r~ .T he 4ivadihg.it.uk0cytes
sectete etlZyn\es that lire lllenibers of the b11l.trix
met:aUopro.teinas e f-amily o-f ptqteins. 1 hese
metailoproteinas~s ad(\ to the ptoteases already
produced by s~ll\M .cells. The rising level of the
metatloprotei;na:se~ tips the bal.a nee ~tween
proteases .and its irihibitors, effectively ini~ting
degradation of the IIHl.trix. This phenomeobn has
been ptqposed lo .initiate the events leading to
menstruation. 2 .
Menstruatlon (Figures 10.10 & 10.11)
Markee surniised that the vascular ~ges .
that occur in menstruation are in response to
growth cycles.fFigure 10.12). He also surmised
that there were .marked changes in blood flow to
the endometrium during the time of growth
r~gression and that these changes are e~~ntial
for menstruation, that is, endometrial shedding
c
 CHAPTER 10: ENOOMETRIUM AND O'ECIDUA 157
-----------~-~---___:_------:--~-...,__,~--~----- -~

with bleeding. He ~mphasized that the .

endometrium is supplied by two types of vessels:8

1. Straight arteries, whiCh supply the basal one

third of the endometrium. .
2. Coil~orspital{cur~) ,arteJies, which supply
.the superficial two-thirds of this tisspe. (Figure
H>.l2)

As the regression of the endometrium .o ccurs,

the coiling of .the spiral arteries . become:s
sufficientlY severe that the resistance to blood fipw
in. thee.e vessels is increased 'S trikingly, causing .

~ .t0.12Uterine ~ture.
r

hypo~ ohhe endometrium. Th~ t<;~~ta~.~i~

is fue .primary.cause oltmt;ioiJl~trialf#ero~;~d .
then tisst ie degener.at:ion. A ,;P.eJi~i~f
vaso.constri~tiol\ p.recedes the':'.onaeti>,of
menstruation and is the tno~t .s triking and,
constant wcnt.obsenred in the ~I);Str:q:a,l ~
The inten$e
.
vaW<::onstrlction, ,o f -the spifal
. .
8rter1es
-
..
,. ,. _
!. ..,~ r.
. serves to funit b!ood loss during tnen~traati,.z.
:' ... . .... ' ..
~ ;
\ .. '
~

Menstrual b!eeding is .qf both . ~ and

venous o~gin, bu,t.~efial.p_l~g1~t~ifibly .
...g
. reater;-Eridometriatblee'difi~'i"Ci'tiJ~"'""""-
' : . ,. e-k':'~g . ~ - ..,.J...
----- -----... --- - -:--- - .
ru-pture~r-=m--men't>n!;or "by~a.
spiral artery, wiH~ consequen:t :bel!1:!ltQma.
fonnation. distension and . ruptUre ottruperli(;:ial'
endometrium. Then fissur~s 4e'le1Qp ill th,.e
adjacent iunetionali:e layer a nd b19()(1 .and-
fra gments of tissues are detached. Hemorrb:age
stops when the arterioles ate agajn CQilstricted.
The changes that ilCcbm:p any l>artial tissue .
necrosis c:l:lso serve to se~l off th.e tips of the
vessels.2 Reeptthellal~tion occurs bY Qiension
of the residual glan<iular epithelium O\fer the
denuded surf~ee. The peripheral .~gions of the.
endometria l cavity, such as tbe isthmus and
perituba} ostitjm, both of wbjch re~ intact
during menstrual period, also c ontribute to
. tl :- , res urfacing the endometrium. u
...
' : , . I'. CLINICAL ASPECTS OF MENSTRUATIQif
. ~-.
Menstruation is the periodiC disch'1rge of
FigUre .10.11 Mens~ation. blood, mucus ari.d cellular. debris from. the uterine

Seanned lly: C
 (
158 SECTION 11: PHYSiO.lOGY OF PREGNANCY

;,.
mucosa, and occurs at .more or less-regular cy9llcal
and predictable intervals from. menareh~ .to
menopause except during pregnaricy~ .lactatk)Ji,
anpvuiation, or pharmacological mtervention.
M~h!retcrii to til~ first ~u;ti~. wb~s
the term -pu~rty e ncompasses tP.e en~ proce:ss
of sexual maturatj on ln th~ ttan's itio:n t.r-om
ch.il9h~. matUrity.!~ .
. .m ature decidual cell becomes surrounckd by a
endometria) stro mal cells adjacent to the spiral
arteries. and arterioles, then spr~d througbout
the Uterine mucosa and then f.1"9m the Site of
implantation. The endometrial -stromal cells
enlarge to form polygona!orround, decldualcells.
The nuclei become round and vesictilar, and the
cytoplasm becotnes clec:tr and basophilic, :and
surrounded by a tran~lucent membraue. Each
.,..

The average tii:ne.:!Jf'onset cfmen~e is how . p~ricel!ular .memQran~. The ~ficellu1ar atrix
betWeen, ~ ~ 13 years of..age, bu~~y-~ a:s su~ounding the ..decidua1 .cells may provide for
ea.i:ly ~the lOth or as late -~ 'l6._year. It _ijlf1ow at~aclitn;ep,t of the cytotrophoblasts through
b elieved that \yAy compo%ifioill~ more in:i~t cellular adhesion mol~les. Tlili3 would -~de
-than Ple totnlbody-~ghtirtd~thethne the
.scaffolding for trophoblast att-,acbment. Th~
of -o~set o~ .pubettyand ~~~n. ~- peric~lltrlar de.eidlJal cell JP.embqme -a1sp .may
provide .for prote;Ction ,of ~e -decidual edt :agakst
The mpd~ interval -at which .menstruation selected. protea$es..of the (fy!dtrophobla.st!i. .
.oectrrs is con:skiere4 .oo be 28 da~, but there .i s
consld~~e va...-riatiun .e.tru5ng \VotnenJn. general The.deddu;i'~fp~cy;f.scCb~-~.fthree.
an.d-ln the l*.Id<m;g&s e:f 1;1. :given we~ h:W.zze parts -J(a~d {)n ~t$ -~atb.iiUCiU' focati~1i..:tF1guie
a:q:d~~ {196~) an~~ $0~PSS~~tmal 10.1~1 Thq>_o.ition:ofth:d'ec}:dua.dheo:..~~th.
. .cy.~~~~d~rop:du4ed.<tb;at-tli~.m.e,an.:fot;~,cy,~l~.- '!he :site ofb~~tocyst:iffip4uita&n<is ~ 'by .
- : was+~~;fi~.aY.:ao:'~:)the.di~J'~1i~nf'~~#lou.p.:ti~f<~.:, ...trnp.il~~1a~t..;-,i:Qy.a~ion:.;~d.,~o.i:U~~-?th~A~ua
:m~~:now,is..alsb,~~~durition,:-: basaliS;; _;that':I>j).(Q.o:n.ov~:r'lyliig:-~e-en:lar,P.ng,-:
Js +6 -~dey~. altb.o\i;:gli.::pl~g~ {Q.!-i';2.::8':$ty;~: i.s. , blaStocyst, ful.dihiiti.aJ.Jy ,~~&.g.it:~::!he Ie:sf
co:ni>ld~ !itqi'maL'Th~ A.~~. ;~fof~ . . of the utt;~ ~Vity-, <is::f:ii.e 4~ua .~s.
loS't:by :Women dtlling :~ no~.;n:lf"ilstruai.,peiioo.. .. The ,decidua;~p.sUlalis is.:P.wst~pr;olilinent during
..
.-~--~uf2~~$.1; ~tli~e:..o;i.riig:::of':iron.:IO'Stcrot :. fue seroniilw~t,h- of. pr.eli~cy ~d.mternall.Y. is..
every d~:y of:fbe .cy.c1e. in contact :withtne-avasc~-eXt:ta-eiL.~~c-i'etal
membrane, the choiioilleave. The ~der of
-:11!}m.~~~~l ~<!!~C.~m.~-:~p.~. uf .~he,d ili:~. u~~i! is:-~e~r :~Y ~e d~~u& .-~ - . _e~~~~
fr;a"gm~nts:oh~.ndo.metriu:nr~irl't:lr.a~~le. . .. some-tinii!s-.ea:lled-thedemd:ua--vera-aMhe"'p omt-m.
:qtum:titfofbldo'd.:~U,su.ally~-.fhl:.J?lQo<Hs~liqcid;:bUt development -wh~n .ded.G.ua-cap~"Ulaits -and
:if :t.lie -:rate of 'hemo.frhage a ;~~. . cl6t~ of deciduaparietalis ar.ejoined atabo~t 14-16week~
variouiJ ~s ~y: a..ppear. ;Men~ -~li>Q:d is of pregnancy. A~ this .t:inle , the ~din.g-~.ac h as
usuftnfin:a -~tate ot~~~ 1t is~. enlarged-'~no~ghto fill theuterine '~tr. and with
th,a:Ht:is,.eoa,g\lla;ted-a~dt~~~:but'it i1l'liquclie. fusion o'f.t he d~dua - c,a,p~1iJ:ariS ~d '}>lirieti:ilis,
by fibti:iltilytlc:activityin thi; en<lom:etrjurn~'. ' the utet.in~,q:ay.ity- :i;;Jun~~f."O;l>litetate~t II1
eaily prefA<iney. :the..- d~~ua ~~ to -~tl!ldceo,
eventuiuy a~g'a:d~p .qf $,..~~0 ~2
. .. . .. .

.. The<decidua -is .the speci<ilized-- endo~emuih . The deCi~ui parl.etaJis 84d-.dCc;i.dua-Q3.$alis,

of p~gncmcy. Th~ bi~hemi~ ~e between like tl~e ~~ec.r e t ocy ~ n:db:m,~tri~m, each,' a r e
the fetoplB.centa}..urut and the :inother ID:U$:' pass. composed of thr-ee laye~" a surla~. or compact
back. and. forth .thn>ligh the decidua . 1 zone {zonl'!,..com.W,.cta);.;a priddl~ ~'rtio~ or spongy
b.~c;iduaUzation, the - transform~t1on ..of the . zone {zqn?o:- ~.po~gio~a); -with ~D:ma.rits of.,glands
secretor)' endometri~. to d idua, is dependent and tmmerotis srP:all l:JlOod vess~ls; and a basal
on' the action of estrogen and progest~~ .and zone (zona basalis) . The zona .compacta and
fa dor:s secr;eted by .the i.tn.p lanting .bla~.to.cyst spongiosa togetherf~nril t.'le zena.f'un.ctionalis. The
during trophoblast invasion. b asal zone-remains after delivery and. gives.rise .to
new eh.qometriu.m:2
. ln human pregnancy, the decidual reaction is
complete!i only wit h blastoc;y:st implanta tion. The blood supply to .t he d ecidua is-altered as
P redecidual '
changes c
. ommence. . 'first in implantation progresses. As--the embr.yo~fe tus

Scanned 8y: r-..

.

~
 CHAPTER .10: EN.DOMETRIUM AND DECIDUA
----~--------------------------- - ;
grows into the uterine cavity, the ~Jood. supply to
. the decidua capsularis is lost. The blood su.pply
.to the decidua parietalis pe~ists by way of the
spifal arteries, which in turn, retain a smooth
muscle weU and endothelium- and remain
responsive to vasoacth,re ,:;.;gents. The spiral arteries
to the decidu~ basalis, on the other hand., are
invaded by the cytotrophoblast$, and during this
.proces$, -t he walls of these vessels are destroyed "'formation of basal plate of the placenta, and differs
leaving only a shell without smooth mu$cle or
endothelial cells. As a consequence, these
vascular eondu:its of maternal bl<;>od whic:h become
the uteroplacental vessels are not responsive to veiJ:ls; by term, the glands h.ave disappeared,
. .. 'Vasoactive -agents. By contrast, the fetal chorionic
vessels, which transport blood between t'he
placenta and the fetus, contain smooth muscle number and invasivene-s s of these cells to the
and do -~s_p(>nd t6 varoaetive ;tgents. .
.F ipre 10.13. Atrophic Choriontae-ve and ~orion frondooum
growil)g ~to d. basalis.
The primary cellular components of the
d_ecidua a.re the true decidual . cells that
differentiated from the endometrial stromal cells
and bone-marrow-derived cells.
. The compact Iayer.of.the decidua consists of
large, closely packed, epitheloid, polygonal, lightly
staining cells with r-ound vesicular nuclei.
Numerous small round cells called endometrial
large_gi'a.nular lymphocytes (LQLs) .aie scat~ered
among dedd1.tal cells especially in early pregnancy.
. They :are a pa rticular type of naturai -kille r
lymphocytes tha t are bone marrow-9erived.2
Seanned lly:
159
..
Early in pregnancy. the spongy lay~f the
decidua consists of large distended glands, with
marked hyperplasia and minimal stroma. The
glands are lined by cylindricat u terine epithelium
with abundant secretory activity that contributes
to the nourishment of the blastocyst.
The decidua basaHs .c ontributes to the
from the decidua parietalis in two im};X:>rtant
respects: 1) the spongy zone of the d~dua basalis
consists mainly of arteries and widely dilated,
2) th~ decidua basalis is invadedby interstitial
trophoblai;t cells and tropbobla~tic giant cells. The
myom.etriunf may be . suggestive of
choriocarcinoma to some observer$.'
. :Where the. invadillg trophoblas:ts me.et the ~
decqua;, there ts a -zone of:.fibrinbid degeneration, .
the Nitabuchs layer, which is usually.:aJ>sent,when
the decidua Is defective, as in placei\ta:~~ta..
There is also a more superfieial, but.linebh~lstent
deposition of fibrln-Roht stria-a:t-'ffi~. bOtWhf of
the intervillous space .and .surrounding ,. the
Anchoring villi.' .
,;,::;~; ::3 ~;;r~:. ~~:>:~~).
Prolactin ln the D~cidua
. .. The. decidua is the source of prolacjin ,ijtat
is present in large amounts:in the amnioruc fluid
during -pregnancy. -bevels-reaching.-to:as-high
as- -10;000 ngfml.; of-am.i:rionic:fluid are found
during the 2 o.h to 2-4'" week of -gesta~on. This
level is very high coi::J;J.pared with the 350 ngfmL
seen in the fetus -or 150 :to 200 Iig/mL in
matemalplasma. Prolactiriproduced hi decidua
preferentially enters amni()rtic fluid and little or
none eniers mate rnal blood. The physiological
role of decidual prolactin is still unknown.2 It
is believed that decidual prolactin regulates
amniotic fhlid volume and electrolyte
concentr'atio.n s. It can be demonstra ted that
prolactin regula tes water and ion transport in
lower animals, and prolactin binds to amniotic
membranes. J:)isor<;lers in human pregnancy
associated with abhormal amniotic fluid volumes
may be explained by this mechani-sm, especially
id!opa thic polyhyd:runnlos (which is a~ciat:d
wtth a decrease 10 the number of Jt.ljplactln
receptors in th.e membrane). Prola~~it, ~ay be
involved 'in the regulation of surfactant synthesis
in the fetus, and prolactin may inhibit uterine
C
 SECTiON 11: PHYSIOLOGY OF PREGNANCY

' muscle contractility. Prolactin -suppresses the conceptus. Prolactin can a-lso funclion as an
immune .respon.se and C(Hltri~e.$ to the autocrine and paracrine growth factor in the
. pn~Yention Of immunologic refection of the . uterus. 13

POINTS TO REMEMBER

Endometn~m is the mucosal nnlng 'Of th~ uterine cavity

Cycle days:2.0 to 24 :....window of endometrial receptivity t() blastocyst implantation

. lnterf~y :is prOduced by activated l..Jymphbcytes Bnd inhiblts ~ndornetrtal epithe1ial proliferati0n

leukemia inhibiting.factor (Uf:) i s :abundant during the secret~ry.

mbst phase.and.earty decidu;~S
and m.ay have 'a roie .:in embryO :imp1anta~l) . .

- Tumor necrosis factor~ .(TNF~) ~xettsmuttrple. influence on.~llulat growth in the endometrium; its
' aGtivity iS increased _:ttuiin!J :the .proliferative and -m1d$ecretory phases.

~. 'Epidermat~gJ'OWUt-i:taetpr:{EGf:>:-'~1idts',~~en;;tike: acUoPS'PY inte~cting:= ~::esttQgen=~ptor:...

meChanism . -

:. . ..TransfOmiifl9.:growth't.x:lw<l'ffGF~}10fks'~lfgh the$me.:reee:pt()r~:~GF and Q(>th are imP,Q$nt

niediators.of.estrogen..f[!duced;gtowtttof-.tl\Q ;endometrium
. ' .
.
... . . . . . .
. '

GrOYJth.F-aci:or~I,G5}:.pc:(K,r.OteszCe.llu~r: mitoslsJm~ dlTj~enti::~i()O:, .

lnsu!in4ike;_

, - . :IGF;;Hs predomlnantln proUferaiive and ~rty ~ecte.tQry :phase; medi~ts estroget:Hnduced g~

:oUha-endometiium . . ....

IGF-11. appea~:in thi!l mid to late:s~tocy phase and persists in earty pr:egnancy dectduas, involved
Indifferentiation tn response. toprogesterone.

GnRH In human decldual cells tncreasas the .expression of -matrix .meta!loproteinases

. .
TGF~:stlmulates the prOductiOn of.:pata'ijlyroid.:hormone-4ike protein

Thrornboxane K1. is synthesized by uterine tissues, is a :potent vasoconstrictor and stimulator of

smooth muscle eeils

FibroneCtin andlam!nin ~re. ~xtrcicellutarmatrix substances secreted by strom9l cells in response to

progesterone :and are important adhesion molecules during implantation

PGf..2t1 is a vasoactive,peptide produced in the endometrium and may have a role .in the initiation or
menses -as a vasoconstric;tor

. Endothelin-enkephallnasesystem is - ~ hormone responsive paracrine system in. .the endometrjum

that serves to regulate. spiral artery blood now through the- .actions =of :vasoactive. peptides. like
endolhelihs arid the entyme enkeph~llnase

Scanned 8y: ~
 CHAPTER 10: ENDOMETRIUM AND DECIDUA 161

17p-Estradlolts the most potent natural estrogen secreted by the granulosa cells of the dominant
follicle and luteinized granulosa c~lls of the corpus tuteum. Through Its influence, the endometrial
glands, stroma and blood vessels proliferate during the first half of the menstru~l cycle.

Progesterone is the horfllone secreted by tha corpus luteum during the second half of the ovarian
C%1e, it acts through progesterone receptors type A (PR-A) and type B {PR-B), limiting the growth of
the endometrium during the secretory phase of the menstrual cycle.

Dating of the endometrium refers to the day-by-day dating by histologic criteria of the secretory
phase of a classic 28-day cycle

The basalis layer of the endomebium Jies a~ve tha myoilletrium and serv.es to p~:Qyi(je the regenerative
endometrium JoUowing menstrual loss of the functionalis layer.

The functionalis layer .of the endometrium lies between the basalis layer and the uterine lumen. Its
purpose is to p~pare for. the implantation of the blastocyst.

During the earty orolifetatiy~ phase (days .S - 7 of a 28-day .cycle}. the endometrium is only, to 2 mrr.
thick. By the ntth"day of the cycle, the epithelial surface of the endometrium has been restored c;~nd
. reV.ascularizior. of the endometrium is in progress.

~ D~rlng t.he Jate proliferative phase (days 11 .-.. '1 4 of a 28-daycycle), the endometrium thiCk~hs due~l&tt:'
glandular hyperplaSia and an increase in Stromat ground substan~. : 1
nte early .secretory :phase comprises.days 15 - 20 of a .28-"day cycle. By day 17, glycogen-rich
subnuclear. vacooles appear in the ~se of:the cells 1ining th~ :glands _ '*, :. , ':>;,;; .

THis Is the first $lgn of .~vulation and IS likely the result of d!rect.progesterone actiOn in thEi"glandOl~f~?;..
cells

During . the mid1o.late~secretory-phase-(day&:2-t to-28of..a-28-day-cycle); dating-relies on changes.in

the .. $troma. Outst:mding--features. are predecidual transformation of-the .uppert'No thlrds of the
functionalis layer, decrease in microvilli and cilia on cell ~urtaces, protrUsions of apical cell surface
(pinopods) into the lumen, and striking growth and development of COiled or spirai arteries

Postovulatory er'ldortn::tfium is the .mid luteal-secretory phase of the endometrial cycle and Is the
critical branch point jfi the development of the endometrium

The premenstrual phase occupies 2 .to 3 days before menstruation wherein there is regression of
corpus luteum and t.:lpid decline in estrogen and progesterone secretion.

Infiltration of leukocytes during the premenstrual phase is considered key to the initiation of extracellular
matrix break9own of'the functionaUs layer and eventually to menstruation.

Menstruation occupies days 1 to 4 of a 28-day cycle

Period of vasoconstriction precedes the onset of menstruation and is the most striking and constant
event observed in the menstrual cycle.

Decidua is the specialized endometrium of pregnancy

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 f62 SECTION Jl: PHYSfOLOGY OF PREGNANCY
.. .;.
.. /1)

3 Parts of the.Decidua of Pregnancy

o Decidua ba'sans ~ portion cllhe d~idua .directly beneath the site of blastocyst implantation
o Decidua eaps:u1aris - "tt1e portio) overiyinQ the enlarging.blastocyst .
o Oeddua parietalls- nnes the remainder of. the uterus

3 Layers of .the "Decidua Pari~talis

o iona compacta- surfaceor. compact zone
o z6na spongiosa - mlddJe Or-.-spongy zone
.o zonabasalis --,the basal.zone

. Nftabuch's layer iS a zone of fibrinoid .<leg~neration where the invading tr:Ophobtast$ meet :the
~; decid. lt.ls absent when
the deCidua is defective, as in p1acenta accrete

Prolactjn In the~ 1s as high as 10,000 ng/ml of amt:lonic fluid :on the 2l)!tl to 24 11~>w~l{.d
ges~tion -

Poss.ibJe ro.1es nf eeciduat;prolactin:

5,:,. o ~utateS ~mnic!:ie ~ufd v~me and electro!yte concentrations
S' -~ G ma{b:a.Jrtvohl:&f.tn .the tg\Jtation of S~;:rfactant synthesis in the f~tus
:y. .:'.1 . . !. . .0 may mhwrt :uterine .mu~re.eontractil~y
~-~t, .. . o suppr-eSses-:tt~e-frnmune ~pc>qse . . .
~ .... <.
.:.. .:-:.
:.!~ ~- .. ,
f ..... '...
o,-cal'\,also~ftiniton~as"anra~octine.anct.paracrioe:growth;'factonih.lfie. ute!)J?
'! -. . . . . . . . . . .

6. Wynn RM. 1lre role of .e::J.dvmetrium in im.tJI&n.taio:::~..

In PC W.ong (ed,f: Pl-oceerungs -c f Fifth Po:rt.i::r;aduate
l. Spero!f L, Friu M .The utetu:s.. In Clin Gynetol Gourse. ACOG Annual Convention. 1992; PP; '103-
. .Endccrino!..fufcrtil.:..Wiilfa rna and..Wi,llcina.~Ob5; .1.15, . 1-13...... - ... . .. . . ... . .. _.
119.~~118- .. . . . . -.
7. Falany J.L. :Flan:y GN. Re_gulatiofi of e:;;trQgen
.2 .CUnningham ro. ~,L.cVeno .ICJ~ m~ st.' H<J.uth Jc, sulfotrans'f;::'rase in human . enaometrial
Gilstra.p LC pr_ ; 'Westrom KI,). i~n:olaiitation,
embryogenesis and.placental devclopm'dnt. Williams -a:d~n~om~ cells "Qy progesterone. Endotrmology
.Qb13tetrie3;> McQraw-Hill,. 2005; pp. 44-SL . 1996; i37: 1395 .

~- Tazuk.e SI. Giudice :LC. Gr<;)Wth factor.~; a:.nd cy,tokines.
in endometrium, . embryonic dev.e lopm:ent, 'and
. mat~$81: :emb.c y6:nic inter.ac:tions... $em Re.pi:od
End;>erln011996; .1 4: 231~ ''
4. _inet .A, Eugi.n Q, AttiJ.r E, Olive DL. MO<iulation of
leukeniia:inhloitc>cy'fact.(!r:gme.eXp~siOn, and protein
. biosynthesis inhumt\11 end!,)tnetriti.m. j Clin Endocrinol
.Metab 1995; 80: 190.8 .
8. C\lwllngham FG; oa.nt ~F:, Levene KJ, GTis:traplLID,
Hauth JC, We~strom :kf>. Physiology -of ~cy.
Wil.liam:J Obstetri~~. ;McGraw-Ifill200 1; pp. fiS-:83.
9 .. Katz. VL, Lobo RA, Lentz -GM, Gen1hen30n .DM.
Reprp.ductive e ):i.docrin'olo_gy. 'In RA Lob<>. "(ed}:
Com:pre,h~nsive 'Gyn~cology; W Mosby Co .2007;
pp. 107-113 ,

5, Choe CS, . MaeOalman CD, ,L eun:g PCK. Dose- 10. Droegemu.e ller, Herbst, Mishell, Stenchever.
dep.e ndent effects Of,gopaqot.ropin .rel~sing Hormone Rep~~ductive en'd ocrinology. In Comprehensive
.on matrbo:neta:lloprotcina.S<:.{MMP-2,.and MMP-3) and . Gyneco!ogy, C.V. Mosby Co_- ~001; 103-116,
tissue specific 'inhibitor oi metalloproteinase-1
me~ger ribonucleic acid level$ -i n human decidual. 1.1. Mutter GL,.Fenncey A. Anatop:1y and histologyof the
stromiU.ce.lls41. vitro. J Clin Endocrinol Metab 2003; . uterinecorpus. Kun:nan RJ (cd): B~ustein'3 Pathology
88:680. . of the FemaleG.enital Tract. Springer, 2002; pp: 405.

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 CHAPTER 10: ENDOMETRIUM AND DECI.DUA . 163

12. Belsey EM, Pinol APY and Task Force on Long-Acting
Systemic Agents for Fertility Regulation. Menstrual
.bleeding patterns in untreated w omen. Contraception
1997; 55: 57.
l3. MoraS, Diehl T, Stewart EA.. Prolactin is an autocrine
growth regulator for human myometrial and leiomyoma
cells. J Soc Gynecol Invest 1995; 2: 396.
14. Sumpaico W, et al. Textbook of Obstetriql.-2-nd ed.
AssoCiation of Writers of the Philippine Textbook of
Obstetrics .and Gynecology, Inc. 2002.
15. Laylock JF. Hormones of L~e menstrual cycle. In
Blaustein A (ed.) Pat,hology of the Fenl!l)e Genital Tract.
Springer- Verlag 1982; pp. 223-229.

-
~-

.. .
''

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 .- .. - .. -- .. ---- .. --- . . . .. - .

:::

: ..
.

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 11 : .

.;PLACENTAAND FETAL
MEMBRAt{ES
MA. SOCORRO M. SOLIS, MD

Fertilization and Implantation

The Ovum
Fertilization
Implantation

DevelopmentAfter Implantation
Prelacunar Stage
Lacunar Stage
Trophoblast Invasion of the Endometrium
Early Villous Stages
Development of -the Chorion and Decidua

Organization of the Placenta

Architecture of the Normal Villous Trees

Glassifieation of Villous Types
DiffeTentiaJion ana Maturation of Villous Types
Sinusoids' of Terminal Villi

Organization of Villous Trees

Vasculogenesis and Angi og e nesi~

Regulators of Angiog enesis

Oxygen and Oxyg en-Co ntrolled Growth Factors as Regulators of Villous and
Vascular Development
Role of Oxygen in Placenta
Hypoxia in the Fetopl ace ntal Unit
Oxyge n Effects in the Placenta

Hormones as Regul ators ofVillous Development

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~-~. .
< : . 166 . SECTION II: PHYSIOLOGY OF PREGNANCY

; .,...

Non-villous Parts 9f Placenta

Extravillous Trophoblast
Gytokines and Hormones Controlling Differentiation of Extravilfous
Trop:hoblasts ..
Extr.acel!ular Matrix and Matrix Receptors (lntegrins) . - ro
. -~.,.."; .
. : ~(::
:. I ntegrin Switch
Cell Adhesion .Molel;lles .and :Gap Junction Molecules
.Prote.inases Ativ~t9rS/H1bib'itois involved .in Tropho.bl<!st Jnvas!qn ...
:R-oi~ .Ot:Ntw.i>
Q:iCide . . . . . . ,
. Other l=~c.tor;s infl.uehcing_Ttdphoblast.Jnvasjpn .
~cidua . : . ':'
l=ibrir{aid .
Oecid l!o~Tr:oph.oblasUc !nv.asion
: . .
Utemplacent~l Vessels

Fetaland Maternal &ood Circulation

: 'Feta1 .Circ~lation
Matemai 1tculation ..
Placental .Membranes { . .
. .Ainnlon
Amniohlc Fluid .. -..
. l;.'

. Clinictit .and Research AppliCations :"':.....

Teqsile Properties <

Cord .:.:.
.........

,
.I . .

. ..

. ... ~

..

c" ., :1
. . .

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 CHAPTER 11: PLACENTAAND FETAL MEMBRANES 167
------------.....,-~---------~--:--------'-----~~--- -

The human placenta is a hemochorial, villous Fertilization

placental type, Maternal blOod, after leaving the
$piral arteries, circulates through the diffuse
intervillous space and t1ows directly around the
\rilli. The mate~ blood is outside the conf'mes -of
the endothelium ofthe maternal vascular system.
Fetal and ~atemal blood do not mix i6 this type
ot placenta. Fetalcapillaiy blOOd is confined within
the villou~ core a:nd exch~ge of gases .a nd
nutrients occu-r through the outer
syncitiotrophoblast
. . .
bathed by maternal blood.
It ha:s _become hn.portant to have an
unttcrstanding or placental pathology shlqe aJ,1
increasing nuttlber of ~~ with disturbances in. caVity abOut three days after fertiliZation. Fluid
the early steps of placentation show irnp&ired fetal .g radually .accumulates between the cells of the
..and neona tal outcome such as increased
-incidence of pre-edam,psia intrauterine growth
r estriction and retroulacental hematoma and
petmatal mortality. 3 lt ~as -~n speculat~ that
itnproper condi.tions:duritig plate~tal implantation
affect its early dev.e loptnent and 'may result .in
improper functiortihg of the -f?toplacental unit.
Fertilization of the ovum involves penetr'dtion
of the spetrn through the corona radia:ta, fusion
of the oocyte and sperm cell membranes,
completion of the second meiotic division and the
formation of a zygote.
The zygote is formed by the fusion of two
haploid gametes and contains 46 chromosomes.
It then undergoes cleavage into blastomeres. As
division progresses two cells. become four, then
a
eight, and so on until s(liid ball ofeelis are formed
'l mownas morula; The morula enters the uterine
morula and form a blastocyst. (Figure 11. 1)
....
.: ........:-, .
~

.... .._.,..

FER'rlLIZATIOlf AND.~,ATION A ~-n ilage

::1 ;~- "

The fQI"inl;\tion of primary cocytes from which

ova are developed is -compl~te before 'birth. AbQl,lt
two lllillion :priinatt ':~~~- ~- ~r~seitt at birth
but only about 400;'0001ttnain -br-roiole~enc-e.- -
O ver the reprodue~v.e"''pl!ti~<:tatlt '4'00" ' of these
pass through tnatm"ation toovulation. C i-eeU stage

All primary follicles are auested in the -~polo

. prophase of the. fsr~t meiotic division which is

completedjust before O'\rUlation. Ptogres.s through
the
second meiotic .d ivision is ha.lted -in metaphase
and is rompieted when the ovum is fertilized.

. _At ovulation the secortdary oocyte is expelled

with follicular fhiiq from.the surface of the ovary.
The fimbriated end of the fallopian tube becomes
closely applied over the folliCle so that on rupture E early bluloeyot

the oocytC' passes into the fallopian tube. It is
transported to the uterus by peristaltic and ciliary
movem~nt.
Ootytes are fertilized in the fallopian tube
usually witl_lin 12 h_o urs after ovulation, and they.
may not survive for mon! than twenty four hout.s
.before dJsintegrating_
tigure 11. 1. Cleavage of the iygo"te and formation of the
..bl~stocyst. A through D show various :stages of cleavage_
The period of the monila begins at the 12 to 16-<ell stage
and en4s when the blastocyst forms, which ~c,-ibs-wbeli
. then; are -50 to 50 blasfomeres present. E and F a,re~tions
~f blastocysts. The rona pellucida has clisappear'e~ the .
Jate blastocysts stage _(5 days): '11le polar bodies 'sh"PWn in A.
are small, non~functional cells that soon degenerate. {From :
Moore, 1988)_

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158 SECTION tl: . PHYSIOLOGY OF P~EGNANCY

Implantation
Itnplantation takes place 6 to 7 days after to the endometriu.m nrst ~ Th1s adhes1Veness of '" ..
fertilization. At this .s ta.ge the implanting blaetccyst
~ntai.n.~ l 0.7 to .2S6 ceils..a Most of the ctUs -m ake
up the outer well {trophob~st) surroundmg the
blastocystic cavity. This is the forerunner of fue
fetal tn~mbra:ne3 and placenta. :The inner cell rnass
_i(e.o:tbzyoblast) i~ in -~e iQ:Q.er sm:face of.e v~si!?le.
-~
;.tt '
''
' the blastocyst is oriented in such a 'Way that the:;~
embry . onic pole. ~n:_.g ~e em~ryobl.as~ attach t~('~
bo~ trophoblas~ and -endometrium: is a~y --~~
present for _'otlly a s~ort phase. the implantation ,~.
windowS. used for attachtnertt of th~ blastoCyst !(!.
Finding this window is an important prerequisite
f9r succeSsful implantation~ invitro fertilization.
-,~

and the .etnbcyq, umbiliCal cord and art;l.Ilion ~e Alter adhesion, -the n~ process is in'ni,Sion. ~f.; .
. de;.iye_d:frotn.-th~ eells. {FigUre 1.1.1) Trophc9~stic cells of the unpl\tllt4lg c;mb:ryoriic .~
_pol~ ,p roliferate into a doUble 'layered ~phi> blast.6 iV.:
The ~rst .stt.p, qf..l.m plan:tation i'~. ~all~~ The {)1~ter cfthe two layers ,directly -f<icing -~temaJ. ,
appusitioi:l; ~e bla:$~.t J~ adher~ to the ti~J..te fu~s .to fotm t?e ~Jiciti0ti'ophoblSt. The
end9me.t#Um. -Pcpu~Uy . a~ the )lpper ,part .o f the re~g unused cellular components are .c'alkd
posterior wiill..!'lf ~ .uter!Ue .bo<;iy. in -m~$t -~s~s cytotrophoblast
. . . . (FigUre
. ..1 L2}.

.... .

.d12-15

~re 11.2. S~pj.j.fied drawin;gs .o f typical stage; of-early. placcn tal development. a, \l: Prelacuna;. stages. c: .Lac;:unar_
s~e. d:.T~sition:froq~.lS..C}in:ar:to:primazy viU<;>U3.sta,ge. ~: .Secondi!JY villous s~ge. f: Terti!U)' Villous stage..' Note that:tbe
bas3! ~gments::Of the.a nl=h6ring yUlle .{e:f) r:emaig merely trophoblastic, fm~lly forming cell colti.n;ms. All maternal tissues
an in' red;. and !;fetal tis:s11~ Ne ~ bl\le."Fibnnoid-ofmixed, maternal, and .fetal-.origi.n are in lilac. E, cndorilctrinl
ep.i~~l!um;:EB, e~bryQb~S:S~:c:I'~',fit:qtrop~-ob\asts; .ST;:s~tiot:rophoblast; EM; cxtta.-embryonic J?-Csodenn; CP, primary
c horioDic plate; T , .traQ.ec~e an~-R~~-vi.l~ ,J..,, inatemaJ: blood la7unae; Ts, -t rophoblastic-shell; EV; endometrial vess<:l;
Q,.de<;1d1Ja;.~~ 'ru:>~!:l'Jibrinoid;.NF.:i:'Ht<\quci.l~s or ~t~r.opl:).cental.fibrihoid;. 0,-.trophoblastlc giant cells; E'O', ~villous.
cyst~trophoblasq BP, ba.s:aJ.,plaJe: -PB, piac:~ntal bed; J,jutrctlon<1-l zone; M, myometrium: (Modified f.t;"Om Kaufm:;mn &
:scheften, 1992, with ~nnission). .. .

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 CHAPTER 11: PLACENTA AND FETAL MEMBRANES
...,...

DEVELOPMENT AFTER IMPLANTATION maternal vessels to pregnancy conditions and for

anchorage of the developing placenta;U.lo
With progressive invasion, more parts ..of the
blastocyst come in contact with materrtal tissues
followed by trophoblastic proliferation with
subsequent fusion ..

Prel~c-wnar Stage

Froui d~y 7 .8 after fertilizatio~, the

syncitiotrophoblast. mass increases ~d .becQ~es
very thick .at the im.Platl.tation pcle. lt is covered
with branchin.g finget..:like eru:tsions that deeply _..:;
invade the.ertdoJ:l:ietrium.The syncitiottophobiast ....
j~ a continUo\la. ,~y$-ten.;i, :not composed of
individual cells or sjrp,Ci#al units. without
intercellular spaces. Thls staie of':~lid mass of
syncitiotrophobi.a st (with has~ extensions)
represen~ the p~laeunar period.7

Lacuncir Stage
Ficure 11.3. S eetion t:hrough.Jti.i4dle ,of ah.:iJ:D:~g\.'
By da,oy.;!B.:postfertilization vacuole.s begin to embryo a:t 'l tbOut 9 . da)':ll. Re.genet&tion ofthe~d6etrlal
epithelium is taking place. Lru;unae.apP,...ar a:s clear.~~~
appear .in the syncitiotrophobla:st at the in the jarge mass of !J)'tlcytil)t,rophoblast. The~iiiar
hnplanta.'tion pole. These vacuoles grow and e,mbryooic disk is ~~n. (Camegi~ Collection no. 8225).
beCQm~ cqtiQuent, fo~g a system. of !a~u_Tlae (FromH~rtig and .Roek, 1944). .
(F:igtlfe:ll.2). The .seriaratJ.ng,s ynciti<lttophoblasts . ~ . ... ~. . ~. .
are called the tr.abe~l.\lae. As 'inlpl;mtation
advance3:, .t he s;YncitiotrophOblast $preads ove'r the our ing thi~ pJ;".o cess, the endqpi~t.rit,tQl .
entire b}astocystiC surface .i ncluding the lacpnar und<!rgoes cha.nges. The erOding tiophQbul~t; by
sys~. being a n:u:'~J;lanical irrita~t and by honn"'nal
. _. .....-~ - -- ~-~- ... -- . - - --- -- ~ .
.actill.ii}t,- caiiseS:. .the...endQm:etrl,al-.:stroma~ to
By.:da}' . l~ .the 'Qla~t6cy.st.is .deeply. htiplanted ptolifera,te ari(t'.enla!te, ..givfug-ris~tO-the d~duat
and the . uterine. epitheliusn closes ov.er the ceU$;11.12.13
. implantation site. 4 (f~gure 11.3) At this P:ple .the
outer surface of the blastocyst is cQmpleteiy lnvasion o'r l:he s)tndtiotrophoblast causes
tr~sformed to sy.ncitiottophoblast. At it$ Jnner disintegration of th~ maternal e~dometri~ vessel
surface, .it is covered qy a:l~lyincornplete layer walls and matemat blood enters:the'laci1,mae. The
of cytotrophobiast. At 'the itnplantation pole the disintegrating capillaries are surrounded . by the
.trophoblast is. 90nsiderably thit:ker ~m:p~ to expanding syhdtiotrophoblasl~ replacing the
tlle opposite pole. This thicker trophob1ast !s la:ter capillary walls, and fotniing new lacunae. The
transformed to the placenta whe.reas the opposing newly formed l acunae then fuse with the
thinner trophoblast later. regresses to form .the preexisting lacunae thus establishing ma ternal
smootb chorion, membranes. the perfusion of the entire lacunar system . Further
invasion of the 'ttophoblast of the capillaries down .
to the arteriolar and .venular ~ndings provide the
Ttophobta.st Invasion of the .Endometrium anatorr1ic basis for the. final .formation of separate
arterial inlets into .the lacunar system as well as
The.appearance of proliferating and migrating venous outlets. With deeper invasion .of the
cytotrophoblast at the bottom .of the shell starts . endometrium, the spuia arteries are ero~~ thus
trophoblast invasion. This is a ver;y' important resulting in higher -intralacunar blo.od .pl;:~ssure
event responsible not on:lyfot further invasion of. and. the: first real :maternal
.. circulation~
- . . ... f.-the ~

the blastocyst but also for adaptation of the placenta. (Figur.e 1 1.4) ,, .

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170 SECTI
_ON II: PHYSlO_
LOOY OF PREGNANCY . . :;~
--~----------~--------~----~------~----------------~----------------- ~

.s yncytio- eroded maternal lacunar

tro_p~o~ omf\io&
gland network
bla$1 cavity

loc-unar
~-~
natwork

'tr(;:.
"""'"'--"-YIIU:

... ,, . p~:b.l;a~t .':

. . . ) ...
'

:e.xt('a-..;. .
.. . . -'-~\)ryon'ic..
: ,..;tr\~soderm
. .

.A . .. . .. . . ~!;.if~~\ .. B .. ..
~ u,4::~~&-~f~ni':tb:roti&h,hnplant-ed-bla~tocysts. A.~ 10 d~s. B. At 12 days afterf~t:i. The$tage
. ofdev~opmeriHs :~~~:by:th~ ilit~omfu~cation of'the hl.cunae filled 'Wit"P-mat~mal blood. Nqtdxt'.B ~ l.a.$
-cavi~:AA.1ea~e1hin:th~- r:xt:;~:~.crti'b,r,;ycnic ~~~i f~g the be~i!-of:the extra:embcyo~c - ~;it.~- note .
tli_at:~mb~~;ehdbdeti!l8l::ct:Jl~).h.b~:~;to:fo.i'tq';Pn tildnsideo( t~~-P~ti~e.-yolk ,;;a~ {F~~~OQf'~--1~1 -
. . . ~ .

Ear.ly.'Villous. Sta!]eS. . :Begirin.ir:lg:da:y-~ :18~2-0thffrsf fetal,~ ...

ate-obsei'Ved ;.n.~e rt:J:Sencb.J.ln:e. The ap~
On ab.<rut . d,ay .1-2--1.3; increased of th~ cap.ill.aries in the ::vil1ous sttQma mm:ks

!o~-~,:-~
-~:_~-rs~-:o_"~:_r_~se~rv-_?~-~
- ~-- ~-~=--:;~~--.:~:~-~-~
-~
-~:~i!n~ 8 _.~:;_.:~,; -~~~::~~~~~!;~~~:~~~~:!!~ir!
-:~>_l._~:_~-;;
0
:_
b<" w,UJ. u cu nJ.U: u .., .... u.u -r,...~u.cu
..
~and-s(!con4a:ry--villi-; --A: :co~?1ete- fetopfu.ce:t;~.tal
ski~ branch~. th~ :~olld prlrii~ villi composect cirtulatroh is established arounfi.. the .l;>egin:niD.g
of cytotrophonlast .core :crov~~by Sy-ncitium 'fonh of the rlfth week as soap. as eapill2.xy ~ents
1~~tWclli:,lat;ce11J.4ar ro~~~s -whi~~ ~rq~de_.into fuse with each other to foh:ti a -~ :clipillary
-the :.:l~c,u.~a!!. ffigur:e l L Q di' e}'. 'With further bed..
-~rancl:Jm.g ~4 Pt:?~eta~n _p~tive .vi!J.ous :trees
With :est~qlish:.tne.nt- o'f ipt.ervillous 'apd_.
-Q;eYcl.opAWh!!n th~y k~t:h~ir cc:n~t w.ijh the intr.~villcius circul~tio,il J~tal,~d :lila.tetna]. bloOd;
ttdphoplas~c shell thtX::~e - ~c4 ari.~hofi.n_g villi.
come in 'cloS<: - ~nta:ct but -.a:re -always .sepani.ied. .
Th:e iat~nar sy~tem. .l.s -tran:sfor.me~ into the by the :placental bani~r ~ompoSed..of th~ follo~g .
iritetvillous ~pace. laye rs:: 1) continuous layer'-<;>f syncitio.tri:lphobla,st
covering the . viUous s.'t).rface_ 'thus lining the.
After 2: d~y:s., . m~_senchym.al ce1).s from the intervillous space, z ,j lay~r of cytotr~p,bdblast
e.xt::raembr:y:ot)ic me~e:a}lyxp:e 41-yer o.f the primary (Lang!v'!.n's c_ells), .31 J.;:qp)l!='l;>lastic _l>a,sal ~~ . ..
r-h(Jrionic p_late iUvade.fueilli and transform them 4) connective tissue, 5) fetal endothelium..
into seeondary vUli. -{Figure 1 L2,e). The expanding
mesenchyme does =not-~ch to-tropho b4lstic shell. Deve-lopment of Chorion and Decidua.
'!':he Pasa1 segment~ -of-the trabeculae -.consi~t of
:cytotrophoblast. suua;u:ndd ~by. a . thin: she:et. of As the implanted .=blastoc_yst-. grows--and
.syn.cjtiotropb,oblast. These cytot.rophoblastic .feet expands ~nto the 'decidua, the outer pol~ .extends
of thetra:beculae or
~horir:tg villi (Figu~e '11.2 :e, towards t he ,endometBal cavity .an:d th~ ~~~ost
1) are -.called cell columns. 'implanta tion pole -f~rms the pla~enta (villou~

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 CHAPTER 11: Pi..ACENTAAND FETAL MEMBRANES : 171
+.<~

trophoblasts and anchoring cytotrophoblasts). T he ARCHITECTURE OF THE NORMAL VILf"oOS

decidua at this implantation site is called decidua
basali$. The chorionic villi here _proliferate to form
the chorion frondosurn or leafy chorion. At the
site
-facing the endometrull ca...rity the villi ceases to
grow and degenerates. This becomes the ava5cular
feteJ tnem.brane the chorion laeve or
smooth
c horion. The decid1:1 a covering this ru~a is the
deei4ua capsulari.s. The rest of the decidua is
called decidua parietalls (Figure ll.S).
. '
TREES
Clas~ficaon of Villous Types
All villous types come from single precursor,
the mesenchymal villi, which correspond to the
tertiary villi in the early stages of placental
development. Villous types are classified according
to caliber, strom al struc ture, vessel structure and
position within the villous tree.H,ts.t6,1a

The following viilous types have been

described: (Figure 11.6)

uterine
cavay
de.c ldua
b.a salJs
amrilon

- - :.:
- ~ .
___ ..

Fip.re 11.5. Pre~t ~terus illustra ting c!.ecidu!L (From

Ma.rPri & R~eder, 1991).

ORGANIZATION OF 'fa$ PLACENTA

Hum an placenta is d escribed as h emoch orial

or 21st hetilochorioendothelia l. Hem o refe1s t o
maternal bloo.P. whle h directly b a th e s the
syn~itiotrO'phoblas t; cho rio i s fo r c h o rio-n -
pla centa which is s epa r a ted from fetal blood by
the endothelial wall of the fe tal ca pillarie s tha t
tra verse the Villou s core. After leaving the s pira l
arteries,- the ma ternal b lood circula tes throu gh immature i~terr:n.edi<rte vr'Jus rnatu~ in~~ ~~~<"
the diffuse interVillous space a rid flows directly Figtire 11.6. Simplified representation of the p .tt'Pheral
around the Villi. 'The m a ternal blood is outside .p art of amature placental villous tr~e. and typi~cross
the'confmes of' the e n dothelium of the matern~ sections of the various villous types. .(Sourcc:Kauliila:n & .
vascular system. Scheffen 1992)

Scanned 8y: ~
 172 SECTioN II: PHYSIOLOGY OF PREGNANCY

,:

1. Stem Vill1 2. Immature lntermed'iate :vuu

Stem villi have amain stem that connects wit.lt -S ometimes thes e vi!liare called immature vilu
the chorionic plate, branchings of .up to four or immatl,l.r e t~.al villi. These villi te$Ult from
generations continuing to more slender branches maturatiqn of mesenchym~l vil!i wl-.ich later
at the periphery, and anchoring villi. They make transform into stem villi. They are found iniQ.fll.ly
up 2~25 pertent .of the total villous volume of around 8 we~ks and comprise most .1.>f the \Iilli by
the norn:>ai rna~re pl"'-centa. Stem villi s.en.e to. ,.. 14-20 week::~. At tenn. they ntflY be completely
.me.chJinicallysuPPQrt the $tnl~ ohfurVillou~ absent. In most cases, they can~foun(J .in .$mall
tr.e .e"s. '1'}:lelr par til:p:ation in f~toma.t~rnal grc;>ups in the tenter .of -the villou~ t~. the
)[change. end endocrine .ai;tivicy is negligible. placentones" These .villi function .as the growth
centers of the villous trees and are the .prinCipal
Stood flow and blood pre$Sl,lfe co.n trol in sites Of exchange during the .first two trime5ters.
i.ntervillou~ spa~e :is i~portant. lf .p t'essure
increases .iQ. the in~O.us s~. the widths of 3. Matute Intermediate villi
tlie fetoplac~ntal capillarles .are reduced. This in
'turn increases fetoplacental impedance and These villi ,are -long :~d $lepder, AAd contain
red\l~es fetal -p erdusi.on .o f the placenta. nu.tne.r ous capillarie.s~. sriiali te~_ wt~rioles
Malregulaticn }s thought to t>e aIM.jPr-t:(l.eChimism e~.nd ~on~cting :venule;:i. .About.one:fouith.()f the
i.n tbe patb:~enes'i~ . of .intr.a"!.ltedne growth villous volume -~ 'the :.norr....,-u te.::::til plaeenta h~
res6ieti,~ .(JUG:R:} wj$. ab~t. of te.Ye~t.ed end..: composed .o f thi$ .~Ulo"U;s type. T-Jie Jnature
'dlastoJ'ie .A4liEPJ .:UJril:)ilie.at Ro1V.:u . The intermediate vUli .:prc>duce .the .:tei\tillnl'l. villL
my4)fibfo~~$ts . a<rt~a~.$t.:fuipot"""u;mt~~}by~ch~ . They.bave.'Q:: hign;.degtee~otfetal"-~tion .
ma~J.lt~~tt -:rew:.,~ci.<>n:c;f:plB.~tai'adapt to and l~rge exchang~. sur-(~ce .QiiU,cjng them.
each.: o#ier~ w~:ef;l 'fetopt:a~en~ t)iood .flow important .for fetom~tem~ :~Chb:Pge.. They are
in;lpe<ia;nce.:'ls inr~sed d"e ~ -high press~ in. . ~so thought to be j:b:omtnenl $i~ :for llormone
llri.din
th"_e.'- ~~ - ... g..villo
. . l.u~~-it . .:be.do.:..;..-:o..._
. .. can. .'l ...ted
.. . . '.w.""~""'S.~ , ....
p.rQdJ,tttion.,. .
:b y i-etai.a.'t;i~ri :.o.r the myofibroblasts~ 20;2t. .(FigUre
1L7j 4. Termb.al VilU

. The tertninal -Iilli al'\e the final, grape-like

.F igure. 11~'7. ScheJ;Datic r.~presentation of the distribution
ofvilloU$ e:xtta~ar my.PfibNblasta (lilac)in :lar.gecaliber
stem and ~choring villi. UpQn c;ontuu;tion, ~ese cells
shorten th~ length of steQJ. an.d anChorin_g villi, thereby
:reduce the width of the intenrillo~a.space, and increase
the ~pe<lance of maternal intervillous blood flow {red
.ariows}.m this way the fewsis thO\lghUo.gain :control over
the maternal b1oo~ flow in the pla.cen~ -which .the-mother
'lias lo$t as a consequen~e of trophobiast invasion .of the
uteroplacental arteries.
briili.cnrngsc>illie mafuf.e irifeiiPRHaie. Villt fh~
aniount to ao::4o% of ilie Villol:is .SUifcite~Tiie.Vfui
are chat<~,cteriZed by a very high- 4~ of fetal
capillaries and highly d~ted sintiids which are
in intimate contact with the .t:rophobla$tlc sUrface
and form the epithelial plates. ''I'bis villous type is
th~ main site of fetomatemal exchange (transfer
ofo,cy:g en, car.oon dioxj.de.a..,"'ld wat~. In. a -n ormal
miiture placepta. ternrltu:!l v;i1l.i tomprl~ 40% of
villous volume, 50% of villious suiface and 600/o
of villous cr6ss se~tions. A.,remarka.ble reduction
of termj.nat Viili {as in tUG~ wi~ AREt> ~bilical
flow) Jtiay le~d to .fetaJ :hypa~a.:2S.27 There"is a clear
cut inverse n!lati?;n betwee.n. , th~ incid~nce of .
villol,ls v~sculo~yncitial memhFan~s and fetaJ.
hypoXia {Fox 1978).
5. Mesenchymal Villi
. . .
In the frrst and se~ond trimester m~nchymal
villi transforril. to imma ture hitertnediate villi with
branching angiogenesis. By the third trimester this.
switches to mature intermediate. villi with

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 \

CHAPTER 11: ?LACENTAAND FETAL MEMBRANES 173

nonbranching . angiogenesis and ultimately teld Cd)oledon I pllctntone ~~....

terminal villi. There is. a downregulation of the .(villous tret 1

vascuiar . endothelial :growth factor (VEGF) and

upregu.lation of placental grvwth factor (PJGF). If
ebnortnal fetoplacental angiogenesis o ccurs, it
results in maldevelop~nt of terminal villi.

Sin~olds of T~nninal Villi

Sinusoids are capilla.ty enlargements scattered

along the full length of the terminal-c apillaries but
found more frequently near the Villous tips. .It has
been thought that these sin:usoids locally slow .
down blood :now and provide mnple .opportul)lty
fot !etomaternal ~ch~ge. :l9 These sinusoid$ are
~~
found eonti1i.uous with the epithelial plate4 ~d lploctn\ll ~I
.are thought to represent areas of greatest
diffusional exchange.30.3.1 Figure 11.8. Plac~nt-Q.ne theory ofSchuhman.

ORGA12ATJ:ON..OF
.. .. .. ,:
v.lLLOUS i'UES .
..}_ .
Eacb~ Setomaternal circulatory unit is
couipase<l:Ori:me villous t,reewith a. ~co:rresponding
centrlfu~ . perfused :portion :Of.the Uitervillous
spact. Tbj:s. ~unit was called a .,plaoentone by.
SChiibmairiLand Wehler 1982.Some lite).atures
also.(et:to.t his linitn :a "'fetal co:tyledon";1Figure
U La). In t:il;i~ placehtonea pre-.;.a iHng in .th.e
periphery of the placenta, the maternat blood
:en~ the mt~tvillou~ n~ the center of .
the ..._n;;.llS: .. ' ' ar Vspace
,,
~Le "' .. .. .. ,, ... . '
. . . . Y~. .. ~ an... ea e.s. u.J mteMlt()us. space
. ..
nea:rthet:t~:s-~tw~n:xrelghbo'rll:rg'Villott:su-ees~
m termptaeenta; ffie_Villi_ are-:eonc~nfiate<nn-llie
centerS of the villous trees, surrounding a central
cavity as maternal blooc,l -i nflowarea. One or few
villo.u s trees occupy one pla,centa-1 lobule or
mat-ernal cotyledon delimited by grooves in the
.b asal surface of the .placenta.
V ASCULOGErri=;siS AND ANGIO<'.tENESIS IN THE
PLACENTA
Mention is being made .;>f these processes in
the piacenta because of their role in preeclampsia
and intra-u terine .growth restriction. Normal
formation of vessels in the. placenta Is regulated
by a series of groWth fadors such as .vascular
endothelial growth factor (VEGF) and placental
growth ~tor .(PIG FJ, a~ well as the partial pressure
of oxygen in the fetoplacental ve.ssels. Any
i,mbalanc~ or abnormality has b~en .lmoWn totead
to preeclampsia or "IUGR
. Formation of vessels in the pla~en~~..:..~ .in
two processes:
,:__...~ ... : ..~~:!'-:~.:;i.
1. Yasculugeriesis:involves de
novo r~~~~f.'
bloo.c! ves:::els from mesodermall.f.:d.~rived:
precursor cells. . .
2. Angiogenesis i~ the expansion of a ..-eeXis~g
vessel~?ed ~d invol~e~ c~tio~' o'-~'t!~~er
branches 'from :preexisting-ones. . . ~:' ..- -
Placental angiogenesis .i s further subdmded irlto
the following categories:
a. BranGhinl}-an{?;io~en~sis -is the principal type
of angiogenesis from day 32 until week 24
during the developi_Oent ofthe villi'll'bich gives
. rise to a priinitive capillary netwodc.
b. Nonbranching angiogenesis starts11labout 24
weeks when mesenchymal 'Villi start
developing .into mature intermedi.ate villi and
later tdminal Vm.i. It lasts .until tean.
Regt,Llators .of Angiogenesis
: The:most known m ediators ofangi.~esis at""'!
vascular endothelial grow~h factor .jVEGF) and
placental growth factor (PlGF). VEGFis a potent
stiffi.ulator of growth and survival of blood vessels
a,nd is the driving force of branching angiogenesis.
ns tevel is very high in early pregnan~c;y thus .
promoting e.s tablishment of widely b~d low
resist4nc~ capillary beds prev<!.lent in the-Lu:.st two
tr.it)le.sters
. ;.
~
of pregnancy.
' .
. ~-.

Scanned By: ~
 174

In the second half of pregnancy 'VEGF pathologic conditions (di;:tbet.e s mellitus,- ~

decreases and PIGF level'S ste~ply increase and hypertension, ane.rnia., and smoking) and genetic .~
peak between week 2S..32, the .p eriod of the most abnormalities !>CVerely aff'~ct VillOUS and -~~
dramatic nonbranching ~ngiogenesis. Lo11g fetoplacental vascular development. This suggests -~;!
capiUary .lobps exee:!d .elongation:of *e villi that the maturation processes are influenced by :1
th.et;nselves resUlting ~n -coil.i:ng of the capWaries, genetic, endocrine, metabolie and environmental it
b!:llgmg .an-9. 'developJilent of the .terminal vi.HL parameters.
,
"(F~gute U.9) ..
Role of Ox.ygen tn Pla.cen:ta..,
.. w6u Qa!.aficed ..:~ecretocy level$ of vEtiF and
PlOP .9-te ie$p;ons1l$.le . f~r a. b~ pf br.ancbihg Mate:m al oxygen $1.:.pply to placenta has a ..
and .noribi'anclifug.~Qgerists.ttn.q:everilyfonntd stronger impact .on v:Hlq-us gr-owth and
.g rapelike iclnruim villi::of a nonri.ar
term placcnti. differentiation .th.an any other par.a meter. If
Pr:evale'nce of PIGF responSible br pr:edo~ce distti..r\)cd, within .a shcrt ~riod of time it may
of nonbra:J;lching angiog.en,~i.s Tesults in long cause fetal d~th.
filifo~ tenhlrtal villi typical -o:f postplacental
'hypoxia. Preyalenee ofVEGF stim"$te.branchln.g In mo:st organs, alowd~ee of vas~uiarization
an:giog~u.esis resultiri.g :in highly ' btan:ct.led, resul~s in inadeqp.ate qxygenation of :the tissue.
coitv01ute4, s~oi1:, :, ultiply n-otched tenninal\'illi" The tissu~ hypoxia .in tum stimwates capillary.
typ!.~-ofyrepJacentala;nduteroplaeent.alliypo~ growth to impiov.e vascularization .;.u'!d tis~ue
.. 1.1 ' ,~i, E:>Xygenation. _tf,...9n the other band. there is good
~F..:~.s ~~ected,,bY.:.O*Y~: ;I:IYP5>xia~~uses . . va.s culatization and high .t;~sue oxygenation,
...a:n ..-upi.~~latit>;n:-~~f ..YE.Gl_?,.,. a.nd. Jniti.9 :tes .. .fli.rth~r: ~giog~esis-..:is...:.t?lockedr.H:;:. . ..,_ .
<~pensatory- forination of:'I>lo:Od .vessels. "the
dtect" of. oxj.g~ in j>I~in~tli>n ~1 '~, diS:CU,:~~ _ 'rtili> .i~ in contrast ;to:pl2.centa1 Villi>lf there 'is
in ~-~g ~graphs... . low:fe:talcapill~.Q.ensey.,.l~-oygenis,~cte<;f
.. ,._ . .. : ,. ., . .: , . , .. . . . fro,n(th~~~stil~g;~-4t~Sfu.g~intra_~1ace:ntal .
OXY~m-t.;&..\"iD.:OX'Y'GN..:CONTRO~EiY -.:". : . oxyg~ri:!?i.wqiclh:further;iblocks.:angiogenesis:. In- .-.
GROw;t~~r.~~~'~.:~~JO~S.~~~'t.:.;..: .. : Situa'cyonS:.o.1iigh.;~ep.sity...:-OLeao~~ilJ:ru:;ie$,,and high..
~uS~- V~~CUI;AR;n~WLOPMENT oxyge.zi :extraction by. :the . fetal Ci:r.culatio.n ,
.. -~- ~:-.. ' in~P.~~~~ :9~gen t"n,Sions ~e lowered. th~s
Co~tt'Qfof villo:m1 ttevelopme~t ~s- lar:g~ly furtlrer-stimula tin:g- growth of- thealrea."dy -well
"tin:lci;i'Qwn:~ rt: n~:s neen cioserve<l ..'hoWeve:rtna:t develoJ>~d ..ca;p~:be.d~

Figure 11.9. Di.agi"a.mniatic s fuvey

of basic .mec hanism3 .'of
yasulogel).esis a.n.d angiogenesis,
t-heir 'at.tdb u.tioJ?. to villous_
development and their presumed
- par.a~e ci:>!ltrol (red).

Scanned By: C
 CHAPTER 11: .PLACENTA AND FETAL MEMBRANES
------------------~----~------------------------~---------------r------'
Hypoxia in the Fetopla.cental Unit
The following types of hypoxia in the
fetoplacental unit have been defined by Kingdom
and Kaufmann 1997 (Figure 11.10)
ORIGINS OF FE1AL HYPOXIA
~ -~l.l(). Dependi'lg on the ()rigins Qffetal hypoxia, .
plii~ut~:~l};llcy,~enation m1d .placen~ . .uuctUtal reaction
p<it:terrts 19:-:Q~~ene.~ion arediiiex-mt. Jn ~repla,cental
~ll.yp(:lid,a~Jl~ mother:{m;lt@.la, .bighaltit:Wlt. cyaJiotic
he~< Qisease)::causes hJpOX:a .of placaU:a ~d fet\l$. In
utert,lpmttntnu iiypoxia-themcthe:r Ja'normoxic. Whereas
placel)bi-IIIid fetus arehypoxica s a tt8\llt ofutc:roplacental
~aiQIL !:9 boUJ.U\e.~ ~~~!.~~tal hypoxia
stiinUbtt@.~giogenesis anc:J Y~:ilO~~.~e:ation !"~.~~
paifiYcompenSa.te torlijpo:xic e1TC(rtS. lb'tonb'1l5t in post-
pbreenmrb-ypoXlKmomer-annpl~rtta lue noriiiQ;Qe:ana
only th~ fetus is hypoldc fwj]:l fetoplaoQ1~ .malperfusion;
reduced .oxyg~n extr(l.CtiOEJ from the placenta typically
results in an intrap~tal p01 t:lteudin_$n!)Jill.81 values.
~high p02 inhibi~ villous growth and accordingly causes
the.most uvere de~ 'Of intrauterine ~resttlction.
Red p<)int .Shading: O)C)'genation of maternal blood; Blue
point shed!ng: oxygenation of fetal blood~. Den~e point
shading: normal ox ygen partial pressure. Light p.o int
-shading: oxygen partial pressure below noi'Qlal. (So1,1rce:
10ngdom and Kaufma,nn 1997 with permission)
1. Preplacental Hypoxi.a
The mother, placent~ and fetus are hypoxic.
These indude maternal anemia, cyano.tic HORMONES AS REGU ..ATORS OF VILLOUS
maternal cardiac diseases and pre~ancy at high . DEVELOJ>MNT
altitude. The p.e ripher a\ placental villi show
increased branching angiogenesis wlth Clinical studies of the role of honn6lies are
. fonnation .of richly .branchect' b~t shorter ..inconclusive at the moment. Honnon~s i::Jfrently
terminal capillary loops. being iesearcheg-on are the ovarian $teroids in
Stanned By:
2. Uteroplacental Hypoxfa
Maternal cxygenatiort is nonnal but because
of impaired uteroplacental cir.cutawm the pl.<lcenta
and fetus are both 'hypo,qc {e~g. p~lampsia with
preserved umbilical end-diastolic flow). Data
showed an upr:egulation of placental vascular
endothelial grow.....h factor ~t:-GF) C'tpl'eSsion that
;::aused changes in angiogene~is.
3.. Postplacental Hypoxf(l
The feW.s is hypoxic whe~$ the mother is
nonnoxic and the placenta may show even higher
p02 levels than normal, placental byperOJ!ia;2327
E."'Calllple of this is ltJGR With absent mnbilical end-
diastolic flow. Here, the .tetnUnal villu.s eapillaries
are poorlydevelopec,t,, cap~ branching is ~est.
absent and the resulting fetoplacenu:rl flow
impedance. is increased conside~bly. Perinatal
mortality is mo.te than 40% . in these
circumstances and survivors a.re ~at d~~-o.f
neurologic and developmental .problems.~"':4f.fr~ -
.. t _ .....
.~ \
Oxygen Effects fn Placenta
It seems then . that inttapla,c~ntai Q~gen,
partis,i pressure, balaiice betwe~ii ''~d:$~~
endotbelial .g rowth factor (YEGF} iuidp~~htal
growtil faCtor (PlGP'), and angiogenesfs~~iiliig
. and
. nonbran,c:hing) d~~d
. .. . ,, on
.
-~eb:. otb~T
.. . .
,
- .
, .
IU. .-~o~i!i~r rii-~i~~-i.dlil~~i~r:~. phydologic
intraplacental hypoXia favors VEGF expression
and btanching .an,giogenesis-
.I n normal third trimester, ., increased
intraplacental .p02 results in preval~ce of
PlGF and hon;b~ching angiogenesis
Sever.e Jntrap~ace~tal hypoxia results in
p revalence ()f VEGF. end tnarke.d brnnc:bing
angiogenesis
Elevated placental oxygen pressures in SVere
early-onset !UGR pregnancies {PostplacentaJ
hypoxia) are combined with dominance .o f PlG F
and complete . absence of" branching
angiogenesis in tennina1 villi.
:~
~
 "..,{
~
...
..
SECTION ll: PHYSIOLOGY OF PREGNANCY . !
176 ' "'-;
.~
.;./

which .datasuggests that gestagens and.estrogens
may have antagonistic .effect~ o,n V.illin,ls
'development and differentia~n. insulin in -~hich
placentas of diabtic mothers show an overall
incn:a~ proliferation rate of villous trophoblast,
fibrinoid deposits in.all parts Cif the (Figure organ
11..11). Unlike the villous parts Qf placenta, the
they do n-ot pa.rticipate in matemofetal exchange
~cause they are never vascular:ized by both
maternal and fetal circulations. The nonvillous ~

stromal cellsand capillaries resu1ting in large parts of the placen'ta an

have the same .r
. pl~centas and th~ thyt'oid hormenes. In components:
p~ancy, mate~al ~yrpid tuhcti??-is .meffia:ted
by the pla!lenta. _b:ata s~.uest that m;aternal Extravillou-s tropho blasts
thyroid hormones are involVed ~!i villous Fibrinoid
developmentand thus inf].'lle..'J,ce placentali::ransfer Oecidu.aliUd. endometrial stroma
. f.l~tivns for mii!ients and ga~s.
EXTRAVILLOUS TROPHOBLAST
.NON-VlLWUS P.u<rs OF PLACeNTA
!'.his is~e g.ei;lerally accepted tehn -for "the
. Tb~ nonv:iU/>1lS partS .q f th,e p~4t,. incl~d<: entire popttlali:on Of trpphobla-st ~lls residing
the chel'iiortic plate, cell i31an~s., cell coluPiris. outsi~ the vi.Ui. EJqra:vi.Ilcus tuphobli:;t has to
pfuceh~ :~p~ basal I>Ja~. 'P:1argjnal zon .and fulfill two :I.aige1y dillrent functions:

. . ...
~

0 f.~toal mesenchyme

~- ma~rlx'.t-:p:e fibrin-oid
. . .

~ fibrin typ~ fibrloo14

0 endometr.i~l c_onn~ctive ti~~ue

_ placental demarcation dur.ing ,delivery

Flgure 1 LB. Schematic dPiwin_g o~the.distribution of the v arious tropho.bhist populatiol).s {biue)of the h].l.m.<l.n placenta.
All those tr<>phobl.ast c ells that rest.on the trophoblastic basal lamina of membrane.s, .chorionic pla,te, -villi, cdl columns
-anq._celfislands, x:epre.~t the pro\ifq:atingtrophOb~~c ste~ ~ens (Langhans' cells). Where ~ese are close tc ~c intervillous
~~ee (iYs), they-differentiate and fuse;to form the.syrtcytiotroph;o~Jast. U.sually thls .even takes place in iheptil!Xlltal..villi
{v:):Without contact with the i:ntervillou~ ip'ace,'lhe daughter cells of the.prolifer~ting stem cells :(markeqby asterisks)do
not fuse ~cjtially but ~tl;etdlifer.entia_te-and becomelnvaslv:e,.fonnmg-the cxtravillou~ trophoJ:ila~t cdl.S. Thcir 'rouJe.S of
~vasi~nf~gr'aiiona.re s:y:t11bolize:d by Arro;Ns. Exti:avillous t:rqphoblas~ cells can ,b_e found in cellC?lumns.-(c), ~J 1~s
{ci);.-chorionic pJate.(ep), ch9rion laeve {Cl), '8.~pta (~),basal pla te (bp), an\;h!teroplaeet;ttal arteries(ua). Matrix-o/PC fibnnoid:
J>Qin't-sh~de<f; lThz:in-t}"f?,fibrlrioid.is line:-~haded.. {~o(iifie<; from Kaufmann and Castellucci, 1997, with j>ennission.;)

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 CHAPTE~ 11: P"tACENTAAND FETAL MEMBRANES
lnvasion of mater~al tissues including
infutnition of maternal vessels, supported by
lytic:: activities of proteinases destroying
maternal extracellular matrix
Ancborag~ of the pls.centa and acthg as a kind
of glue. between cells of maternal and fe-ta.l
origin~ .
Extravillous trophoblast may subsequently
differentiate into the endov~:scular trophoblast
that are.Jound
a} Within ijle walls of l.,lteroplacentat' arteries
and veins (intra.m ural trc)phobla.s.t )
replacing the me.dia smooth muscle cells
.and Qt.l}er vascu:W.r wall structures
b.) . withl,n the lUUlen ofuteroplacental arteries
tinttaarteria! trophoblast) replacing the
maternal endothelhun or forming plugs
occiudiJlg t.lte a.--teriallum~n.
.f~ot':S..n.trollfng .ll:xtravill()us Trophobla,st
J)lffer-entlatfon Wtd .Invasion
..
1 . Cyt.Ok4l~~ and Hormones . . inflammatocy . cy:tokines
2 . Exttacet1U1ar Matrix and Matrix Recept>Grs
(Integrins) . .
3. 'Cell
.
.adbesbn
, Molecules
:-~-
and
..
Gap Junction
Mo1etilles .
4. Proteiii~~. Activators and Inhioitors
5 . Nitric O;ride
Cytokin.es and Hormone.s Cotttrolli-ng .
Dlfle~t#l..on. of &tTav.filous Tn>phobla.st
. ' .. . . .. -
~ - ~
1. Epidermal groVIlli factor (EGFR) is a t}otent
epithelial mitogen and has a stimulatory
irifluence o n trophoblast inyasion
2 . . Transfonning growth factor-~ fl'GF -~)is present
in. d~cic;_ua and is implicated as. an
immuriosu.p pressiv-e factor in decidua .by
t::!Odu!ating . the response of materri~l
leukocytes-to trophoblast. It has been observed
to downregulate surface expression of MHC
Class I antigen. It restricts tropho b la,s t
invasion, enhances cell adhesiven ess and
impairs cell motility.
3 . Transforming growth factor a (TGF-a)
stimulates trophoblastic groWth in contras t to
TGF-p
4 . tumor necrosi~ factor a (TNF-a) is .a i;:ytotoxic
cytokine that may act to limit trophoblast
invasion. The mo.s t likely so~r-~e Qf TNFa are
. decidual- macrophages ~nd endo.metrial
Scanned 8y:
177
natural killer (NK) cells [large granula~ ;.;
lymphocytes LGL] . Mac.r ophage11 have
cytotoxic effects on invasive trophoblasts
which are illustrated .in preeclampsia wherein
large parts of spiral arteries .i nfiltrated by
macrophages do not .show trophoblast
invasion.
5. Hepatocyte growth factor (HGFl is see;reted by
placental stroma and human decidua; it
. increases trophoblastic invasiveness.
6. Vascular endothelial growth factor (VEGF),
placental growth factor (PtGF) and
angiopcietin-2 tAng~2) are anJP.~c -~
involved. in the maintenance fllld turnolret or
uteroplacental vessels.
7. Insulin-like .g rowth factor-1 (IGF-1) is secreted
by the villous . tnesenchyme a nd sti.J.nulates
cytotrophoblast. to detaCh !mtn ~ l::Q~~
and invade :nejghboring extracellular ~triX.
8. Interleukins IL Proinflammato.ry (IL-2) or:&:lti-
. (!Ir4, ..:. .6, ~'~O;~~J:3)
. ' . . ..
- ~
trigger 'comm,unication among the ma~ . .; } . ;. j...
immune .cells at the implanta,tiori Site.. '
9. Triidothyronme (T3). plays a cr uci31 ro.~:.iil the
maintenanc~ of early pregnancyf:'C . ~/):,;~ ': .
Extracellular Matrix and M.tri~'iR~~rs
(lntegrins}
:E-x traceUula-r---t-ropho blast.s.. s'e'tr-en:--wg-e
amounts-of e xtracellular matli"Jr{ECM)"a100g-:tliei.r .
inv.a .sive pathway comprised Qf fibronectin,
collagen IV, laminins, vitronectin, and heparin
sulfate in a patchy pattern. The uttaviJl<>us
trophoblast .cells express the respective ECM
receptors .( integrips) 'for ECM molecules.J'n.tegrlns
are membrane proteins that act as reCeptors for
ECM molecules. Blocking ofthese integrin binding
resulted in.loss of trophoblast cell :adhesion tp the
ECM. .
Cell Adhesion Molecules and Gap -Junction
Molecules
These molecule s are secreted .to .tstablish
either cell tQ cell conta:cts, matrix adhesiOn.Qr fill
up gap junctions imPQrtan.t for ~ll pro~ra.tion
and differentiation, to mention a few: E ca"ffiedrln,
N-CAM neural cell adhe~ion molecule. clnnerin
40,'and GEACAM l. :~
~

-------------------~~~~~~~~~~~~=-~~~~~--------------------- ~~-
178
Proteina.Se~
Among the best studied proteinase.S are the
matrix me.t.alloproteinases (MMPs) that are
involved: in the turnover of extracellular m atrix,
acting as glue- .a mong maternal-and fetal tissues.
These proteinases are also related to the initiation
of labor and to the separo.tion of the placenta from
the u~.rine wall (Bryant Oreenwood . l998).~ 9
Nttrl.c Oxtde
Low Cb!fcentration of nitric o:xiqe (N0)::'-1-S. ccmp'I exe;;. They are geneniJiy -found . .in the
pxvd'.lced by the
enzy;rp.e .n;it:ric oxide .s-fllthet;ase . deidua'basalis as -comPa.rea to decidua ~~s..
(eNO$} ,causes vasodllatatiqh while .higher. NO
prbd\l:ced by the m9--crcrphag-e nitr~c o xide
synth~ta~ :(IDNOS} are_Said to be Cytotoxic.
Oth~r Factor.s . whfeh Influ-ence Extravf_llous . ~nd become invaded by trophoblast t:elb. In.
TrophPbtitrt 'Inva.iio~ .are:
'1) Blood. group anti~~ '"'i
:2} '.-:~c'cifaj9r Bis'i:&i)m.P.atiblit:y'@.mplex):-.Cla~s !
1--and-:Cl~~s .II-mole{:ul~:_; (HLA~GJ; .
3) .~_gen ~ pr:~s~u.re . ~t ~e :te:toril,~terrial
~ttrac. . (~yaji . .&:,~ufm~ -~9-0o: Kadyrp;. suppofts.
.'2003}':
4) t~phi:>olasLap<i:P..tQsis:~.:::.. : ..
; 1"
5) -Multinucleated trophoblastic giant cells.~
:6) .. J..Yge..,p,oly_gona,L~v.illo'\.l8 trophoblast.cells
. .
'DECIDUA
A detailed. diS:CusSion of the :decidua is found
k .~ spa.rate'.<:hapt~r: Mention Wil,l be xhade .:here
'pq>w~te~ deci!iua- ~ccepts .th.e inva<iin.g Jet:al
-trophob~tits s.nd :dos riot reject the f~tu~ . .
Decid.ualiza:tion is the cha1-;.ge that 6ccurs
th.e .c~dp~etri'ui:b in respons e t::l blast.ocyst
impliui'tation. The decidualized endometrial
stromal cells are called decidual cells.
The.dec;idua contain:s a relatively low number
of T cells, and B .cells are absent at the site of
~plantation -.t hus. a classical recognition_ reaction
of .the tn~P.l:J.Ob1as(is unlikely. ~5o, the )nv_a sive
trophoblast cel~s. qo n o t express the classical
_polynioq)hic .MHC!.I ' rool~les ..
"t
Human endometrial . large- .granular
ly mphocytes (LGLs) are reglilar constituents of all
--~-----
-:~
(
SECTION it PHYS_IOLOGY Of. PREGNANCY ::~-
uterine implantation sites and are closel:y :related :t;~
to nat'Urfll killer cells (NK) . Evidence is :;i
accumulating that there is maternal rec:ognitioo. ~}.
of tht:: fetus by endometrial NK c~lls wJ~ch ensures : ~f
immunologic protection since the tr~ph'otilast -
expresses the non-classical MHC-I moleruks. It .
is the c:;lassic MHC-I molecules that trigger aT-
cell me~ted immune response..
Maternal macrophagesin the :implantation ite
.are capable.. of pbagOC'.[tosing .cellul~ debris .ill the
maternofetal area and. of cleari.n g imnn:ne
Ma~ophage3 .produce a
wide range of cyiokines
which .are involved lri iimiti.Rg or sup_pOiting
trnphoolli.st invasion. 'In normal ;m;gnancies, the.
walls of .spiral.art~rie:s are gevoid o(mactophages
pr.eedampsia., deficient J;.rterial tivphoblast
inva~ion and.U,.cteasedapoptbtictr.op'h~l)l~teells
.ar.oun.d the uteropla(::erital arteries . co~iate with
. _!a r;ge ..nurn~rs ~o.f I;Il<l,GI;oP.~lli;l.~s.~~n ..Jhe.. ar..tc,rial, .-,.
media .(Rei.:?ter; -et '41. l$ 9 9, l3ur"k1!;t ~- 2Q(Jl}. ~ 1-_s..
. . Ma~phage ~ttk>rt is : mh1bitedby.hjgb.'d~
of pr9t;esttCGQ.e~ ~J<!-iniil.g why pO)gesterone
. .
~opP,pbia:sdnvasion.
. -
. . .
.
FIBRINOID .~ .
Fibrinoid :i s one of the mo~t prominent
com~rien~s ..o-f..-hili:n.a=;. .:?lacenta-, is ~onlitiro.;;s,.
noncel1u:.Ia r; -more or less homogerious; ..Jtis
thoug'h,t to hav~ several functions: 55
Inci:eases mechaniail stability when d~j>osited
.~stem :villi; d:lOrionic _
a nd basal' plat~
Repres11t$. tp.e_ "glue." that guarantees
aqhesiveness of the p lacenta to the uterine .
walf
m Cp'ritributes in regulation o'f intervillous
cir culation 'by fib'r:inoi'd d e positicn and
obstru~tion o'r poo'rly perfused areas .
Pt;>ssible (uncbonal role as a b~rrier to
tropho.blast invasion
Possible invasive ness -promoting activity
Possibly provide an effective transfer routeJor
macrc;>mole cules bypassing the
syncitlotrophoblast
Pos sible . morphogenetic function. and .may be
Involved in n!e_pi thelialization. of dani.aged.
.
'v illpus surfaces ..
.Jmmtino.logic sign.lficance - may mask fetal .;
antigens thus preventing their reco~tion by
Scanned 8y: ~
 cHAPtER 11: PLACENTA AND FETAL MEMBRANES
maternal cells; it is thought to protect fetal
cells from already sensitized maternal
lymphocyte~
Roilr's nbrim)ig is a superfic.iallayer of fibrinoid
found in the basru plate facing the intervillous
space. Langhan 's .fibl'lnoid is iound alon:g" the
chorionic..plate at the interVillous surface .
NitabucMdibrinoiti (uteroplacental fibctp.oid) is
located in tli .imn:tediate matemofetal junctional
zone and lui.i'fcommonly been regarded .lil:l th~ site
of immunclogic proc esses. It "$e.parat.es
superli,ciiilly positione4 ttophoblMtic cells from
basally loci.ted clecidual cells tb:us marking the
m aternofetai border. It serves 4 battier function
prot~ting fetal-antigens against identification by
maternal c.ells so as .to avoW direct c ontact oi fetal
tissues with sensitized :nia.te.rnallyri:lphocytes. This
layer !s the site of J>lacental separation.
,
B F lg.ure
D
ps , l
.!!!
-:: ~--.-
i :
~ .. . ~ ~
:': .
. .g_ ~
Scanned By:
179
beciduo-Trophi>b lastlc Interaction
Trophoblast invasion in normal intrauterine.
pregnancies is a controlled process such that
trophoblasts normally do not penetrate beyond the
inner third of the myometrium. The control
mechanisms however are poorly understood.
Every cell type in the maternofetal junction has
dev-eloped both mechanisms supporting and
inhibiting_invasion resu:lting in an extremely
complex but well-balanced control system. .
UTEROPLACENTAL VESSELS
The uteroplacent al . arteries ate branch~ or
direct continuations of myometrial iu:teries. As
soon as they enter the decidua and basal plate.
they are al$o called sprrat arteries or spiral~
because of their s piral course (Figure 11.12).
11.12 . .. .' Sth~~tic
representation of irttentiliJ'~Ii,iid "
endova3Cular tropboblasf~in
human pregnanC"J. A: Befori.~l;; 6 .
of g~:station , the uteroplac~nt.al :;
arteries.are ~alter~;-. S:.,S~:.~;or ..
the pr~~cy"ihduced:pbjaicilogic .
changes ofarteriesis~.by_
generalized endothe~' ~Pti'ili"a~
endothel!al vacitoliz8,tion inuscuta:r
di~9J~~~?~n .lmct':$.1it-hr;l1biic:n
dHation~~e:--After' -ap~te- or
trophobla$t ce!ls-in--the--'t"8,SCUlsr
phvaloi09IQI
cbW>QH, ~a.
surrounding, but:prior totrQP.).loblast.
nmaa gHbtion invasion of the vascwarwalb, ~~:
2 of va.,s cular ~hanges, maXimum
arteri;ll dilatation.O<:curs. U: Oi!ty in .
. the final stage of.pregnancy.:;Dlduc:Ed:
changes: of titei\)placental arteries, '
smooth muScle cel!s and.e ndOthelium
of the ::..lre ady w~ally .dilate~ . -
ar:teries are replaced bytrophoblast ..
E : Note that failure o(e ndovascular
troph~blast invasion in iri.traut~rine
gr ow th r es trict ion (IU.G R) a nd
p reecla mp s ia is restricted to t h e
J ..; ; .;\._
~ phv~ 09Ja1
~ - ., :.~-.....,.. changes, ~~age II~ placen tal bed and does not affec:t .
\ -~ _ _) ~, _;\~ normalge.t.atio n segment of the uterop lacennt
.- ' ..."' ~-"' artenes
:
- ~
1
(:- "' ' in the later b a sal plate of the .
{,~ ~ ~-~ .~ ~
:~~~: ~:
~
,. L ~~~~~:~s~~s~:C\~;~~:;~~~
. . . - / ~
. ~"'
pla ce.nta. Blue, fet al tissues; red,
(above, attached to the pJ.ilt!enta}
separates from the ptacen.fl!l .bed
't~ ~110pho
v-..scvtar
o ~t . . ( remammg
h . . r
. 1 10 _.t e ute~~ ,a -ter _.
, '); . ~ . .. : (iielivery). (Modified and exten<f~.(rom :
. fi<i'\ '\..~ \ . f r:-
: ~~ --~;:.: Kau mann, et al., 2003, with permis-
s ion.)
~
 ~~~
,~ .
~~ .-. ,;
180 . SECTION II: :PHYSIOLOGY OF PREGNANCY
-------~----_:.____________________________
.. ,....
....,!~.

Around days 11,12 the first contact betwe_e n

endometrial vessels and intrapla:cental lacunar
system is. c;stabUs"hed. The first . m~ternal
erythrocytes leave.the eroded "Capillaries and enter
the trophoblastic lacunae.

The .uteroplace.Jltal arteries -c ross the uterine

wall almost perpendicularly up to the eighth 'Neek, .
gradu!illy beootning.oblique: as placenta enlarg~s .
and becomes amtost parallel to the basal pJate by
ten weeks. The exS.ct number of -spiral arteries and
venous openhtgs that perfuse the pl~centa is
u'Qknown.

Trophoblastinvasion of ~teroplacental. arteries

convert them into l9w resistance vessels that .are
unable.t.~ Cpnstri~t. Physiologiech~ges according
toarosens, e t aL 1967 inClude (Figu:re ' ll.i2):
1. apparent r~pl~cement of endothelium arid
:nedia smo.o th muscle cells by inv-asive
~phoblast

2. 10~ of: e~stldty

Figure 11.13 . .Uterus of pregnant wo!llan $how:ing_normai
3. .d ilatation to Wide irtcontractile tubes placenta in situ. A. Location of section shown in Figure
\ ! ;' .
11.14. B. Location of section shown in FigQre .}1.15.
-=. .()f. ~asomotor
4. ...'Ib$$ . . control ". '

All~~(: clull.l.ges resuit in the refiucti.on of

m~t'~'blood . flo.w r-e sistat-ice, incr~ased
l-1-te,w.pl~nii'C~-Q~rJ~~Icii!.~~~.~~~-:-g-tia'rarifeed
m.rudnium ~a:temal blood ~U;pply to :p-faceilta.
Dclicle*~e$;0r physiologic changes in the :~eries
- ~ abnonnal and are a "signifidmt characteristic
of p~~psia1 hy~1:tension in pregn:ancy and
fe:t,aJ. :~wth retardation~ 56;6o.61 The uterop}4cental
vemsbave.:a. ~"kedly re(luced muscular coat and
.t rophoblast ~U-s .may be locally abse~t from.-the
v~:ssel wa)ls. P la;cental villi. have been foupd
~diPg deply into the openirigs of tnatetna l
pl~.tital v~ins suchthat they .ate transfuse d into
int~fvi)lous space.

FETAL .:AND lUTERNAL BLOOD CIRCULATION

IN Tire MATURE 'PL)\.C~NTA

A s~ct.Qn . th.,-ough the mature placenta

(Fjgur~ 11.13, 11.14 & 11.15) shows the amnlon,
chorion, chorion.i~ villi and intervillous spaces,
.decidual (basal} p_la:te, and myometrium. The
mater-nal surface .(Figure 11.16) ~hows the 'Figure. iL14. _Section of fetal membranes an(l"uteros
ir.regUlar lobes' divided by septa consisting of .corresponding to l etter A in Figure 11.13 A .. -amnion; C =
fibrous tissue. chorion laeve; 0 = deCidua parietalis; M myometrium

Scanned 8y: ~
 CHAPTER 11: PLACENTA AND FETAL MEMBRANES
Figure 1 :1..15. SectiQn of plad::nta .a nd uterus corresponding
to letter B in FigtU"C 11.13. (C .. chorionic plate with fetal
blood vessels; D ... ,dedd~a basalis; M - myoJ:!letriu,m;
P- ptacentalvillt).
Fetal Circulation (Figure 11.17)
Deoxygenated l;>lood flows to the placenta
through two umbilical arteries in the umbilical
cord. Upon eptering the ptacenta, the umbilical
vessels begin branching within the Villi and form
capillary networks. Exchange of substances
occurs by diffusion _out of the ca-pillaries, i nto the
intraVillous space, through the villous trophoblast
and out into the'intervillous spa,ce.where maternal
blood batl_les the syncitiotrophoblast. Oxygenated
blood then returns-from the phi.centato the fetus
through a single umbilical vein.
Scanned By:
181
- -
Figu,re 11,16. Matern.Usurface .9fano~~~-p!aeenta,
- -.....:
Maternal-Cir.cu!at!on
Maternal blood enters through the :basatiP.:~te
and is driven up toward the chorionk:: p~te by
-matemal <;Uterial.pressure and =disPet!;eS :ia;terally
to bathe-.tbe chorionic villi. Maternal blood then
_&ains back thro:ugl) venous open,ings:in;theii>asal
plate and -enters the uterine veins. - --
. ,. . ,.. ... .' ~. '
PLACENl'AL MEMBRANES
.The.lrue-.memhranes :.~()rinally inSert S,t-the
..edge...:of.-the,~placenta:-an~--contain :the- mnnibtiC:
fluid .and -fetus. Membranes rupture during
delivery due to stretching or _artificially by the
birth a ttendant. There are i:hree distinct layers
of the membranes. the amnion, chorion .laeve
and decidua capsularis.
Deve.l opment of the Fetal Membranes
The trophoblast of the implanting blastocyst
is subdivided irito one early implanting half (cells
surrounding the implan~tion pole or the-basal'
chorion) and one later implanting half (celis
surrounding 'the antiimplantation pole or the
capsular chorion). With appearance of.the fli'st villi,
the basal chorion bec-omes -t he-chorion froridosum,
the forerunner of the later placenta (Fig\i~e 11.18).
The capsular chorion at the_antiirilpiari~on J}ole
begins to degen erate by the third w""'e~ k, the
intervillous space obliterates and tropli:oblastic _
shell fuses -to fon:rl the smooth chorior1-1choricm -
la eve) . The e ndometrium tra n s forms b y
C
182
-.,_..
~

Fetal
cifc4la:tioo

..,.:..--, .. .. ..-.. . .

Ern~olt~'tii::i_t tmrir.;
."J_..,,.v.1-E&NA:L Di:.ooo
. -. :PitJiwAYS: . . .
.. ~ . ::
. ~; '' .

.t,.ftiAL. CIRcUU.TICm'~ : i:: .w.ID~'tiRCQt:ATIQN .. . '

: THE VICloOs TREE . ~ -ttnl:fWra,Qus'SF>-"c
t i. .
Mchol'~'vltw'i .-o- :~~~~ .
. .
.
. 'f';'fr~.:-_
: ..... :~~~~~~-
.... ' , . .. ..
........ '
. . . . ..:: . . . .
:

~ 1,1.1_7.:. Sdi~mati_q:dia~t:9f e,;~(?_A;tbroy.&li aJ}tU,:"t~ piacent.a;e:rui.ret:a'tio,nof1he:Vil.J.<m:$-chO'~n:fC}'otb the

.dec?&:Wt~iJ .'(I)) an:a.~c::-fef81.:~cid :iiii.i:ta~.nt2~:The .m:atemal b~($1 fio~iiitci:t..l).e.l,n~s:~ in.:Cunnel-
siul:pea iJP.illis. $d 'exenan,ges :~wttl,{''the(~t1it.Pi09d asthe ~aterrnu bli>:Q(>.~w~. tir9".~~we~:~~:.-~''Pt"'&~.ng
. -artcrialbJood-pushd~veno\Bbl~4ntotheenaom.etrialveins,~bieh-a.reseatteredover-Jheentire~oei:ffithe"<l:cl:idua
-basali8~--Note-al~. that::the.um:bilica,l~.Pis~-d~xygenatede.tal-blopd-J~.the-place~~-an4:.that:th~-Uinbilical-vein
ctrr.ries mcygenat'ed blOod to.th-e ftu.:,.''The C:Otyle'don:s :nrc sepatated from each o ther by placental (aecidittil) se;pta. Eac'h
.<.cyledonronsists .oftwo Qr mo:re mainsteinvilli'lindtheir many braches. {B:ase~ on MP9r.e, 199&).

differentiation of er.:dome.triat ~tiom~ .cells i nto contact with the decidu~ surfac;:e of -lli~ uterin~
decidu~ cells, and is henceforth ccilled decidua. wall over nearly its entire surface and functions
The ee~<;h1R .belo~ and lateral to th~ blastOcyst as a pan!.p'licental exchange organ. Thi~ is limited
~4 'later the placent;a is called .the basal-decidua however by the absehce of fetal vessels within the
(deci!:J,ua ~s) , With c<?mpletion C?fitnplantation smooth chorion.
vf t'he blastocyst the -deGidua ~loses .over the
:b'Ia.stqcyst and this. iayer -i~ qilled.capstllar decidua Layers of Placen-tal Membrarie.s
Jdecid'4a capsularis). Allthose parts oft~e decidua
-t,hat line the :uteril)oe -cavity :without being in At birth, the following layers of membranes can
~ontact with the blastc:yst:are c;;illed ,t;p.e .parietal be s een histologieally:
4eCidua.or .decidua -Y~r~. With .ip.~~~~g:~~ of
,the conceptus, the sm<;>oth c horion and .c$..psular .L arnnionic epithelium and basal l;unina
. cl:ecidua toucpes the parietal decid~ of the 2... amnionic mesoderm
. <;>pposi.rig:uter:We we.ll.-:B.ytS-20 weeksjhe smooth 3. intermediate zone'
:;ehorion and - ~litpsular- .de:Cicl~a fuse:s with -the 4 .. c):10rionic. mesoderm
parietal decidua and obliterates the uterine cavity. 5. trophqblast
From this date onward th,e smooth chorion has 6. decidua

Scanned 8y: ~
 CHAPTER 11: PLACENTA AN.D FETAL MEMBRANES "183
----~----------------~----------------------~----------------------~---------

AJ.!NlON The amnion contains hirge- ~ounts of ~

The .amnion is composed of an inner layer of
epithelial cells, planted on a basement m~mbrarte,
and is -connected to a thin connective tissue layer
by ftlatnentous strands. It .can be eaiily ~eparated
from the underlying .chorion. The amnion does not . initiation a:nd maintenance of uterine o::ont:ractints .
possess its own blood .ve:>sels. It obtains its
nutrition and oxygen from the s urroundi ng
chorionic fluid, amniotic fluid and fetal surface
vessels.
though whether it "is niaterrta} or fetal in orimt
rerr-ains unclear. -
. .
Prostaglandins have a sigtlificant tole .in me
(Smieja, et al. 1993) and the amnionic epithcliutt
seems to he a n important source of. t.h!:3.e-
prostaglandins. Amnionic epithelium -is the ~
exclusive sour.ce for: prostaglandin E2 (PG.E.2. ~

The amnionic epithelium is composed of a Interleukins; well known to re~

single layer of flat, cuboidal to columnar cells.
Though the appearanc~s of. the cells vary, there
appears to be .only one single uniform cell type.
Amnionic cells contain ultrastructu-ral findings
that seetri to favor intraamniohic .lipid synthesis.
pr.ostaglandin biosynthesis, are also producet .:n.
the amnionic epithelium. Rote, et al. 1~
speculated that h:itraamnionic infections--irui:Lce
prod uction of intetleukins that in~.se
prostaglandin production.

banned 8y: C

184 . SECTION ll: PHYSIOLOGY 0F PREGNANCY
In 'humans, ox ytocin is a myometrial
contraction stimulator but onJy. when it is
c.o mbined with increased leve~s Qf PGF2et. 6~
Oxytocin ~ceptors are pre&ent mt4e amnion as
well .as in the chorion laeve. 67
Leukotrienes, <!- cytokine :group denved. from
arachidonic acid are also produced by th~
atnnion. 68 The authors state that th~ cytok:ines
m~ affect uter:ine contraqtility be~i<ies thdr
functions as mediators -qf 4runune .reactis>h and
~sodilat4tion.
Endot;he.iin-1 .are also .pro:Uuc'ed by the
atil.Pionic eptthe lium and appears t() be involved
in the regulation of anmionic flUid h~meosta.sis
as .it .i s' known .t o promote watet tt-'q.ilsfer acro~s
epithelia: of Other organs.
._
,tpe amnionic epj:fh.elium cont,ains ~bonic
a:n:)::ly'~;,~nz.Y#.i~~~-1:~~l1'4:.Cf\+2;6?;?;~~h.ii::h.:. n~t e'licit 'i;inm~nolo~ic .. r.eactiQn~ ~hen .
is :ln"Y.olv~d" :in':i>'rchi.b 6:nat-e.::oarb i>h:: ,d'i<lxid-e t:rt.~Pl~ted~7;~A:J?. timicrobiaLprojX:r.tks.~ :of: :th'e... :, .
-~~it-is 1i}Celyth~t1ll.e:anull:opic:~ptih~lium.' , . anirii6z:l :are 'Vte1i d~ti:it~~75 .
isresnsib~fot ~t:h{g:_tp.e pHOf:the;~l?le
fluid. at
..
aboct pH:' v;:tQ~. . . . . . .
The role of the amnion in the se~e.tiori of
:ammoclc fluid is ~~ll'unce~ . .lt is.. geperal),:y
a~ted.
--.v._r tha:.t the ~urees
. of antniopic fluid aJ"e
.
multiple. .
.AmrdonkFluid
Aronionic
. .fh,Iid is P,erived.
. fr.6.m .m ultiple SOUrces:.
j
1. PoSSible ~cretory PF~~es of the ~<;m.i9
e pitheijum
2. filtration offlJ.iid from maternal vess.els via the
' .pa?etal decjdu~ and the chorion laeve
3. ftltration from the fetal vessels or in. tlte
chorionic plate .~~ .via. the umb-ilical cord
4. u rination bf the fetus
Scanned 8y:
{
5. filtration from intracorporeal fetal v~ via
fetal skin.
~ionic fluid volumes throughout~ .
variesr.. with a mean of 1000 m1 at 33-34 ~
followed by a decreaSe: in volume until term. 1he
pH is usually 7.10 'With maximum values of7_4.
. Fu~ther constituents inch.ide: glucoa.e, ~
amip.oacids, .albumin and glo'buliri :.iS
. irmininpglobulins;lipids ;(6holesterol, ~ ]J
pb3spholipids,.ledthin, $phlng,omyel,inJt Ure;a. uric ~~
acid, . .c:r.e ati.n.in-e, .:bilirubin, h'otm9nes ;~~
(pt9gesterone, estradiol, estriol, testosterone}. ;;i,
..';'1:.1;
....~
Cll:nlccd -:and Research Applf:catton:.s oj~
The ~nion is readily separated fu>n;1 the
chorionand.is row_idely availab1e, It has:~~
as (l.:r essing :for burn~ .a p.d other . ~l>'Ulidfl.r: ~
A.tm:+ionic epith~lill'!ll ~oes not PQsseSa hliinan
le~ocy:te antigen . {~) ~ antigens,and does
.
Ter.site;hfopertt,es.~j.-the -14~.
UM:BI!:i!CAL COM
. At L8 d~ys .t:he embryo is :a f4ttten~aisc
between the amnion and yolk:.sac. As ~ ~
tu.b~ eloa:gates, tne embryo lmlges into the
amnioni<:< sac and the il'ors;:tl part 'of :the ,;)lk..~
forms the gut.
As pr.~gnancy advances, the yolk sac becomes
smalleT and. its pedicle longer. Bj th~ 'IIl.iddk of
the third month t;he expanding amnion.~ .
the. exocoelom.t fuses wi,th the:c;horlon .lacve, .and
. cov;ersthe bulging placental qisc and thelate:rnL
~unace .of t11e body stalk:. The body ~talk is :the'n>.
ca:Ued the \lmhilicil cor:d.or funis.
C
 CHAPTER 11: PlACENTA AND FETAL MEMBRANES 1'85
-----------------------~------------ -

The cord at term contains two arteries and one

vein, which was originally the left umbilical vein,
the right vein disappearing early in life. The.
intraabdominal portion of the duct uf the umbilical
vesicle usually atrophies and disapr..ars, but if it
remains it forms a Meckel diverticulum.

Cord Structure an4 Function

The umbilical cord extends from the fetal

umbilicus to the fetal surface of the placenta. Its
diatneteds 0.8 em to 2.0 ctn with an average length
of 55 em. Lengths nmging from: 30 ~m to 100 em
have been .~ported. ~adUlations or false lm?ts on
the surface are due to !olding a.Pd tortuosity of
ves8els longer than the umbilical cord itself. The
extracellular matrix is called Wharton jelly (Figure
11.19).

FroPl the wnbilical vein, blood flows into the

ductus .v enosus which empties i..>to the inferior
vena ca:~a .;i{;ld fetal hepatic circulation and into FiCure 1 1. 19. Cmss secticrr u' umbilical cord ~~g
tbcfirlreriGrvena cava by the hepatic vein. umbilical vein and arteries. ...... . ::;k~:~~
J.. :. z.~-~2}:.~:. -.

,....
. ~ .. .~~tt,::..

POINTS TO.REMEMBER
l 111~ hY!n~!l P..l.~~f')ta Is a h?m~n.<?.r:i~l vUlo\Js type wnerein fe.ial and matema:::iood.do not mix.

.- . About two million primary oocytes are present at birth but only about 400,000 erain by adolescence
and atout 400 ot'these pass 'through maturation to ovulation

The zygote is fonned by fertilization of the ovum by the sperm. It undergoes deCJ'E!E' into blastonieres;.
and forms a solid ball of cells known as morula. Accumulation of fluid be1een the cells of the
morula for:m a blastocyst which is the impl~ntation stage.

The outer.cell wall of the blastocyst. is the trophoblast, forerunner of fetal merm:anes and placenta;
the inner cell mass is the embryoblast from which the embryo, umbilical =rd and amnion are
derived.

Trophoblast Invasion of the endometrium is responsible for further invasior i the blastocyst and
for adaptation of the matern al vessels to pregnancy conditions.

Primary villi have a core of cytotrophoblast covered by syncitium. When mes:chymal cells invade
the villi they transform into secondary villi. The appearance oHetal capillari::;n the mesenchy_rne
marks the development of the tertiary villi. :;:z::.
7,..

Scanned 8y: ~
186
~---------~.-,.-. -:s-.E='" 'cn=. -:--O:"':"N-:-Jt- =-PR: :E: :-:G:-NA.~~ N-::C:-:Y~-----:~--~:.._ .,.
: _....,...P-:-H-YS-:-1---:0:--:LO:-G:-:Y--::0-::F:-

~.:~

:Afetomatemal cir~1atory Uf;lit. catted .a .P1ac~ntone or fetal cotyiedon, is composed of one viHo.us
tree with ~ corresponding ~rfused pOrtiOn of the:intervillou.s .space. Several villous tr.ees occupy one
placental lobule or maternal' c<>ty,le<Son.
. .
.'Decidua l~tlori 'is. cl-.a~e that Occurs -irr the .endometriu rr. in (esponse .to blastc0rst implantation.
it\e
The decid'uatized :endometriai -stroin'al cells
,'!.' ..
:cill!ed decidual cells. .
.
.are '
.

Nita}?uch~s fiqrinold lslbcate<Hn~the Tmmediate:n,~ternofeta,l junctlonal.zone and is the site t>fplacental

separation.:

Fetal c~tJ:t~tionr- OeoX'Jgenat~ bloo4 floWs to 'the ptacenta through two umbilical arterie:; in ~

umbiii~ epr~. ~and within the .p~~ba begiris branching to form capillary networks~ Exchange .of
: ~ubst3r;!Ce~ ~rs~oy diffpslon ,~ pt~::~llaries. into -the intravil!ous ~pace, thrpug_ h ~e villoi.IS
- ti-OJ)hootaSt ~.nd:oi.Jt.intotn~ mte~$ -S;pate when~ maternal blqod ~thes thesyncitk>tr6phoblast
. Oxygenated. bloed :returns froin tl1e ~~ta to I:J)e.-'.fetus thro;t!.9 ll a.,singie.lJmbllical vei.n.
. ' . . ' . ' ': . . . . .. .
.
.
M~~ai. circulation- Mat~?lblOod enter:Slhrough'tlie basal Plate ar}d is driven 'toward the up
~nic-plate b.y'_maternal art~rial ~!'ess()re~andifisperses laterally to !>?the t.'le chorionic viiiL Maternal
.. .
blOOd~ndtains back throl)gR -~en_Ous
.' .,
\o~~in~s
: . .
.In the basal' .ptate .arid enters t9e uterine veins.
.
~ .ol>.:.: . ..~ . ' .
.,. The- f~id:t ,m embranes .ate:_~~ ..qp pf.~three distinct layers - amnion, chorion !.3eve, ~nd :deeid1,.1a
. ~:;, :ea~u'taris..i... :. . . .. .. , .... .. ::-- .... .. . . . , .. . . .: . .. : , . .. . , . . : ... .. .'
' . ~ ~ . . .. .
In ihe .'trciphobtast,-.tliebil5al'-Chori<u1=be;comesm~ chorion frqndosum, the foterunner~ of.tne later.
placentp. me
yapsu!!lr.Chqrion::at oth~;antiimplantation:pole begins .to: degene'rate...by the.thlrd week,
. 'the.;if.ltem}JIO~s.sp.ace:ot!l~eratg.s..aqd :tr:qphpbl.astiG sh~ll.. fl,lses to forrtlthe:smocth chorldn : (~llbrion ...
::" iaev~). .: Ttk::endo:metr1iim:Wnifo~rms;~py' ;differentiation. of enctorriet:J:iaf str6ma! cells.:into -deCkjual .
. -~cefls;iandi:is f:!'eheeto.fth"calle<f.d~.eidu~~-The <ieeiduabelow.. aiicr lateral :to the.biastoe}~arii:l ~ter the
p~ta:)s,c:311ed",.tlie bak.t'. dec.ldua-;tde:c id.u:a .- b~$ali~)- Wi~h ce_mp:~tiol) :Qf ifTIPJ~ntaQqn ..of the .
Pl~W.YSt'tDe Q~dua, Ckis~~ over:'ttle b~_stogst:a~ this layer iscalled eap$ttt~r decictpa (aecldua ..
capsutai'i$}:<Al~those~parts-:pUI:l:de99uathatiinetf1ei.JtennecavrryWithouFbeing".irtcont()ctwif.h tlie
htastocyst:~re~ca!lett- th:e- panta'lcct:e-cfdua 'b rdeciduavera; .. ..

Th~ ariml9n i;; COfn~ of an in~r layer of--epit.~elial cells, ..p!pnted .o~:a bas~Jj{e!'ltmeri)b~e.and I.
is-connected to athin~nnective tissue l~yerby .filamento\.ls strands. ltdoes not.j:>ossessits6Wn blood
ve~!s; :~nd 'o~tairts its.ntrtritlortand oxygen 'from the surro:,.mding. Chorionlc .fluid, .amniotic fitiid and
fetal_surtace v~s~,~ ls.

A.mnionlC:fluid votum.e tnrotJ.g~out pregn:aney vai:l~s wi!.ha mean of 1000. ml at 33-34 weeks, fOlloWed
bya .p~cn~a.se.in .volunte .until term. ih'e p H is usua'lly 7.10 with rnaxirnt;Jm vall)es of7 .4. .

The u.mbillcal sord:atterm .contains tWO arteries CJ.n'd on~ vein, which wc;.s origina!!y the left umbilical
Vein, the right Vein disappearing ceq.rly in life. 'the irttraabdominal portion of the duct of th e umbilical
ve~cle usually atrophies and d!sappear's, but if it rema'i!)s, it fortns a .Mecke i diverticulum.

Scanned 8y: ~
~
 CHAPTER 11: PlACENTA AND FElAL MEMBRANES
1. Beminlchke K. Kaufmann P, Baergen R. Pathology of
the Human Placenta Fifth Edition, Springer Science
Business Media lnc._Ne-:; York, 2009.
2. Curu:Ungbam f, Leveno 1(, et al. Williams Obstetrics
. 22"' Edition, McGraw Hill Publishi.-tg P.ivision l,JSA,
2()05.
3 . 8eck t. a..'ld Heywjnkcl E. Berechtigte ~md -unberechtigte
Befurchtung~il in der Reproduktionsme<Jizin.
Gynikologe 1~; 23: 24g.,2s1.
4. BO)td JD and :1-iarni!tOn WJ. 1'he Human Pl{icenta.
.Heft'~. CJ!mbrldge. 1970.
5. Ps)-..Jioyos A. 'Fhe "implantauon window: can it be
ei)larged or displaced? ~cerpta Med .I nt Cong r Ser
1988; 768: 23i-'2S2.
~. H~aet CH and Streeter Gt,.. Pev.eloptn!!nt of the
Uit>~e bubcyo. Contrib Eqibryol Camegie lnst 194.1;
29:15-'55. . D1YQfjbroblasts differentiatiOn. Histochen; Cett Biot-
__..:. .. ,T:. ,.. . . . . . i-9%-; lOl:-415-429.
?~ W'~l~ .GB Md Streeter GL. On the placentation of
- the _ma caque (Mae&.ca mulat~J from the ti.Jne of
iinplantativn until the fonnatiQn of the defl.llitiv.e
plaCCJlta. Contrill .~bryol Caro.egie lnst 1938; 27.:1-
- ~.- - Mic1"9SC. Re$~Tecld~3:29--41, 1997.
a:~:~~~t~d ~J. Two h\iinan ova ofthe.preVillous
.~~'hBViQg lUlo~n age ~fabout eleyen md ~lve
-:<ti.Y& ~ely. COntrib Embryol Carnegie Jnst 1941;
: 29:l27.lt56:
9 . PijDmbOf$ R, Robl!rteon WB, ,BrQsena l -and Pixol). Q.
:T ropbohlaat.. in.v.{lsion-- -and--the-~stabliah~ent- .of
.haemnchol:ia.l_p!Jtc::cnta:tion-in .marl and -laboratory
animals. Placenta 1981; 2: 71-92.
10. t:nders AC. Cytouophob.)ast_ invasion of the
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stage ()(implantatiOn. Trophoblast Res 1997;_10:83-
95. . .
11. KAiser R. Ober -die Ruc.kbilduvgs~orgii:ilge in .: d.~r
. Decidua :w~end der Schwangei-scha,ft Arch Gynakol
1960il~2:209-220.
12. Dalleribach-Hellweg _G and Sievers S. Die histologische
Rea ktion des Epdomett-ium a u ! lokal applizierte
Gesta.gene. Vircho\VsArcliPatholAnat 1975; 368:.289-
298. . .
-13. Welsh AO and Enders .A E. Light and ele-c tron
lllicro$COpic examination vf th mature deCidual cells
.o fthe rat with-emphasis on the antimesometrial decidua
and its degeneration. Am .J Anat 1985; 172 : 1~29 .
14. Kaufmann P, Sen'DKand Schweikhart G. Classification
of human placental' villi. I. Histology and scannin_g
electron microscopy. Cell Tissue Res 1979; 200: 409-
423.
Stanned By:
15. Castellucci M and Kaufmann P. A three-dimensional
study of the normal human placental vijlous core: u.
Stro~ architecture. Placenta 1982; 3 :269-286.
16. Castellucci M .Md Kaufm.ann P. Evolution ol'the stroma
in h\Ullan chorionic villi throughout pregnancy. Bibl
Anat 1982; 22:40-45.
17. Cast~lluccl M. Kosanke a, V~enelli F, Huppertz B,
Ka:ufma_r.n P. Villous oprouting: f~n-damental
m:ecllanisms of humail placental -deve~Qpmmt. H um
Repr()d Update 2000; 6: 485-494. .
ia. Burton:GJ. The fine ,s~~cture of the hu,ma,rt placental
. viL"u3 -as. reveald b y -~ dectton Drlttoacopy.
ScaJ'...ning Electron-Microec 19"81; '1:1811-1828 .
19. Kr~~ :n.; and:.l?aik-et JC. Contnlctile ~of the
smooth tnuscle in the hU!llan plaQentiL CUn Obstet.
Gyne(:Oll~63; ~:2'6--38. .
20. K:ohn~. (3, Keitschanska S,.Qeinir ~ 1\1,\lt K.u;fn!apn P.
Placental Villou-s stro~na as a modellfY$i:em for
. . . . . ~- . )j,~ . :.
'U>~-"...,
. 21 Ddriir' R. t Kosanke ' G :J:"' r>- v,. ....~-~~~~ s''
,~...---~!',~~ . .
and Kau:fmapn, P.: Classilleatii}n ofhQman-jllite':d:ttal
.stem villi:.review of structural-and funclion.at'&S~.
.
22. 'D emir R. Kayisu uA,~-Y.,Cemc~~:~c;,K~'i(U1..,
ET, De.m irWeusten AY.and Huppe&tz g;~,si<ili;edtiRr
expression of VEGF .and ita receJ>fbn:' ib-.;Wiiiii.n
.p1acentai villi during very e8rly ptegnalit.f.~
~~~~~tt:~s -.d~~
23. Kingdom ;:J cp l'qid;Ka.Ufn;iann p; OXfien'ii:Q.d pliici:Jital
vUI.ous :d~elqpr:nent: origins ciffet81 hypOxia.l>l.acenta
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24. Kin~dom JCP, Burrell SJ ~d. Kaufm.artn P. Pathology
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25. King~oin JCP, Macara LM, Krebs C, Leiser R and
Kaufmlt!ih P.Patholo&ical'basis for abnpnnal timbii.ical
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26. Kohnen G, 'Kertsc hanska S,_Demir Rand Kaufmann P.
Placental villous ~:trotna as a model system for
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27. Macara L, KingdomJCP, Kaufmann P, Kohnep 0, Hair
J, More tAR, Lyall F and Oreer IA. Structut'al.Malys is
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pregnancies wi_th :abnormal u mbilical artery Doppler
waveforms . Plac enta 199 6; 17:37-43.
~
188 II: PHYSIOLOGY OF PREGNANCY
2s. Fox H. P-athology of the Placenta. 1st Ed. Sau,nders,
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. .
29, Arts NFI'. Investigation OJ) the vaSCUlar $)'Stem of the
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30. Amstutz E. Beobachtungen Ober die .R eifung der
Cborio.nzot.t en in (ler: menschlichen Placenta mit
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~t.'~) 1~; 4~:12-30.
31 .Ka\lfJn..luln P and ~gdom JP. ~1o~~tnt or t he
vaac1,1lar sjstettf~ th~ -pla:~ta.ln: W ~u :e.M OM
R\tben)ii.k<Ja): Mo~esla.Of~~.P.P~
. 275.~:~A~demk:F!l~.20QO.
32. :SibJ~. c,t, .~ . 9~ Cetitl I, ~t .a1. .PafhQ~I of
intn~tdine .groWth ~~~n (1\'JQR~ncbi~ona
.dm.ved.:frOm a Et;ro~ Umon .B~oe!i ~ ~Q~ed
.Action PJ'4)ject "l~porumce or Oxyten ~Qpply m
bitra~t~nne . O:to.~ Re~c;t~d 'Pi;ep~cle*'-A
W~op ~eti<>r4 .~ta~:x>2; I-$7~~: ..
3~~-ClWiioclc...Jonc;$ P$, Ka~iUlil: P iln4 1.41htw ':tM.
~~cfh\ltll8.n~tetoplaf!ental,;v~o~C$1$.'&nd: ,.
. :~~~O.lj~ t. N,o~~~Q~~~ntQ<;~;,- .,
2S:U1j.;.;113. . .
~4. '}UUzl M, Li\i~Je l> . ~d Sc:k~&bt.r"p.a~b K.
:,pj.a~nt~verlriderun&eil ~ &PUCttf)se. :Atch
; ~~Aia?l197i4;:~u~~;u~. . . . . . . . em~rPJ,iulplan~an4.P~~:P~ .
.. -.: . .....:- .
~ ~~i.iR,. ~e,y ,tv/,.cy~ . $-J ..~ :~JWK.
:~&rfw.. :tw.o:~.;...i.,.:.
..~ gr~tMa~~IPPECGF
. . u'Qraeh:D
48. Damsk};CH.
~ :~~~:h~pl~~:throjlghQ~:&~tatiop..
~~~-.J.~';J. ~~1.lq~~
. . .
3 6r Reail~<Ml :o$~..~i.lai-~x\aWio-v~ -iF~ Til~
. ~ceta.fl;lypobaric'hypoxia .on:.the:~~ .Y:i!U:e>f the
bUiilanpJaeen~~ytiol l993; 4S9~3.0$P .
~7. JCQSD,nke Q, Ka~yro:v }.{, Ko~ ~ .~d Kau~. P.
J~~emal nc;ilUa ~~ults in :iil~ proliter'lltl~n ln
. hum~ :J>t'ii:een'W
357~ .
vtu.
'rfuphobtast Res.t998; lH~39-
.
38~ Wheeler T, ElcockCLMd Anthony Fw. ~gi~genesis
;and heplaceotal environment. ~cert~ 199~; l6:j289-
'296. . 20: 229-233.
39. WiltingJ, B.itkenh~er.R, Martiny-~aaron o, ~~eo,
. Christ a,
&ichmann A and .Weich HA. Vascular
endo.thelicl v<>wth factor (VEGF) 11-nd p~enta gtowth
- factor lf'lPF):.homoJogous faetots specifically affecting
endothelial cens. Ann AriS:t .1995; 1:7$:' 331;t..
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inducea. proliferati9.n .Q fvascular en4o.thelial ~ells and
apressil>.n o~ fik-: l whhoutaffecting lytnpbatic ves~eb
:oC the chorioallantoic membrane. Dev B1ol 1996;
. ma~~
Scanned 8y:
41. Shore VH, Wang TH, Wang CL, Tony RJ, Caudle ...,..--
and Torry DS. Vascular endotheUal ~
placenta growth fact().r and their receptorainl801~Uo:ll
human trophoblast. Placepta1997; 18:657~.
42. Khaliq A, Dunk c, Jia..g J, et ;tl. Hyp~ ciown.
regulates placenta growth factor, whex-eaa i~crowth .
restriction up-reg\ilat~a placenta growth faetor
exprc;ssion: molecular evidence for pt.:centa! . ~
hyperoria in intrauterine growth r:estrlction. . . lnftat ;;-,~
1999;79: 151--170~ :~J
43. 'Kosanke o . l<adyr'Qv ~. i(~n- H :.rut
Matern~ Mesm. """t
re8Ulta -in -~cre&aed -~in . :~.
P. :l
human -place=1t$1 villi. Tto}>bob!Ut -Rea ls.98; 11:339-. ~
... -- 3.57. . . ' t
44. KaufinannP l\ndCastelNcciM. ~~~
in the human pla~~ 'I):ophoblaat Rea 199'1;:1&.21-
65. . . ,
45. -Aplin JD. Exprc$$ion Of integrin ..i.Jpba '6 beta. 4 !n
h~m:>ppobJast.-nditaJoA !rem~
~ta 199.3; 14".20,3;-2lS. . . . .
46. Apllnjo, l-acey H.. ai&P T, Jo.nes CJ. Chen CPand
. We$tw.ood..M~. (lz\11l1h::fa<:t9r,..e~aeeUW.C. ~,:t:rix
. synef$Y~-~C'~~~~>f,troJll:u)l)laW~:~~ .
. . s~ ~a2000; as-.1~20:Z.
47. Damsky C~ $uth#iaJ;id A a.nd ~er S. E:tttecenlilia'
matrix 5.; A<Ule~ve intei'acti.l~ jn early m...,m&lian .
. ~ 1.993f7:132().;;',},329~ .
.. . Kit
um t..t.:J.n--.~-
. ,e . ......-... . .1
r~tes n~~ ~bobla.at 'inv~ion. Dado~u;nt
. : l221;.!20:~~t~... _ .... - ..... - .... _._:._____
49.' ary&.ni"'ortenWc>Odoti.' ~ ati-&ceii\itU~d"tlie
human fetai Jilemb~ea: atruct\lfe &Jld function.
Placenta-1998; 19:1-11.
50, Postl>v.it Pd, Adatn~ MA find Qnibam CH. Does nitric
oxide play a role in th~ ~tiology C)f ~psla?
Placenta 2001: 22 Sut>PlA:S51..,$5S.
5 ~. Reister F, Ftank HG, Heyl Wf'.t t al. The !listno.,ttion of
mactophages in the pl~centat ~ . in pnWnpsia
differs .from that in healthy. patients. 1'1aoolta 1999;
. 52 . Reister F1 frank HG, Kin_gdom JCP, eta!. M~phsge
induced a-poptosis ~its endovascular trophoblast
invasion in the uterine wall of pree~ptic women.
U!.b invest 200~; 81:1143-1152.
53. Kemp B, Kert:tcbanska S; Kadyrov :N-, Rath W,
Kaufm~n P and Huppert% B. J.nvasive depth of
e~travillous .trophoblast correlates.rwith cellular
phenotype-a eomparison olintra a.nd . utrauterine
impl9J)tation .sites;HiStOchem Cdl Biol 2002; 117;40 1-
414. . .,
~--------------
 CHAPTE~ 11: PLACENTA AND FETAL MEMBRANES
54. Burk MR, Troe~er C, Brinkhaus R, Holzgreve W and
.Hahn S. Sev.erelyr.e duced presence of tissue
macrophages in the bas~ plate of pre-eclamptic
placentae. Placenta 2001; 22: 309-316.
.ss. Fox H. Pathology of th~ P\acenta. 2nd edition, Saunders,
London, 1'997.
'56. Feinl>erg RF, Kliman HJ and Cohen AW. Preeclampsia,
tris<>my 13, and the placental bed; Obstet Gynecol
1991; 78: 505-508.
57. Fein~ RF. Kllman HJ and Lockwood CJ. Is oncofetal
librone-;tina trophoblast glue for human implantation?
Am J Patlloll99:1; 138: 537-543.
58. Fein~ .RF. KUman HJ and Wang CL. TranSforming
growth :factorbetll stimulates trophob4tst oncofetal
fibronectin synthesis in vitro: implications for
b'ophoblast bnplantation in vivo. J Clin .E ndocrinol
Met.ab 1994; 78; 1241-1248.
S9. B~o3ens JJ, Pi.jnenborg R and Brosens IA. The
xnyometrial junctional zone spiral meries in normal
and ~9,.~.rmal pregnanl;iea: a review of the literature.
: _, Am JObstet ()Jnecol200~; 187: 1416-14-23.
~- Brosen~:.t_ The utero-placental vessels at term- the
.d istribution .a nd extent of. phy.s~ological changes.
. '!rophobJast.R es i988; 3:61-68.
61. Shq;'~.~Land BO~J. The maternal blood supply
. . . . , to th~ ~-placept~ in pregnancy complicated by
inttautetine fe t.al growth retardation. Trophob~t Re~
i i
1988; S: 69-82.
62. Okazaki'!', Casey ML, Okita JR. Ma~onald PC and
Johnston JM. Initiation . of human _pf!,I1~t.ifll'! ..XII.
..Bioiji}llies1s a.ii!CDiC:ta.i>C>lism .;r prostaglandins in
liiimin rarumemb~c:s an:<f ut'erine d.eci&ua.. &n J
ObstetGynecol1981; 139: 373-381.
63. Okazak! T, S?.gawa N, Bleasdale JE, Okita JR,
MacDonald PC and Johnstcn JM. Initiation of human
parturition: XlU. 'Phospholipase C, phospholipase A2,
and diacylglycerol lipase activities in fetAl membranes
and dtcidu,a vera tissues from early and late gestation.
Biol Reprod 198.1; 25:' 1'03--109.
64. Smieja Z, Za kar T, Wa lton JC and Ols on OM .
Prosta glandin .endoperoxide syntha se kinetics in
human amnion before and after labor a t term and
. followingprcten'n la bor. Pla centa 1993; 14:163-175.
65. Toth P, Li X and Rao CV. Expression of hCG fLH receptor
gene and its functional coupling to the regulation of
cyclooicygenase-1 and -2 enzymes in human fetal
membranes. Place11ta 1993; 14:A78.
66. Fuchs AR, Periysamy S, Alexandrova M and Soloff M.
Correlation between oxytocin receptor concentration
and responsiveness to oxytocin in pr egnant
myometrium: effects of ovarian steroids. Endocrinology
19 33; 113: 742-749.
!!tanned By:
'' 189
67. Benedetto MT, de Cicco F, Rossielli F, Nicosii'AL, Lupi
G and Dell'Acqua S . Oxytocin receptor in human ietal
membranes at term and during labor. J St~roid
Biochem 1990; 35:205-208.
68. Rees MCP, di Marzo V, Lopez Be:nuU A. Tippins JR,
Morris HR and Turnbull AC. Leukotriene release by
human fetal m embranes, placenta and decidua in
relation to parturition . .J Endocrlnol 1988; 118: 497-
500.
69. Crescima nno C, Muhlhauser J, Castellucci M,
Rajanienii H, 'P.arkklla S .and K&u!mann P .
!mmunocytoehemical exp~on patterns of carbonic
anhydrase isoenzymea in humsn placc:ilta, cord and
membranes. Placenta 1993; 14:1.11.
'70; Miihlhauser J, Cresclm.anno C, Rajaniemi H. Plu'.dcila
S, castellu~i M, MilovanoY AS and ~a.cn P.
Immunot..istoche mistry of cerbonic .anhydrase in the
human pl&ienta and fetal membranes. Histochemistry
1994; 101: 91--98.
71 . Mann'SE, Ricke.~, YangUA. VetkmanASand Taylor
RN. Expression and lucalb:ation .ofaql.lapprin t, and3
inhuman fetal mcmbr8.I!CS- AulJO~g;~~~L~i'
187: 902-907. . . .. . . .::. \ Jt!:i_-._,_.,
' i...:. ,
7~. Queenan JT, Thompson W, Whitfield CR and .Sh.sh Sl.
Amniotic fluid vo,lum.e s in normal preg~t~., !un J
Ob.stet.Gynecoll972; ll4:J4...38... ~:~
. ..:{ .
73. Redmpnd,.AD. A.mnio~drtsSing. LanCet 1984;..,1 : .900~ .
.. ~ t .
74. Akle CA, Adinolfi M, Welsh .KJ. Lei~:.vi~S:~.MCcoll
1. Jmmun~genicity .of human .amniotic. epithelial ee1ls
after transplantation into volUJltcers. J.ancet 1981; .2 :
1003-1005 .
75. TalmiYP, Sigler L, lpge E, l<'inkelstein Y and Zohar Y.
Antibacterial propertiea-ofhWli3ll amniotic membranes.
Placenta 1991.; 12: 285-288.
76. Klima G, .Zerlauth .B, Richter,) and Schmidt W. Die
Mi.krotextur von Amnion- \li'ld Chorionbindegewebe.
Anat Anz (JenaJ 1.989; 168: 395-400.
77. Klima G, Urlauth 8, WolfHJ and Schellnast R A study
of lectin bindmgs to the fetal membranes. Anat Anz
(Jena) 1'99 1; 173:87-91.
78. Wyatt-Ash.mead:J IU)dAshmeadA. F1acentalmembrane
bursting pressures. Modem Pa thol 2004; 17:275
(abstrac t 41).
o)
79. Lavery JP and Miller CE. The vis.:oelastic n ature of
chorioamniotic membranes. Obstet Gynecol 1977;
so:467-472. .;.. "
.~1:.
,...
: ~'
~
 1 .

l ;,;

I
'-

.:'t'':...-
,,., .
';.'i~.';.~ 1:": ..
~. .,, (. ' ~

'r ~~:~c:~~:.~!ht:-. :~ ~ , ;. 1

.: ); ;,. .j.-.~iQ:f,~sq,. ;),

::_:~:i~J-~~~: .1,...... - ~ : ... ; -

. ': -.

'I

Scanned 8y: C
 12

PLACENTAL HORMONES

LILIA PAGTA.KIIAJ.~-LUNA, .MD

Placental Protein Hormones

Human Chorionic Gonadotrophin (hCG)
"' ~ .. Human: Placental Lactogen (hPL)
Chorionic Adrenocorticotropin
Ghorionic Thyrotropin
Relaxin
Parathyroid Hormone-Related Protein (PTH-rP)
Growth! Hornrone Variant (hGH-V)
_Hypothalamkf-tike Releasing Hormones
GortadOtrophin-releasing Hormone (GnRH)
Corti~fi'Gpin-releasing Hormone (CRH)
. .GroWtlVHonnone-releasing Hormone(GHRH)

Other Placent'a1' Peptide Hormones

Leptin
NeuropeptidE Y
lnhibin and:P\ctivin
. Placentali steroid Hormones
Progest'erone
Estro!fen!
Fetal 'Adrenar Glands
Fetal Conditions_that Affect Estrogen Production
Maternali Conditions that Affect EstrogenProduction
Direction~t: Secretion of Steroids from Syncitiotrophoblasts

Scanned 8y: ~
.:.-192
---~~~~~~----~i
..--- - ;.
SECTION II: PHYSIOLOGY OF PREGNANCY ... ;;.,..;
------------------------------------------------------------------------~~~~~
;:~
..,'
'i . . .. .:
;

INTRODUCTIO~ and obligatory relationship with fetal adrenal~.

secretion _of C-19 ~teroids w~ich is the prec~rsor ~
Steroidogenesis in the f-eto .. plac~ntal unit for es .t rogen synthes1s. The .hum.~nf!
results from critical interaction and syncitiotrophoblast has been demonstrated ti~W.
_i.nterdependence of separate organ systems that utilize LDL-cholesterol from maternal plasmafor 'fi
individually do not P..ossees the aecessary progesterone biosynthesis.
. .
. :t."
,-eJiey-matic capabilities. The p:-ocess of
st~idogenesis co:usists qf a fetal, placetital and
"aternal compa.t:treent.J The sy:ucitiotrophoblast -.
~1he.major site of steroid. and prot<=it;l pr9(luction
. .lri'tne,p~~en~ {Figures 1~.la & !2 ..lh) .
.

. .
. .

protein
.Gyriecol Endocrlriol ~ In:fertil,_ . .
Figure 12.~. -An~o~ Pa.I1S -o f ~e endocrinecOIIU>.On<::Iit..
of, the,placental iilm.:of th.e.fetal:'m at=.al -communication .
.
..,-.--.-~ -
syst~:~:rro~ yne!e~~ir.-~~..sJ1mnl,t~i'e~- ..
tal adrenalsteroid,ogehe~s. F~.tal - dehydroepi.andro_S:taOne
-.
COmoosed of 3 comoartments: s-Uira.t:-eana-r6a:.::"oH-d.:eny~pliii1lrosterope -SUl!~&re -
tran.sported to the,placentaahd converted to esttadwl.i?'b .
' ' ~feW placen~ ~ a:nd estriol; r~speetively~ The fetal !i:ver ~s-theinajor:~te .o f
production of..low-densit)t" (l.,D.L) ch.oJ:esteroJ, the _
px:fuq_p:eJ:
precursor -for fetal adrenal steroid9g~nesis. 'Cholesterp~; .;
derived from maternal_p~a::ma, sez:V:es as the precursor for' :
' eomDiementarv. form~oomolete unit. utilizes progesteronebiosynthesis_it;t ~e _p1a~n.ta (Willianls Obst,et.:..
rics 22nd Ed).

Matefll,al compartment:
s ource ofprecursors,
PLACENTAL PROTEll-t HORMONES
~learance of steroids

Fi~ 12.lb. Ster-o idogenesis in pregnancy.
. \ S.t-eroidogenesis in Pregna'n cy -(~lgure 12.2)
Hu\llan. tfoph.oblasts produce steroid, protein
. and peptide hormones in enormous amounts. The
.. hype:restrogenlc state -of pregnancy has a uniq~~
The human p lac enta als o .~ynthesizes laige.
a mounts of prote.in af:ld peptide hormones: .
chorioni.c gonadotrophin (hCG), human placeotal
lactogen (hPL}, chorionic adr.e nocorticotro_phin . .
~ACTH), growth hormone variant (hGH-V),
parathyroid hormone-related protein (PTH-r:P};-
calcitonin and relaxin. lrihibins, activins, .
cytokines and atrial natriuretic pep tide are ,alSo_... . ..
synthesized by the I?lacenta (Figure 12.3)_ ..

Seanned 8y: C
 CHAPTER 12: PlACENTAL HORMONSS f93
--~----------~--~------~~----------------------~~-- ~-

.Table 12.1. Steroid productionrates in non-pregnant and

nea.r term.pregnant WOtnen. FdaiQmpartrDcnt ~~...._. .

.... .
Al:f>a-bqrot:in ~llcc""'-
PrQduction Rates (mg/24hr) GnRH TRH GHUf
c:RH~

Steroid* Non-pregnant :..

Plhll~kcnor-
hOObGf ACJH
171} -Estradiol 0. 1-o.6 lQ-:20 . I>Pl. .'hCJ' ~
Estriol 0 .02-0. l ~0-150 . Grvwtto~ .
PA~gesterone 0.1-40 250-600. lqt:-1 EG' roG
Aldost~ne 0;05--0:. l :0.1$0c0,600 J(;F:D P!XF fdlkesin
l -12 . ~ lrh\ia
Deoxycorticosterone 0.050.5 ra;a. AaJ)'ia
Cortl$61" 1~30 l0-~0

Estrogens and -.progestero.ne are produced by the ::

..

placenta. Aldosterone is pioduced by the "tilaternar-

:adr.en81 ilaM in tespcm~to the .atimulua ofaQ.giotensin
n. Deoxy;::ottlcosterone ill ~U.Ced .in exuaglldw
tissue sites by way.- ofthe 21-hydrcx:ylation of plasma
-progestenme. Cortisoi production during p~cy
i$ not increased even t hough the. blood levels are
e:~d .bca::.usc: of dtcreaJs:ed clearance caused by I . .I.
jncrea:sed i:Qrtisol-hirtrling globUlin (Williams Obstetrles.
Figure i~~3. Protefus a;t;>oc.iated with pre.;.ilnq (C~
22~:fE4J2 orneeot Endoerinol Inferot7th Ed: ~hap: s p. ~ ": .
_. , . . . i- . ~:. !:.. ..
.. ';.~~-?~ '

Placeutal protein syn.Lltesis is influenced _by anterior pituitary gland of men and non:,.prCgilafit
hCG anda.v.ariety of_grt>wth factors (Figure '12.3). women.

. The ":h uman placenta . .also produces

hypothala-mic;.J.ik~ releMing and . inhibiting
honnones: thyroid-releasing horn1one .:('rRH),
gon:a(JotrQ:phin .releasing hormone (.G nRH),
~EQt.!:Q'Q!!m.~r~l~e~mg~h'?!me>..m~J~Rtlh .wwtll-
h.9.rmQn~ .. .r.e.leRing .: hg.:r..m.o.ne (GHRH) arid
SQin?-tc)staPxi (Figure 12.3).
In the. fetal campartment, the -protein
synthezised is .alpha~feto proteiti :and in the
maternal coinpartni:~n~ there is production of
prolactin, relaxin .and other decidual p"r oteins
(Figurtd2.3):1
Human Chorionic Gonadotraphln -(:hCG)
This pregnancy hormone is.a glycoprotcin with
biologiCal actiVity si.niilar to l uteinizing honnone
(LH), both of which act by way of the plasma
membrane LH-hCO r:eceptar. HCG 1s produced
almost e;l{clusjvely . in the .placenta but is
synthesized in fetal kidney and other fetaltissues; 3
Although some m-a lignant tumors,
trophoblastic neopla~m. produce hCG~ its
presen~:e in bloo.d and u rine .of reproductive age
women, is.almos t .a twaysJndicative of pregnancy.
Very snuill amouJ}ts of hCG are produced by the
. . . . ~ '.! :. ~: ..;H ~"'...-" . .
The carbohydrate component proteets'the
molecule .fr:Qm ~tabQJi~IIL 'Jbep~~ of
the .intact.~.le.Culei3"...36~.: lhe.hCG)jiijleMile
is .c.o.mp.o:sed , of :.dissimilar..-alpha..alJ4-.;beta.
subunits. There is .no biological actiVity c::ither
separated subunit. Bioactivity which js binding
to the LH receptor is only present if the two.units
are combined. Isolated subunits cann ot bind to
ijle LH receptor and therefore, arc not bicactiv-e.
Reconstn.tction of :analphaand beta subunit gives-
a molecular activity !Otrnil~ to the honnooe from
which the beta subunit" was derived.
HCG is s tructurally identice-1 to the
glycoprotein LH, FSH and iSH through identical
amino acid sequence .o f the alpha-subunit. ... The
amino l!ci<l sequences of. the beta subur.it.o f hCG
is distinctively dissimllar from those of IH; FSH
and TSH.
e .g. Biosynthesis -~ .
. ::~- -
The rate limi~g synthesis of . the. jkU.bunit
results in low to undetectable circul~ting levels
of free P-subunit throughout pregnancy. Plasma

!tanned By: ~
 1.g4
---.----,------,--~~~---:----:--.........----..-:(1

SECTlON II: PlofYSIOlOOY OF PREGNANCY ' ..-,.;~
.
----------------~------------------~----------------~--~----~----- ~
..
. -~;:
._.

levels of free ~-subunits increase steadily until
the 36tltweek of pregnancy atld then plateaus till
~e end .o~ pregnancy. Ttte secretion of - ~..hCG
corresponds roughly to the :placental mass,
wb.erea.s the rate of secietlon of the complete hCG
to
molecule is maximal at 8 10 weeks of ges~tion.
levels ~ 1/3 of that in maternal plasma. The ~~
atnn:iotic fluid concentration of hCG early in :;~
pregnancy i~ sim)Jar to maternal plasma Urine./1.
concentration of hCG follows the patum of ~:
maternal plasma. 1
. ~

Placental GnRH, produced in cytotrophoblast, acts
in a ~crine manner on .syncitiotropboblast to
stim$te hCG ptodution. Other. a,genta .believed
to in.U~ence hCG secretion in trophoblast are
inttr~ili"l-6, epidecinal growtb.fact9r arid cyclic
W..P. Acti:Vin. stimulates and inhibin inhibi~s
pt04uction ofGnRH ft:t;d hCG~4
C~Uidar Origin of hCG
Significantly, higher plasma levels are found
in . pregnancy with multiple fetuses, single
erythoblastQtic fetuses wi:th maternal D-Mtigen
isoimmunization, hydatiform m.o le or
choriOCEltcinoma and at midtrimester i."l WOJ;I)en' -~
with a fetus with Down syndrome (llse\1 in
bioch~ sCreening). ~lativdy low levels are
found in ectopiC. p~gnanc:;ies .and impenc:Ung
spontaneous abortion. Assay of hCG fo.!llla the
basi$for tbe majority of pregnancy.tests..

At le$s ~ 5 weelcs, hcG is ~ressed in both

.s_y:ncl_tiotropb~blast ~d ~otrophoblast..; At the
peak Qf ma~al )evels ~~r in gestation, hCG is
UQ .
~
~
..
prod~ced ::$ ost excl,'Qsively irJ. the ..syp.citiotroJr 12!1 ,,.
I
'
'
ho'b~t. ' ''\+
.000 .

~i
I
:3' 100 I hCG ......
. ...J
I
-~
J
~
I
eo ,. I
J
~ l: 4
~
Moleadar Foims of hCG in [Jriru! andPfa$ma ~ eo I .iiJOo
a:; [l.
..c
~
I

there:- are :.multiple:forms :Of'llCO':iil. inatemal,

pl.a$a.: .~.: utine:. an~;they.~~nonxi<>ustydil "- ~
40

20
..
.. .I .

I
I
1!)0
1
a

bidactivity~and: iizU:nunorea(:tivjty,.So!Xlc'portion;;-. . I
I
...
of-~bCCtm-c:U~e~llPni~~}wJlll~g~t.ide- . 0
li.nlc~ge~: hut Jlte J)~~~~gical __~Jig__niit~~~~~ 1! 0 10 ~
- .
30
- ~
40

~~J~~ed_ .(Qrm.~: .Qf hf~LpredJ>.mirn!ic_iD Weelca'G~~II on

h~tidifom mole or -chori<>earcinOtnfl. (Cole &
Imtltr, 2()02).
The jnta~t hCG molecule js- detectaPle iri th~
plasma J;!f pi"egne.nt . wo~en ~bout 7-9 days aftet
the Jt4dcyle s~e ..of .LH ~e.t p~cedes pmlalicn.
HCG enters maternal blood at time .ot bla~tocyst
imp~~tatjon . Bl<;>od levels .increase rapidly,
dQ~l;>Jin.g every -2 ~ay~; with .maximal level~ a:t
about 8~ 1Q w~ks - ~estati<>n '(FigtJ.te 12.4). Pe;:Uc
levels reath abo~t 100.,000 zniU/mL between the
60th and OOth day-a after tbe last menses When
the .hCO . ti~r exceeds l,O(>O..l,SOO IU/L, vaginal
ul~nography $hould iiientify ~ intrauterine .
ges~tion.t Beginning at about 10-12 weeks
g~sta:~op; tQ.atemal plMrp.a levels .b egin tp decline,
reaching a n~~ir.at abQut20 weeks. Plasma levels
.ar-e' 1ilaintahi.ed at fui~ lqwer level Tor Ule rest of
the pregnanc y. In fetal blood, -pattern :Of
~p~~ce is thesame a~ .the :xnotber but plasma
Fipte 12.4. Connt+atioM ofhCG, hPL. and CRH in
serum of women throughout normal p~gnancy. HCG
plaa.ma l~v~a fan;tJ).ela ~rlne level, rapidly rising from
appro.~!ltel.Y '1 0/till by6 ~cJcs after LMP to. an average
value of11bout 100 .ItJ/ml between the 60th -80th day after :
LMP. (WilU~'.a Obstetrics 22nd Ed.)
Metabolic 'Clearance of hCG
. The metabolic clearance 9f hCG -is 30 percent
through -the kidneys, and the r~mainder in the
liver and other pathways.
Biologic Functions of hCG
1. Rescue. and milintenance of function of t he...
corpus lufeum. tconHnued progesterone-.
production). The progesterone-prod.u cing life .
:span of the corpus luteum -of menstruation .
'
could be prolonged for 2 week.s by hCG

---------------------
Scanned &y: C -- - - - - -
 CHAPTER t2: PLACENTAL HORMONES
admlnistratiCin.{)HCG takes over for the corpus
lu~eum about the 8th day after ovulation or 1
day after implantation. Continued survival of
the corj)us luteutn is totally dependent on bCG
and in turn, survival of tbc pregnAncy "is
dependent on C()rpus luteum progesterone
Until the 7th Week Of pregnancy. I Progest~rone
luteal syrithesis begins to decline a:t about 6
weeks despite cntinued :and increasing hCG
production. There is down-regulation of li.CG-
LH receptors in the corpus hlteuni -wben
trophob1as~ produce sufficient l>rogeste.r one
for pregnaricy mainte1l:ance.
2. . Stimui~tion of fetal teSticular testosterone
:secretion. Before n 0 days, there is no
fetal
anterior pituitary LH. At a criticai time in
sexual differentiation of the male fet\is, hCG
enters fetal plasma ' from the
syncytiotrophoblast, .a cts .asan LB surrogate
and stimulates repUcation: ot testicular Leydig
tells- -and testosterone synthesis to pr<)mote
male ~a:I differentiation.
3~ Stim:utation ofmaternalthyx:oid activity. hCG
. bin.dsto the TSH recep~rs of.thyroid cells. La-
... ,:~ hC(lteeeptor is~ressed in the thyroid'., ~d
..,posS!oly.. :hcG stiniUiatesthyroid actiVity via
the lM.::h cG receptor ~d by the 'TSH r:eptor
.as welt Studies have indicated .t hat 'bcobas.
inb:iu~ethyrpid 9.ctivity ~q @ayQe the second
p~~~ .~~~J~iC. ..~~~~~_ce:
4. Promotion of li!ia:xiri' secretion by 'the corpus
1\lteum (Du ffy & co~workers, 1996)
5. Promotion uterine vascular va sodjlation and
myometrial smo9tlr mu8cle relaXation' via LH-
hCG ~ceptor:s .(l(urt:zJ:nan. &.qo.-wotkers,-.2 001).
Human Placental Lae togen {hPL)
It is a l so .c alled huma n c horionic
s oma tomamm o tropin o r .chorionic growt h
hormone because of its potent lMtog~nic and
growth horinone-like bioa ytivity, a,s well as its
L~UnQChemical re.s emblailce to human growth
hormone. It is concentratedfu syncitiotrophoblas t3
,.and is detected in trophoblast as early as th~ 2nd
or 3rd week after fertilization of th~ ovum. Before
6 weeks, .hPL is also identified i11 cytotropho-
blasts.5
Scanned 8y:
' 195
Chemical Characteristics:and Expression-
HPL is a single nonglycosylated polypeptide
chain that is structurally similar to hwnan
prolactin. The production rate near tenn i3 about
1 g/ day and . this is the greatest hormone
production in hl;lmans.
Sen.tm Concentration.
HPL is demonstrable in the placenta within
5-10 days ~fter conception ~ detectable in
tnaternal sCf\lm by 3 . weeks post fe:rtiHmtion. .
Maternal plasma eoncentration.rises '1.Ultil34-36
week, with hi_gher leoJels in late pregnancy. HPL is
secret~ primarily into the maternal drcW.a:t ion
with ve.ry little :tUttounts in.~U;mal urint ~ in
fetal1>16od and urln~. Jt ~ppean that itfJ-rOie :in
pregnancy is 'm ediated duough m.atmw ~s.
There is . a -possibility that it has :oome_: ~ns
hi fetal :g rowth.
The :r ate 'of bPL : se~retion is PtP.~t.tio,ru.d. ~- '
the plac enta:l...mass~:. Studies sugg~b~f:tthe :
synthesis of :hPL is stimu:la:~ed b~~
insulin-like wc>wth factor- I ancl'::inhibifed--by
. PGE.2..AAd PGF2i:l (I;Jb;;lllnJick &. ~lJ.~.J9.87;
Genvac ev & colleagues, 1917j. 'frplong~d
xil~f~~~ ~~~~~~~: llie)~(~f.:~f.me...;;;ni~Y. .
leads to 8.1). increase in the plasma concentration
of hPL~ Very h~gh maternal levels are found in
multiple gest.al;ions;
Metabollc Actions of hPL
1. Maternal lipolysis and incr.ease in levels of
Circula ting free fa tty adds, thus providing
energy for ,maternal metabolism a nd fetai
nu trition. . .
2. Anti-insulin a ction or "diabetogerucaction
whiCh lead s to increase i n .maternal insulin;
favoring protein synthesis and provision of
mobiliza:ble amino acids for transport to the
. fetus.
. ~:~t .
3. Potent angiogenic hormone ma}iplay an
importa nt role in fetal vasculatu~e fotlruition.9
~
 196 SECTION II: PHYSIOLOGY OF PREGNANCY
------------~--------~--------~----~~--~----------------~~
.,
. '4

HPL is not required for a successful Parathyroid Hormone-Related "Protein {PTH-rP) : :~

pregnancy outcome b ut functions prim8.rily to

ensure nutrients to.the fetus especially at times Circulating levels of PTH-rP are .significantly.
of maternal starvation. Studies indicate thathPL . elevated in pregnancy within the maternal but
directly affect; fetal tlssu~ metabolism, not in the fetal circulation (Bertolloni &
including synergi stic actions "\\f,ith i-nsulin, colleagues, 1994; Saxe & colle.a glles, 199'1).
es~ally on.glycogen synthesis in the liver. HPL. Synthesis ba~. been dtown .in adult
may be the fetal ~owth hormone."' myome trium, endoJttetrium, corpus luteum and
lactating mammary ti-s sue. It ls not produCed
in rumnal aduJtparathyroid glands. tt may have
ChQrionic AdreQ.ocorticotropin an im_port~n:t ~utorine~pa.racrine role within
the fetal-ma -terne:l .u.nit as well a'J on tht:
The placenta h-as bet!n .de:m'Onstrated t-o adjacent myomeirlUl;ll.o In the placenta.iUnay
synthe-$ize all ~h~ _px.oteolytic prQduet:s of actiYate receptors on the trophobla~t to ptom.ote
proopiomell:mocortin; ACTH, lipotrqpin. and .P:- calcium tr~sport for f~tal bone gtQVrtb aud
~dorphin tGenazr.Sn.i & caUeagu~s,. 19!5; Oda,giri ossificatiQI\. .
& <:oUeagues, 1979) . . The phystolo,gJcal role- of
pl~n.tat ActH is unlcar. Plaeental ACTH" is
secreted i:n to the ~other or fetus eluting ~ Jlcnnon~ Varlant (h~H-V)
P~~bh: ,.... . but', ma:te:rnSJ
~~"""J: ' .ACTH
. dOC$'.not . 'the.
. d'OSS
. p~t;a'to. theifetus. 'Pla:cen~.AC'l'R is not under . Thi$.i$:not :exptessecl in t.~e .pitui~ ;:and i$
feedback,'; regtil~:tJ9n" bY:t:,:g\:t,t~ocotti~oidy"'iuid . . l"efe~.d -to '>aS.the . placep.bd .gr<>wth hQnilbn~:.
e~la,ins~the.Tmate~nat~.~par.tial.:;:r.e.sistance -:to. .... h~V~.i.$::.synthe~~d .. ~ c;th~,-~Y,c.i.tj~.. ~ _is
-depmethasone" . :sup.p r.esslon. ... Placental: : p:rese)l~.: in--maternal. plasma by :2h~6 eekta~ .
coqicoti'opin~releasirighorri:ione. (CRH)' s~tilates .. inc~a$$Az. .~, <;Oncent.ration by.3 6 wetb ~.d
the synth~is and release of. chorionic A111.. an4 plateaus-in. !.evel . t.her~~- It :i"s .nQ"t. ~
:a~J1~~..:pr.odue:~~Ofi: .of-: CRH ..Js-~ posifively ,b y.:piaci;ttnu_..G HRii .bU~- ~pon4s , i,nV.~ to
~te~!."1>y ciortiS4)L ~ :systenF iS: ,important . ~ . matenJ'Jt.h ghieQ.s e . l(!;v.ei~..,, pr-~t~c:tiJ,t_g,;~tiCos.e
!orcon~~gfe~lungm~fura,ti'cn :&nd,'ibningp 'f,.;. ... a~eila'bl!J~:!or ,t.it.e;:fetus. ~, ..l~:i$ _,a: ,~~y;fact1)r .m
~tiOru()Xytoclh is a: poten.t~$timula:toro!C.RH .tnedi:;lting. ins~lin .re sis.t s.nce. in pre~cy
Md Aetil p~tal. prGduction. ~bout -:&. coJ1~gues, 20Q~). "It~ ~~te
.. . . .. . gtatJ,i.n t.Qgeneais.__afid.J.W:OJ~s!~. iJt:..matmat
. Chot.ic;,_il.lc-.Thyrotropiti -organs,.thus influences.fetal growth by-affecting.
matetn~ meta:l>Oli$01. 1
There is evidertce that. the placenta produces
ch<>rlo"ruc thyrotropin but no evidence that it:has Hypotba!a m1ct.lk_, Rel~a$lng .ltb.~ones
a si~ficant biological role in pr.egriancy.
F(>r e~th of the kno wn :hypo.t)ialaini:-
Relaxin teleasi.J;lg -or inh~b.itin_g hormone$, Gn.lfl. TRH,
GHRH, arid somatostatin, there ia an analogous
:Relaxin .is expre.ssed i n hum.a n eorpu s placental hortnone4 11 , indicating hier.4--chy of
luteU)n, .decidua .~d placenta .l 0 It is a peptide control in the syn th esis of chor ionic trophic
that is ~tructurally simila r to -in sulin a nd hoiT!lone:;.
1nsulin-like growth. factor . Relaxin along with
rising proges terone leveis acts ..on myometrial Gonadotro:phln.-Releasfi:lg Ho~onc (Gn.RH) .
smooth muscle to p romote uterin.e relaxation
.llnd the q4iescence o\;>served it:l.early pregnan cy. Immunore.a~tiv e GnRH .is present in
Relaxin .and n!iaxin -like factor s ht.the placenta cytotro.phoblasts but not in syncitiotrophoblast.
and fetal membranes may play an . autocrine- It functions to regulate trophobt.astic production
pa.racrine role in the extracellular. m a trix qf hCG,: and is likely the cause .O"f.elevatjon of
de.gradation in the puerpe.r ium (Qin . & maternal .leveb of ,circulating.: GnRH in eady
colleagu~s, 1997)~ . . pregnancy. 12
"4

Scanned 8y: C
 CHAPTER 12: PLACENTAL-HORMONES 197

Corticotropin-Releasing Hormone (CRH) OTHER PLA~ENTAL PEPTIDE HORMONEs

CRH ls produced in non~pregnant women. at Leptin

low levels of 5-10 pmol/L. During pregnancy,
levels increase to Rbout 100 pmc;l/ L in the early Leptin normally secreted by adipocytea, is
third triinester to about 500 pmol/L at 35-36 initially believed to be an e.rtti.-obeeity hormone
weeks and when labor begitls, increase further by and now known to regu1ate bone growth and
about 2~ fold (Petraglia & co-workers, 1989, 1990) immune function. 18; 19 . It is secreted by both
cytotrophoblast and syncitiotrophoblast, and
Receptors for CRH are present in the maternal levels are ..significantly higher (Henson
placenta, adrenal gland, -s ympathetic ganglia, & Gastraca..'le, 2004) t.ha:n in noh--p tegnantwcmen
lymphocytes, gastrointestinal tract; pancr~as, artd that in the fetal circulation. Fetalleptin levels
gonads and myometrium. Trophoblast, chorlon- are correlated positiVely with .fetal birth-weigh~ and
:amnion artd'<ieciduaexpr:ess CRH-Rl and CRH- play an importantrote in fetal development acd
R.2 receptors as well as several vari~t receptors growth.
(Florio & colleagues, 2000) CRH tan increaee
trophobla~t ACTH secretion, indicating an
~utocrine-paracrine role for these h(;mnone~
(Petraglia & colle~es, 1999). Large amounts This peptide is found in the brain, sympathetic
oi tropbobl~st CRH enter the maternal b.1ood neur ons innervating the cardio-vasc-Qlar,
but . ar~ -bcund, by CRH-binding proteins that respiratory; gastroiatestinal and- .geriito:~.jiaxy .
;make-itf.biologically inactive. systems a nd .ha.s been .iso!ated,:Jrom-- pJI'i~htal ...:....
. . . .. -:-., : cytotrophobla-sts (Petraglia & coll~t:i989) ..
Othik :proposed biologic p.ctions are Treatment of placental cells with nedro~tipe- Y .
induction t:>f 8tnooth muscle- rel~ation in releases CRH (Robido-ux & c6lleagt.l~s': 2000W''
vasc~lat --d ind myometri al tissue, _ a nd ...
inmnino;~Qppression . . The. rising levels of CRH . In:hlbin--&nd Activln : ....:. '~.J ~.,:.:.~--
t .-\ . : '".

near- the~~nd of gestation - and ln,duction of

myom~CGntractions indiCate that CRH may
be. i,nvoived with the initiation of parturition. 13
Pr-ostaglandin formatio~ in the pJfl.cei)ta,
amnlon. c.:aoriort la:~vae and dechh.ta is
ifi=r~:tt'~-ed-'by CRH-1.., 'rurffier -suP.<il!~!!i.!h~
pol:etHtat'r ole .. o-rctnr Til - the timing of
parturition.
Glucocorticoids act in the hypothalamus to
inhibit CRH, bU:t in the. trophoblast,
glucocorticoids stimulate .CR.l-{ gene expression.
A positive feedback loop has been con$idered ih
the placenta: placental CRH stimulation of
placental ACTH formation ~ placental ACTH
stimulaticn of adrenal -ghw<><:orticoid formation
and -.-t glucocorticoid stimulation of plaeentalCRH
expression. 1s
Gro~ Hormone-Releasing -Hormone (GHRH)
GHRirs exact function is not known . -Ghrelm,
another poteniliu reglltator of hG W6 or a paracrhie
regulator of differentiation17 , b .e xpressed in fu-st
t.timester trophobla st.
. Inhibin.and ~ctivin belQng to th'e-~
growth-factor beta (TGFj3) :signalirigf8mily)\\ 1{~~ .
.
.:!!lh!..'~.lJ;h. -~-~g!ypopr:P.ie.itt-hoJ:tilone,. .inhibits .
pj_tJl_jggyi:FSJi..re.!.eas.e.Jt.:is .produced.by.the: testi~
ovarian granulosa cells .a.'ld the eorpuslute\l.IJl.
The placenta produces inbibln n-; llA- and pB
subunits. Inhibin A is the principal bioactlve
inhibin secreted during pregnancy. Highest level
is atterm (Petraglia & colle9.15--ues, 199_1). Placental
inhibin production together with large. 8lll<>~ts
of placental sex sterojds inhjbit FSP. SCl'etion and
preclude ovulation during pregnancy.
Trophoblastic inhibin synthesis is inhibited by
activin Aand stimulated by hCG, GnRH, epidermal
growth factor, transforming growth factor-a and
PGF2~ and PGE2. Inhibin viaOnRll regulatehCG
synthesis and secretion in the placenta (Petraglia
& colleagues, 1987). Inhibin is not seen in fetal
blood before labor but is found in the umbilical
cord after labor begins.
. -~
Activin is closely related to inhJbin~ctivin
enhances FSH sy:n thesis and secreti@ and
participates in the regulation of the menstrual

Scanned By: C
1'98
~--~--~--------~S~EC~
. t~
:~~ ..~li:~P~HY~S~~~L~OG~Y~O~F~P=R=EG~N~A~N~C~Y~--------~~---~-.~~
. N~
----""-"---~~-----~---------------~-- : :~
"2

~
t .
)' .
,.~

cycle. Jt has roles in cell- prolif-el'ation; : P~erone ;~"':

embryogenesis, osteogenesis, differe~tlation,
apoptosis, metabolism, homeostasis., immune
....../ :~
response, wouud repair and endQCtine .function.
100.0'
...~.~--,"'' -Vi.
Activins.are also nerve cell surv'iva! factors. It has so.o ,, _,; P.
~.
;' ~
three forms: A, B and AB.20 / Estradiol
,,
I

Chorionic activin .a nd itihibin. 1U'e .rt,s..U~tors I

I

within the pla~nta for the.p~ucthm ot'G~RH, I

I
hCO andJ>teroidS.;inhi:bin is in'bibitoty and a.ctivm I
I
I
stimW,atory. Tbey .may se.rve funtions:i,n placental I
n:ietabq~ proc~s.~ othe~ than GnRH ,~fhes~s I
I
I
but the~~ arc:- s till under study .Pla.eetJtal and I
I
dait81 inlUbin @n~. :a.etivin early ~ .pregnancy

/
'I
I ,
1$laY indicate.their possible roles in embtyognesis I
. I.
and local _ittu:n'ilne responae s. 1 Aethrin levels I
t I .
actively decline after defurery.

0.1
o.os .
" a .12 ." ,zo 2 za:..n. n :.a.
Gestational A~.(weeks)
After .(/)-1. 'VIeeks . 'Of. ,gu:tl\t-ion; .Qv.at.i~n . Figur~ 12.6. ~a~m.a . le-Yels of progesterone, emradiol,
pt"C>&~Ile -:pf()duction is--mini~_el. 2 After-about . ~ttone,esti:trOland'.estricHn women duiing the'C:CU.r8e"Of
:8 ~...:;;t_hep~n,ta :~p~<tp:e);>~""as "the - gestation.(,~~o;.'2001;-.Fr0m:Wj.lliama.0~22nif
.. w~.(;.progesteron~ :and7,oonti.Btie$~ tOincrease-,_.. .. Ul :-. , .
ptod\lCtion :throttgb!'ll,lt-P.regnAncy:}: By:the end,oL . . ... . .. .
~Cy~'~:~'Vd,s-;ofp~~terOi\e~:-.ro- -
~ooo -tbiies 'tboee .in nonptc;gl\~nt wQtn~n. . rtog~~terqJJ,~ is synth.~~d .frps:g rho.~~~
:d~~tttg,-c6tt'~lre"1fttrge~'l)t-ttr~ ~ov~R'an-'(1yele itn12 ....S:tep-~n:eyxn-atit: p~e: Fitst;iClil)f~l
tF'mUes~tzs.:45-: t~-;6)~~-m-e.-aall.y~ct;tTn:-,r.ate: -is Eonve:r~eci to :f>"teg.fi.enolone .viit.nin-ue
is 2SO .:Jng. ln pr.c;gnan(.:!ies With-multiple fetu~;J. mitochondria, in .a . .reaction catalyzed by
the daily ptPdu'etian rate maybe .>6006 .m .gjP,ay. cytochrome P450 choles terol -side-cham deavage
$o~e enzyme. .PregnenOl()rie leaves the mi~ondria
and is conv:ert~d to . proge-.s terone in the
end_op~~smic reti~'l:llum by :3(}-hy~~rQid
dehy~r.og~nase. P:roge'st-eto-ne is. .r.eleas.e d
i~~ec:}i'a\tlyth-f'augh .a , process of diffu~i<m.
Altho'\.lgh t he placenta produces a .large trmount
ofprogesterone, there is a limited c,apacity for the
~ .
'biosynthesis of chclestero! by.the trophoblast.
'rhus, the placenta; must rely on exogenous
cholesterol for progesterone formation. M~temal
plasma cholesterol is the principal prttursor
(90%) of progesterone biosynthesis in the
placenta. 22 The trophoblast preferenti3lly uses

.__
LDL cholesterol for progesterone biosynthesis.23
The rate of .p rogesterone synthesis is largely
... dependent.on,the.numb.er ofLD L receptorsonth.e '
plasma. membrane of the traphoblasts .and-
Figure '_12.5. Mnte~al plasma progesterorte (Clin Gynecol primarily independent. of uteroplacental blood
Endocrinollnfertil 71h Ed. Chap. 8 p . 260). flow. LDL receptors are localized in coated pits on

Scanned ey: ~
 CHAPTER 12: :PLACENTAL HO~MONES '199

the micr.Q;'-;i llus tn~.~lnanes of syncitium. Role of Progesterone

Hy~olysis of LDL rel~ses e~ntial ~o.acids
and chole~terol esters. which m tum yield fatty It prepares and maintains the endometrium
acids and cholesteroL Essential amino acids and to allow inlplantation, has a role in suppressiltg
fatt-; acids are tran's ported to the fetus. and the maternal immunologic response to fetal
.cholesterol is used for placental pro.g esterone antigens thereby preventing maternal rejection of
bio~_ynthesis {Figures 12.9 & 12.14).
the trophoi,Jlast and has a role in parturition.
Progesterone ser-.;es as a substrate for fetal adrenal
gland production of glucocorticoids an.d
The fetus contri.but.es essentially no precutsor.
minemlocorticoid~. 1
Pi:-egnem~lone.sulf.ate maybe the mo~t important
precursor for .synthesis ~d m~ta:Polis:Jil _ef Plci.cental &trogen
ptogesterone in huma n de~idlla and . fetal
Dnetnbr.anes. Px-oc\uctioU,. ..
The y}at~P:t.Jl produces huge amounts of
Proge$terone and Fetal Well~Bei."lg
estrog~s usipg .blOOd-:-,b.orn,e:steroidal precurscrs
from the ma .ternal and "fetal adl'erte.l glands .
. Thex:e is no rela#<m.ship .b etween placental
pt(>"~~vne synthe$i$ ~d fetal well~being. as
Ncnnal human =pl'egnancy is a, hyperestrogenic
state. continua!ly ih~.reasing -a s pregnancy
prc;>g~sttone bios;tnthtsia .ll'UlY )lenlist $ev~.a1 pr<;>gresse~S, terminating abruptly after delivery.
weeiq, ~"fetal d~th. The amount of estro.g.e n produced daily by
syncitiotr<~phoblast duringthe 'laSt few wks of
. .. : . . . . .
pregnancy is equivalent to tha.t pro<b.t~m<l<'day
~geat~~~ M.:~l>ol4.m Dur';dtg ~cy by. the:: ovaries of no less thari 1000oV:UJB:t"i>ry
'r :
women.
. Pro~sterone mef,a.bo.lic; c.l earance.:rate is the . . ~ . . . : -.~ ~ - . :r V:.~.;.. .
~at.n.~.: ~~~.in non ..-pt~tt'l:an:t .W'-vmen and. m en . Du$g_the~st.~-4. w~ek$ of.p~gnancy:.P$g .
. :,Q:Q~i~i~q:, '~ete i~ a <Usp~port;ionate levels of hCG =n uililtain ptoductiO.Qf>.(e.st.l'J:@.oJ,-:in:
. ip_c-<as~J.n ~the pl~tsina ~once,ntr~tion ~nf . Sa..: -the maternal corpus Iuteum; Mat,e~~~i:P:us . .
dihydropmgestetone as a .res~t ()f.$ynthesi~ in luteum production of estrogen sn~:p~~~~Ae
.$ yncitiottophoblastfrom pl~ntali>~tetone decr~ases s~griifieantly . by the..':7-Jb::;W.~ek"'! Of
and .fetaJ.~erive.d precur110'r~ This. 5d'"-J"Cdtted pre~ancy~ The.re is a lut~~p)~~~ ~tion
metg;~"rlt'~ -eontt~hu'tell to
the ~ti!ttLtiee. in by the 7th w~k: so. :that more tlia.~ 50- ~i of
-pre'gli~ lijt~t"tlle .Va86press6r .acUortor estfog~n ~nteiiiig ~tlie~m~te"Oiardrcutation.Is
.QJl~Ot.!Oi11
-- - ~smlp~-:m.
~ '-YD~ . ...terone-:-'is . aiSo.convert.~a
. <'"
-proouceamtlie'f>Ta"Ceiita.:26~ -iiieie~iS-atran'Sition
tn the potent . mlner~lo~orticoid of the steroid. mlli~u -"from orte dtpendent" on t:Jle
d~xycortieosterone..in pte_gn:ant.wolilen 1llld in n1atemal -corpus luteu.tn to one dependent on the
the . fetus, ... thus tln in.c rease of . . developing plac~nta {Figure 12.7}.
de<>zycorticosterone in the matefl)hl .a rid. fetal
Biosynthesis
cQm:Partments: The extra-.adi'ehahfo~atio'n: of
de o)cycortlcostet.one frolt:l dircula:ting The i>~thways .for esttogeii fiynthesis iii the
progesterorte acc6iltits fot th~ va$t majority of human placenta differ from those"in the ov.sr.y of
its prQduct.ion in. human pregnancy.25 non-pregnant women.
Ovarian theca cells . synthe s fze
Thirty to 40 pereent i>fproges.t eronei$ s~reted
as metabo.l#es i n the urine, .bile and fece~. Sa- androstenodione7 granulosa cellS 7 e stradiol.
Andros~eno<iione is pi"Qd:l,lc~ de nqvo from acetate
requ~tion of proge&terone is the lll8.jor. pq:thway
and .cholesterol, catalyzed .by aromatase 450 ~
of progestercn:i~ . m~Ut:boUm,1. The .m~tabolites. of
sa-cUhjdro.progesterone are bioactive in the brain, estrone, , acted upo:n by estradiol dehydrogenase
7 estradiol.
facilitating the .action o ( :GA:BA. (an .. ~ruc1olytfc ....
agentJ. With the de}ivery of the placenta. the In human trophoblast, neither chole~~l nor
sudd~. drop in this _.metaboUtQ may. a.ccount :for progesterone can
serve a's precursor for~trogen
the d~velop.ment qfinie~r:al depre~ion.in .~ome qiosypthesis. It d~~s not express ~ter~t~ 17a-:-
w~nieri "(Ma:jewska & colle.agues~ 19~9). ' . . . . hydroxylase/17 /20~1yase (CYP 17J,.;:s o the

Stanned By: ~
200 .
conversion of C21-steroids to C19-steroids which
is the immediate ~d -obligat-ory px:ecU,rsors of
est:wgeJ?., is not ~ssiple.
The. C19 .steroids. ~ehydroepii::ldrs.~~=-o~e
.{DHEA) and it.~ ~ulfa-t;e (Dli-EA-$J (-aqr-enal
~gens} act; as ~strogen _l)recu.rsors. (Ri~res
12~a, 12.10)_ .
-~ 12.7. Materp.alplasm~~>.ri}p.ghl.ed'~s .
. {Clfu:Gyne~;&;_~~~- ~,~-~~'p~<&p;~S}- . .
:1:1 .' ~.. . . . ' :. : . . ' . .
'. ~::.;! ~'!" )-..... .... ~ . . .' .I':. ' . ~.; .. ': ,, , ..,. ...
. . . . . .. ..
.. ~~tal-~li.!~th~is;:,.. -~- . . . ' . . . :. ,. . ' "' ''
Seanned 8y:
T\e ~~~.....y of,cQivmoo. o( DRF..A-S t.>_e.:tN,dl<>_
l ls:
t~tEA~s
. +HDHEA-?~--HAndrtis~ioae+H
.
.&n..e
.,
.{sis)
-
Type! (1~1)'
"" &niliol
Note: s.rs (stemi4 a.ul!atase}, 31U-iSD
{3!>-hyrl.~
deh~~). CYPl 1H~e P450 aroinai:Dt} 'snd ..
~-t J'7PHSOl~l7~h~id deby~. Ue
prindpal'iy located -4lthe ~citivJ;rophobl.Mt (&nrn&mt &
co~ '2000b; ~do.&..;:olkagu'ea, 1990~
The f~.aOr.enal P.Qrtex i~..pnnppally.tl,t~most
import~h:t ~.u:r~e.s ()! -plaen:ta1 estrogen
pre~U..-iol:"$ jn h~- -prefW.~- The ~
-~~ "'f sn(:llcepb.SliQifetU~'liave.no. fd-JU -Z9nci
whiCh e.xp1alli th~ ' '!ow utina.ty -estrogen. giri.'lg
evi'de:q..c~ to the :fact that- :the _',ad;re~al. cortex
proVi~ ;vnt. ':9r -ln.Ore. slibs~c;es that -~ as
p~tah~trogqn~pr~~-.i.$lre;:higir;.-leveWof' ,--
D.li.E.~~ incorii:'.blood.' ()f:p.orilihl .- neWbomsa.lso
S'.l~$1-! ftii~~: The ~e .- amdunts Q'f -:mttA:,.s in
. .p~~~-.~<i~ti.l ;.trl~~<~onge~ ~hal,r-"lif~ utiiqu~ly
. .;~;ft;as::~the.:.prin~::'iji;ll:;ciicUia:.t;mg:;pr~fot:
-~The. -th~~-~. ~ :tb~. ~~ta~ll~ ~~}~- _of
;r.ne;m..a;teniliJ::-
fo~!f~~:;;:!t:::~=~~~a4ien$1~--g1an<ls'd_onot:jnmuce
sUfficient .amout}.ts-:of PHEA-S: d~g. pregnancy
tO- ac::;Qwn:t :for_:more ~~ a ..fra:ction .of total
.placental~el;l -bio:$ynth~si$~
.:N~ --tetw. .-a bqut S.O pe~t . of' the -~tl1ldiol
produ<;id ill the.- piacenta-.a.ri:se~ fr&m .-~te:m<U -~d
po ;~ntfrotil ~et ,p~~ .pHEA-S. 29
~..aq!~tal
-~tta<liol,is.th(:_pt'imaiy:esttogen irctila:tingatteim
{Figure 1)2.10)_. .
. '
PLACENTAL ESTRIOL SYNTHESIS
. , ,'~ ' ' .' I , . - ' '
~
f,j.' . .

_ _ _ _ _ _ __:..:..:::..:.:.__:_::..:...:.....:.:.:...:....::..._:_...,....:........,..,-.....
CHAPTER 1-2: PLACENtAL HORMONES _ _ _ _ _ _ _-:--____,..:0

16-0HDHEA-S. Near term, the fetus is the source

of 900,.{, of placental estrjol and estetrol precursor
in nor.mal human pregnancy (Figure 12.11).

P1gqre 12.11. Synthesis of est:riQJ(Clin Gynttoi Ehdoainol

lnfer'tll. 7th .E d. Chap. 8 p. 264} .

. - Fetal.A.Uenal ;G!an~s .
.... ~=....:.:.,; ,....-+ -~ :::..::.i.;t.:.,... ~. ~ . .. .
~!pre 1.2:9_; Prcgestero.ce synthet>ia {Clin Gynecol
En:d~ounrettil, 7th Ed. Chap. t:J p. 261}.
.Compared -With 9,dUlt organ&.f! thc i8.(!r~~l''
corte.":: is the .l argest organ of .t he fetus. ' .4trterW.,:; .
the ietal -:ld:renal glands weigh the sam~ . al!<>.thoSe ~

:j} -(U!L~
~~ -~~l'r~~ -:lH
!r~.(lrt.~ r of an a dult. (li'igur~ .12.1:2}. More:than 85:~t
of the fetal -g land is the fetalzone, ~}),is ab~t
in adulta. The -fetal Z()ne begin~>:involii.ti.J;ig

lr ...
. -. . . . ..
im.m~ately after birth.

f~ "'":"""" f - .:
t,...
1.:. : .. ....
.. '
. .. :
.
~.. . '

T ._.,.

-r . u !).............. .. ~ ~ ......._..~
. : -~ .
I P'tSoen~ I
K. . DltA
llUASO. ~ _, I ..
T . ~- .
If oo~ I f. .Ndrollcftclfiooc
. Tes~aa."'-:
.
_:Cortex
~~===: :
l H ...
.

..
Figure 12.10. Synthesis of estrone and estradiol (Glin
Gynecol Endocrinol Infertil, 7th Ed. Chap. 8 p. 263).

. The placenta .s ecretes several estro_gens, e.g.

estradiol) estrone, estriol and estetrol. In the Meeutla
hemochorial nature of the .human placenta, the ----
majority- of these estrogeils in released .into the
maternal cU'culation. Maternal estriol and estetrol, t 2 .c 6 a 10 1214 16

almost solely from. fetal precur~ors, have low AQe.(years) -~~-

~;;.~
sensitivity and specificity as .indicators -of fetal Ftgilre J,2.12. Size of adrenal gland 1Uldits-eomp6ri.tht parts
wen~being. Other.measl,lres-of fetal wen-being are in utero, <:hiring infancy,_and during cbildhood. (Adap ted
currently used. from Beth~ne, i97>\).

Scanned 8y: C
202

The daily production of steroids by the fetal

adrenal gland near term: is a:ourid 100.200 m,g/
day, compared to 30~40 mgfday in resting adult!J.

-F~.al Adrenal Gland Growth

The enOI"TQ.!>US Size atld very gr.eatcapacii)' for

steroid eynthe.sis made investigatOrs think that
a$ide fromACTI:I, there ate ot}ler sfW1uU for growth
of the adrene.l gland. I-mmunoreactive ACTH
decreases in fetal plasma:a~ pregnancy.~s
and. as fetal adrenal glarids e.:Ce gro~g ~pidl,y
(Win~;s coU~e$, 1974). ACTH is neC:easaey
for the h;lpid growth.of the ruL.~nal gland durin~
the ~tter part ofpr~gnaney. It is likely that :the
rate .of growth of the fetal ad.renal gland is Fipre !2.13. R,e!Nlation of fetal adrenal ,steroid<>genesia,
innuenced by factors secreted bY the ~nta.. LDL us~ and clloleaterol mc:taboliaiJl. (D$d~hydro
epian4t'oaterone sulfate; ~g-p~gnenoloru;}. PS ia
prOduc;ed in the fetal zorie ancl c:ortiaol prim.wiJ.y in the
~~rtex of.t he .tetal adrenal tJands.
The adrenal fetal z.on.e cell& have a severe
dcficlencym 3PHSD~tluis linliti:ns~~ conversion
of pr.~gp~iiolone:~tc--:: prtige$t~r.one:<:and":l::-za-
h~terone;-anC)bligatQty.~pm:OQrtisol-
biosytith~a~ Howev~t. th~re -i& .veJY~aet;ive.steroid .
su,lf~uanreraae . activi~y :in<the.-.t ctal adteQ.ai - . . ., ...
gian4Jio ~ua<itj prlneipal ~etoty- product$ are~ -
,

P, , . i .e
~lone:r.: llulfaw,anCJ oftEA.:s~ : ;':
.. .. .

Fetal AdrenaiSteroidPrecursor

The precursor for-fetal- adrenal steroidogenesis

is cholesterol. The fetal .adrenal glands can
fr,tnthesize chole~terol fro_m acetate. The rate of
de novo cboh:sterol syrtth~sis by fc;tal ~dtenal
"tiSS\lC -is extremely high but st.jll ms\iffii~Jlt to
account for the steroids _produced by the adrenal
.glqp<ls. Therefore, chol~sterols (liPL, ltD~ .apd
VLDL) ate assimilated from the fetal circulation.
The fetal adrennl gl~ds. ate higl)ly dependent on Flture -12.-14. Atlr.enal 6teroidogenesis (Clin Gynecol
End<>inol'lnfertil,7th Ed. Chap. 8 P 269j.
circulating LDL as a source of cholesterol for
optimum sterqidogenesis23.3 1.32 (Figures 12.13 &
12. 14).
4. Fetal-placental sulfatase deficiency - 110
FETAL CONDITIONS THAT AFFECT ESTROdEN ~ydrolysis of C 19 steroids, no precursor for
PRODUCTION e~trogen biosynthesis. .An X-linked -diSorder
that affects <mly males with lch~yosis and
1. Fet~death - the .important fetal source of associated with delayed onset of labor.
precursor for estrogen s)'nthesis isab5ent 5. Fetal phicen.tal~aromatas~ .deficiency -
2 . Fetal anencephaly ~ very limited placental androstent>dione ~annot be eonv~r:ted to,
syntbesilJ of estrogens, especially estriol estradiol; Withviril.ization of mother-lind "female
because oflimited availability.of C19. steroids. fetus; males have ~elayed epiphyseal Closure.
.3. Fetal ~drenal hypoplasia~ no fetal adienal Cl9 -.d1;1ring puberty and are very tall With defiCient
precursor for estriol synthesis bone mineralization

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 CHAPTER 12: PLACENTAL HORMONES 203

6. Trisomy 21 iDown syndrome) - ,second sources . of C19 . . steroids for estrogen

:trimester screening.sbows a:bnon:nallevels of synthesis. Estrogen is produced principally
:Cstrio1, alpha-feto protein and hCG. Explaiiled with maternal .p lasma C 19-steroids as
by inadequate formation ofC 19 steroids in the precursor
adrenal .g lands.
7. Deficiency iu fetal LDL cholesterol DlRECTIQNAL SECRETION O.F STEROIDS
biosynthesis: !imits fetal adrenal production FROM SYNCITIOTROPHOBLASTS
of estro~n precursor
B. Fetal erytbt:oblasto$is: elevated levels of EstrQgens synthesized in the ay:n citium
estrogens ih maternal plastna due to placental preferentially enters the -matetn8.1 c:L""Culation.
hypertrophy Gurpide and coworkers in _1 966 repolted that more
than 90 percent .of estradiol and estriol --from the
JIATBRNAL COND!1'10NS THAT AFFECT syncitiotrophoblastenters matemal..J?IasrDa Later.
.i"LAC~AL ~RQGE!f PRODUCTIO:N the same in\Testig~.tol'$ deinhnstrau.t.tbB.t ~85%
of placentalprogesterc:me enterS nui~ plasma
1. -Glucocorticoid treatment - glucorticoids and very little to the fetus. .
inhibit maternal .flnd fetal pituitary ACTH.
~tion resulting in t!ecreased maternal and The major r~$0n for the -directi~ movement
fetal .ad.renai ~on df OHe,A-$. towards the maternal eirculatii;n b :the
2. M.alt.-nal adienafdysfunction - e.g. Addison hemochorioendothel:ial form of ~nta:~on.
disease. decrease prindp~- arrects estrone Steroids .. fro-m .the .s yncitiotrophoblast enter
and .is~~ol maternal blooddirectly. Steroids ~ ..Yllcltium
3.' Ma~;nvariat.t androgen-producing tumo:-s- do not .enter. fetal ..blood direct1_i.'~~.6id1.fuust
seerdri.;~: Virilized !etna!e .fettis With a tumor traverse cyt(>trophoblasts ~ 7 . th_~,~tui"ectl.ve .
that pto<J.uces a nqn-srolnatizable C 19-steroid tissue of the villous core 77 then :ti;;e;r.~ v;~.()f .
. andr:og~~ cr prpd.uction of testosterone early . . the fetal ~pillaries 77 Jetal .b lood. .Steroids in
inpiegnancy .t hat exceeds t he. capacity of .the fetal .capill.aty. can -th~. reenterrtbe cimti.ective
p1acenWU:arDin.i:ltase ,tissue of the.Vill~u$ eore"tb ~ntei. ~S;rn:~~- .
4 . Materil,_a lrenal disease .. lowered urinary The net result of this is a substa~Ji gi:eater
estriol i n women with pyelonephritis is the entry of -steroids into .t he matern.alrCirculation
. cc:m~ce of d.it:n'in.ished ~nal . clearance _compared to
biood.
the amount that ~- the. fetal
-
5. Gestational
'-....
,. . .
~ -.
trophoblastic
.... ...._.. .. . '... . .
- ' '' '' , '
disease
.. .
- No fetal

POINTS TO REMEMBER

Placental .syncitiotrophoblasts synthesiZe large amounfs of protein and peptide hormones:

hCG. hPl, ACTH, hGH-V, PTH-rP, calcitonin, relaxin, activins, inhibins, cyt0 kines aiid atiicilnatr.uretic
peptide. '

For :eaGh of the known hypothalamic-rele~sing or inhibiting hormone, there is an .analogous placental
honnone, mostly e0ming from cytotrophoblasts.

The human placenta produces TRH, GnRH, CRH, GHRH and somato.statin.

Blood levels of hCG, detectable at 7-9 days after the LH midcycle surge, doubles every 2tiays, with
peak levels of 10.0 ,000 miU/rnL between the 60th-80th days after t~e last menses.
c

. When hCG titer exceeds 1,000-1,500 lUll, vaginal ultrasonography should identify an irdfauterine
gestation

. ~says of hCG form the basis for the majority of pregnancy tests.

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 OF PREGNANCY

li.CG rescues and maintains :the corpus luteum, stimulates. fetal testiyular testost~rone, ~cretion,
stimtilates matemal thyro1d activity, pro'motes relaxin secretiqn and uterine VaSC1.Jiar dilatation and
myometrial muscle relax.ation.

hPL Is the rnetaboftc hormone o f pregnancy and maybe :the fetal gf'O\Nt!l hor:mone.

hPl is respor.~ible for maternal lipolysis .and fncrease in circulating free fatty acids, has an:u-insYiin or
diabetogenic action, isa'pbtentangipgeni~h9rmoneand may play an Important role in .fetalvas.Cutature
f~t:matlon.

lnhlblil :A1s the .prinGlpa(.bloaCtive lrHi!bin ,pr-QC.iuced ~y the placenta .and inhibits .pitUitary FSH~
:-...
~
. ~
ActMn:!s-:Stimuiat9r:y to lhe ~.~~Jon<>t-'GnRH, hCG and sterok .Under study are.fts variOoo .roi.es '
.in
me~bollc:and 'growth ~ses. .

:Ptac;eiltal syncitlotrophobtasts synthesize large amounts of progeste;one i'lnd ~gep.

M<rtemarp~~~ .Chotemf:'(>l-Js.the prtn~lprec;ur.Sor of progesterone blosy!,"lthesjs in the .ptarenta

.Ther iidimit~ capacity o f ~phoblast5 :for. CholeiterO! bicsy-.:thesis. . .
.....-~:
.
. Piacer.ltal,'prqg~teror:re,.syn.th~i~.;h~sno~tela~nship .with fetal .well~teing.
.. '\. .
ProgeSterone .h<is . rO.IeSAirpt,gnar.cy:maintenance;. mate~l immunologic..:response -to :tetal an~gen
.and: 1n~parfur'fti6n '. ' . . . . . . . :

. ,.. ..: E~tr~~sy~~- ~~;~ert;~idah'J)~rsors~froh"Hh.e inatematandfetal.~renal.glaflds~,NearJenn;.

'':'::.. hlilf6f~.esltatridt;fs:def.iv~~fr0i"tr: fetahadrenai'DHEA,:.S and; hatf:.from.matemaLPl:lEA;,S.:-:. :. .:.' -

Ninety-p.el-eent of.$Stfiot :m ttieplaeentaaiisesfrom 'fetal 16ctOHDHf:A-S. The felalliver conVerts

fetaJ .~nat~DHEA-?:to i&.QHIDHEA-$, . :. . . . .
. . .
The-fetal .adrena!s are qua~titatively'themost important sootces of placental esfr()gen .precurS-ors in
hurnqnY,regnancy.

Matemal.e.sti:iol, almost S9jetyft:om fetal precursors can act as indicators of fetal wel!-being. HO,wever,
low Sen~'itivity and $peclfacity cf .th~se- tes~s lower .their 'diagnostic value. 'Together with :alpha-feto
.proteln ,an~ tiC;G levels, Jheym .ayjnqteate Down '~y.ndTome.

Maternal an~!:~ . fetal coilditions can a'ffect placental estrogen 'prod\Jction.

The directiO!l'aH;ecreticn .o f ~strogen 'frqm Syneitium is preferentially to the maternal circulation.

3. t.;icGr.egor W.G, Raymoure WJ, Kuhn J{W, Ja.fl'e RB.

'L Speroff L, Fritz M: The endocrinology of pregnancy.
Gynecologic Endocrinology and.Infertility, 7th Ed. 2005;
2-95.
2. Cunningham G, LevenoK, Stevan B, Hauth.J , Gilstrap
~. Wenstrom K. Placental hormon.es. :Williams
O.bstetrics ,.72nd Ed. II:3:7.
'Biologic~y activ.e chorionic.gonado~ophin.synthesis
by.the human fetus. Science 1983; 220~306 .
. 4~ Petr.aglia F, Galtin elli A, DeVita D, Lewis K, Mathews
~.Vale W. Activin at'p arturltion: Ch.ang~.otmatemai
-serum level!! a,nd evi.dence for binding site:s in:
placenta and fetal membranes. Obstet Oyneco11994; .
84:. 278. . . .

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 CHAPTER 12: P-LACENTAL HORMONES
. 5; Maruo T, Ladines-Llave CA, Matsuo H, Manalo AS,
MOChizuki M. A novel Change in cytologic utilliation of
hCO and hPL in lat trimester. Placenta in tl1e course
of gestation. Am J Obstet Gynecol1992; 167: 217.
6. B{&dburyJT, Brown WE, Gu.ayLA. Maintenance ofthe
corpus.luteum and physiologic action of progesterone.
Recent Prog Horm Rea 1950; 5:151.
7. Tom~r Y, Hu~er GK. Pa~es TF. Human chorionic
go~ado~pbin interacts directly with recombinant
human TSH receptors, J Clin Endocrinol Metab 1992;
74: 1477 .
. 8. Gnunbach MM, Kaplan SL. On placq&1 origin and
.J)Uril!.cation of chorionic growth ho;"mone, pro!.&clin end
iu iminunoassay in pre~ey. NY kad Scll964; 27:
167.
9 . Corba.o AM, Martinez OLE,~ C. Roles of prolactin
and related members of the prolat:tiii/.growth hormone/
p~tal iact<>gen family .in ~gene&a. J Endoainol
2002; 173: 219.. -........
.
10. ~gis: lN, Mandel M, oreenwoo4 GO. Re~ gene
exp~won in human .,eproduct:i-..~ nsaues by .insitu
hybridization. J cun Endocrinol Metab 1995; eo: 130.
11. Siler~Khodr TM. Chorionic. :pepUd~ :NCHD Workshop
1968.
...j , .o .!~ - I
12. -sner-Khodr TM. Hypoth8lamic..like peptidea of tile
....
..:pla~ta;:.:s~.m Reptod Endoerinol1'983; 1: 321.
ta. W:adhwa PD, Porto 'M, Garite TJ, Chicz-DeMet,
Sandman. Maternal CRH levels in the early third
trinl~~~ predict length Of huutan g estation. Am J
Q~~l~- ~ll998> . lfi79~JD19.
14, joii~s S.\, challis .}RO. Local atimuJation of CRH in
huz:nan placenta and fet~ membranes. Bipchem
Biophya Rea Commun 1989; 159: 192.
15. Riley SC, Walton JC, l-leilick JM, Challi.s JRO. the
localization end distribution of CRH -in the human
. placenta and feUd me.m bnuiea thfoughcut gestatioG, J
. Clin Endocrinol Metab 1991; 72: 1001.
16. Horvath TL, Diano. S, Sotonyi P, et al. Ghrelin and the
regulation of e nergy "balance- a hypothalamic
perspective. Endocrinol200.1; l42: 4163.
17. Gualilo 0, Carmines.), Blanco M, et al. Ghrelin, an
novel placental-derived hormone. Endocrinol 2001;
142:788.
18. CockTA,Auwex J. uptin: cutting the fat off the bone.
Lancet2003;362: 1572.
19. La Cava A, Alviggi C, Matarese G. Ynraveling the
multiple r oles of leptirt in inflammation and
autoimmunity. J Mot Med2004; 8.2: 4.
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- 205
.......
20. Chen YG, Wang .Q, Lin SL, Chang CD, ChuntJ &hd
Ying SY. Activing signaling and ita role in regulation of
cell proliferation, apoptosis and ca.rclnogenesis. Exp Bioi
Med 2006; 231.
21. Diczfaluxy, 1roen P. Er.dl)Crine function of the human
placenta. Vitam Hotm 1961; 19:229.
22. Heilig HD, Ga:tteareau D, Lefevre Y, Bolt~ E. Steroid
production !rom plasma cholesterol to place.n tal
progesterone in hum.a ns. J Clin Endocrinol Metab 1970;
30:624. .
23. simpson ER, Carr BR, Parker CR, Mi!ewich L, Px>rter
JC, MacDonald PC. The role of serum lipoproteins in
11teroidogeneaia by the human fetal ,adrenal cortt'.X. J
Clin Endoainol Metab 1979; 49: 146.
24. Everett RB, W01"ley RJ, MacDonald P<i. Gant NF.
Modification ofvascularresponsivenealJ tn an,giotensin
l.l in pregnant women by IV i:lf!laed 5?-
dihydmproge~terone. Art! J ObatetGyneco11978; 131:
555. .
25. Ca5ey ML, MacDcnald PC, Simj>son ER. Endoc:rinok>gic
changea in pregnancy. wuliama-.;:Textbook~ of
Endocrinology 1992; 977. .<:
- ..,-....r-,'1;. i:' O:.:..v ~.
26. MacDona!d PC. Placentai .ateroidoge"n'eaia. 'fetal
Ho.m eostasia Vol. 1 NY Acad Scien~e:, 1955.
27. MacDonald PC, SiitCli PK. The in ~vo,mechanismof
estrogen .iD subjects With trophObla._atlC tUmOtL" steri>ida '
l%6; 8:589.
28. Bone.r uant M, Provost PR, Drolet R. Loca1l.mti.oo of~
. .. : :
1 17P-hydtoxyateroi~ dehydrogenase . .mRNi '~d
pr.otein.. Jn . ayncitiot~Qphoblaats -.andinvuive
. cytotmphoblests in.th-e human term Villi. J .Endocrinol
. .2000; 165: 217.
29. Siiteri ~K, MacDonald PC. Placental estrogen
biosynthesis during.h uman pre~cy. J Clin Endocrin
Metab 1966; 26:751.
30. Doody KM, Carr BR; Rainey WE,Byrd W, Str..clder.RC,
Thon:i!UI ,_TL, Mason Jl.- 3Phydroxysteroid dehydrogenase
activity in gland1,1lar and extraglandular human fetal
tissues. Endocrinology 1990; 126: 2487.
31. Carr BR, Oha shi M, Simpson ER. Low density
lipoprotein binding a:nd de r.O'J C synthesis of cholesterol
in the neocortex and fetal zones of the iluman fetal
adrenal gland. Endocrinology 1982; 110: 1994.
32. Carr BR, Simpson ER. Lipoprotein utilization and
cholesterol s_xnthe:;is by the human fetal adrenal gland.
Endocrinology 1981; 108: 2154.
:~
~.'~~- ~
~
'~ .

..... .
:',

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 13

FETAL MORPHOLOGIC.AL AND

PHYSIOLOGICAL DE\'ELOPMENT
LYRA RUTH CLEMENTE-CHUA, l\ID.

Morphological Development

Introduction
The Ovum, Zygote and Blastocyst
The Embryo
The Fetus
Monthly Stages of Development
Fetal Weight Length
The Fetal Head and Brain

Fetal Phys!ological Pevelopment

Cardiovascular. System
Circulation and Changes After Birth
Bto.Qd ~n~ :BIQOd Volume .
. .Hematopoh~sis.arld .Hemoglobin
lmmunocompetenee-ofthe Fetus
Nervous System and Sensory Organs
Digestive System
Gastrointestinal Tract
Liver arid Pancreas .
. Urinary System and Amniotic Fluid Formation
Respiratory System
Surfactant; Composition, Formation and Regulation
Endocrine System
The Pituitary Gland
The Thyroid Gland
The Adrenal Glands
The Gonads

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 . 2Q8
------------~----~S~E~CT~.~~O~N~II-:~PH~Y~S~IO~L~OG~~Y~O~F~P~R~EG~.NA~
. .~N~C~Y------------------~. 111-
.-----------...--...,..-----__,__------- ~~
. . ::~
The gestational period has 'been traditionally ;~~ : .,
~,,~

M~RPHOLOGICA~ DEVELOPMENT OF THE.

:Ftl'OS 'divided into three trimesters, each lasting for 3 . .- . .
cale.ndar months and e~ch having important '~
-~~uotlon and Definition of Terms . ol::)s~etrlcal milestones. For exam,ple, spontaneous ': . .
. . . .a bortions occur.during the first $tmester, whereas .;~
. . tJntil .very recently, !he fetus has grown .i n a sui'Vival r-ates. are higher when the.infant is born . -~
pmteetea environment, hidden from the outside in the third trimester, In addition, blood pressures ".
world. Recent technological advances are lower during the second trimester.
u"lttatound, .c ardiotocography, Doppler flow
abldieJ~ feW blood and tissue sam,plin,g, $lid .The OvUm, Zygot~. ~d the B.lastoqst
.. f~: haye opened :U}>:thefetus'wQrld tQ ~~ . .
~':.an .orPw.~ tha~ is q~tE. ~ble or
taldia!~O.fl~tt.an.4 :or ~~nqin.J ~ >Cbt!.ngcs .
lli t be:i\lppl1 O! .~utrient~J and .sa~ _l:n a ~Y
. ~P~~.nWm,et.

' .. ,., :'fhe_ae phy.siological responses., altb:o\lgh

(ijfi'~tent
(rpm tho.se Of the adult, ate enfU'.ely
. :aPJmippa~e to .Bu~vi:val in utero, and t:an be The sq.tdent should note that :OVUlatiOn agt :
~~~d~ m ature fetal respon ses that .enable and not .&nenstrttal age :is the .nfetence used in
. gtolflih aild..:d evelopment, and prepare th~ this ::Hscussion . of . the . e.atliest . hum~ <.
. ~uslfor tlie rjgqrs of birth andsubsequent development. The division blto stages Will
. :~t.lll ;devC:lopment.., _ bopefuUy.:plakeJteaslet to :d~'De.: these evc;ttta .
which . otherwise arc familiar only 'to the
~ rewa is now considered tb be ~ patient embryologis~:
Jlld;U snuch aa the mother.
t;, . . . 0-2.rlay.s (~~&9< nArttnwwation~ fertilizatioPPf,.
. .. }l,'~ia :chs,p_~ d~swith'the. event$ of human the,oV:uttl take.s~pJace, usllaJ1..r in:.1Jle:m;np'Plla of' ...
, .pi'enl\~al-'de'f~iopJn~nt frbJU tbe ' mome~t cf the .faopiantube; :jujd the;~; egg~ .: ~-
. ~neeptlon ;until":b irtb: Tlie "emb'c yomc :p erioa- the zygo~. (Stage lltn~nd~oes aserie~n,f.mitotic
;sY&m(:!'!:Ule beginning of the second w:~'k after cen~sl~i)~~sit~veJ$do:W,n ,toward the uterine
,~~latlo~-and. .. ends . at approximately . lD c~ty. : ptoJb!.Git!LP~~~!i.!~. ~f.l:l.al,lerce~l!J
;~tl~week~ ..The previable-fetal. period-le.st knQWJl..a:s_:blaStomere.s. , . .. . .
. frollt. fl ~ 19 gestational weeks, :and the viabie
'!eJ:$1~riod lasts 'from 20 to 40 gesta:tionalw~ks. 2-4 days .JStage 2) ~ days later, it enters the
uterine cavity a.s a mor.ufu, a solid ball of 12.. 16
. Jt . ~houldbe noted that gestational age ,.(also cells. (Stage, 2) On the ,4~ to the. ~da day, the mon~la
~~ as mtnstrual age and age of .gestation} is becomes the blastocyst by aeq~g a fluid-IUled :
.cateulated from the i11st day of the last mertstrual cavity :with a rlistinct oU:ter cell lay.e r {the.
. ~noel (LMP) and is generally used durins.the fetal troph()bl.S.~t) which gives :rise. to. the placenta, and
'}>enol'\, in ultrasound, and in clinic.a l p~ctice. the inner cell rnass which . giv~~ :r ise to the em.br}ro
~~ancy lasts .for about 280 days, or 40 weeks, and the extraembryonic tissues.
9 '%~endar months, or 10 lunar months, when
c8,1~lation is made from the LMP. 4-6 days (Stages 3 & 4) The zoita pelhtcida
at
disap~ars this tiine it-ld the blastocyst attahes .
$mbryologists calculate ovula tion age (or to the endometrial epithelium (Figure 13.1).
Wi>tc.Onceptiotl age), citing events indeve1opment lmpfantation of the blastocy~t .begins at the end .
!:rOm the time of ovulation, which come 2 weeks of the ta~ week after conception, usually taking
.after the LMP. Ovulation age is used when place in the midportibn of the fundus of the utema; . : :
describing. the embryonic period. and often, the more frequently posteriorly than anteriorly. .
p~e\riable fetal period. It is 2 weeks less than the Primitive chorionic villi begin to form from the : :
gestational age. For .example, 7 weeks ovulatory outer trophoblastic cell layer, marking the end of..
age would be equivalent to 9 weeks men's trual . the zygote stage and the beginning of the.
gge . embryonic period.

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 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT ' 209
----------------------------------------------------------------------------~~~

Table 13;1. The23 stages of embryo,~jc ,development.

CR ~ S~.:s M9.in E~emal Features

Length After
(mm) ' Ovulation

~2 1 Fe~doocyte
2-4 ' 2 Morull!
4-6 3 l3hlstQcyst
O.l . . . . . 4 Bilamuui.!' embryo
o.2;;o.4
. .. :: 645.
. '
' ~-
s B~emb,Y9'~th . vlc r.vt
primi~eyoUt ~(:
.... .6 Trilamihar embryo with
primitiv.~ streak : .
0.4-1.0 ' .15-17 7 .. 1iiluniilSJ"~hl"YO'With
notocl:lon:W p~cess
-l;.;o-t.S: . 18-20 .8 P.ri!cltive pltand ... , .

n9tochor~al canal fotb.::d Fi~i3.t:n~ainrnatksu~ar;iOrthe~ariaileycle,'

1~$:'2.0 ., 20-22 9 Peep neurol grooves; first fettilization and. early .human dev~lopment. .(Reprinted from
somites present Williams ObsteL.-i.cs 5~ ed. as taken tro~ Moore, 1988).
:L~3J) ' 2.2-24 10 :Neuralfolds begin to ft~.~;
e~bryo straight; 4.-'12

11
'-~~~i;~~:
e.l#. Y
~:~

_J'Y() - &~ . ~
The Embryo

1316 pairs otsoinitta 6-12 daya'(Stage :5) During the ~rid Wee.k.after
-4.~!).0 .. ''26-30. 12 Upper)imb buds appear:
ovuf:itl(m, th~ iim~::- . cen mas~ ~ete~Jh.i~~$'.~in;f>
~udal neu.ro.p(l.re closed;
tail !iPPearlng; 21-29 pairs a two-layered d1 sk (the .bll&.mmar. ..~,mJ~r"Jo)
ofsoniites s epai-atin;g the .blastocyst ~vity in~Q,::~; ~-~Uer
5.0-6.0 2 8-32 _.13. Four pairs of brachial amni<;>tic ~vity' and .a !ar:ger primitive yolk cavity-
.. . . '
arches; lower:limb buds . the.priina.ry- yolk. &ac...:(FigureT3;2} 'n:ie twQ iaY~rs .
~ppear; :tail preli'ent; 30 or
--"' i . -. ... .
~ ..
more.somites
ot the embryo at this Um~ are
.il_l~.:~~.tR4~.rm
6:i);~~o'.:<.~i ~ss 14 Len~ pits snd na$81 pits bordering the a:mruotk caVitr and . ili,e :~~~nii
visible; optic cUps present bordering the primitive yolk cavit-j.. At .'tl\~1eiid of
1.0-iO.O . 3538 15 Hand plateS fonned; lens the 2nd week, the site of implantation J;nay,J>e seen
vi~lll~ ~d Jlasal p~ts by the naked eye as a S1nauelevated,area of
pri!iiili'li!ilt .
~6 F~t'pla~~f~d! Hlinl
endometrium -that- has~a ,eentral pore filled with
pits.-faceventrally;p!ginent blood clot. (Figure 1-3;-3). ~ -
visible in retina
17 Finget rays appear; 12-'17 days (Stage 6 & 7) -At the beginl;ling of the
auricular hillocks
deyel~ped
~h~r<l . week ~ter ovul~tion (or fer:tijiZatlon), the
14.0~17.0 44-48 . 18 T oe rays and elbow regions embryonic disk is well-<lefined and the body stalk
appear; c:yelids r.re fonnirig
_17.0-20.0 48-51 1;) Trimk elongating and
sti:aig!ltening; midgut
herriiaUon into qmbilical
cord
20.02~.0 51-53 20 Fingers distinct but webbed;
scalp vascu13.!: i>lexus
appears Amniotic
22.0~24.0 53-54 ' 21 Fingers free and longer; -cvity --""'l'-:>11""'
toes.still webbed
24.0-28.0 54-56 . 22 Toes free an.d.lopger;
eyelids and external ear
.. more developed
'28.0-30.0 55-60 23 Head more rounded;
fusing eyelids.

Reprjnted from Kalousek, Lau, & i3aldwin. De~elopment of . . . . ' . -~ . .

embryo, fetus and placenta. ln Di.mmick.& Kalousek (eds): Figure. 13'. 2; The tWo-layered embryonic diskderming the
Developine.n tal Pathology of Embryo and Fetu~. 1993, smaller amniotic caVitY and the larger primary yolk cavjty:
Philadelphia: J .B. Lippincott. (From Kalousc::k 1993).

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~

_____ .....,..__.........__:....S-:-E~C::"'::'TJ:":":.O~N-:-.J-.-I:~P~HY-:-
210
Flp.h 1-a.a, V-ery early h~man ges.tatl~rt ~howS:n:g
ilnplal'itationd~. .(From . the - eelleetion .of or;. -~
~.Department of Pathology, The Medical City).
pri~itive s~ .i s fotm.ect,
is differentiated. The
:gi~~ ~::~e. embryoni(!,mesoblast{vihich Will
becOme m:e~4.ermt, resulting. in a ~nar
em~ b , .~ \\1:\th.~~: noto:cnor.dal~ pro~~as; :this ~. 13.~~~bry~~~ear1{l~.~ty~~atthe4th~k .
. .:...a.
t:lO , . auJ'e~i-1-S
t thCIU!
. 'dUS:
:am,\4-:1:
'.. .d ..._'VJ.U .the ,. . .a.fter.~tio~
verberalco~ and the ~u'da1 part ofthe.base
.of Ule alU:Wi\1 develq.p. It als.o sel"Ve.s 1is .th~
cratilocaudaJ ll;ltis ()f. etnbzy.ontc _development . week;:~a:~ .c~rtj.'Iiza~QI)-. (8: week.:gestation), the
{Fi~
' .
13JJ)~.
. . . . .. ..
_
: . .
Ftgnre 13.4. Diagram of .proliferat,ion of the cells of the
primitive streak, forming the embryqni~ mesoblast artd
_prixn.itiv~ )criotas in(,ti~teqby:arrows~ _
(From Kalcusek 1993},
The succee ding Stages. of embryonic
de.velopment cqnsist o(. .initiation of neurulation
and formation of somites ~(Stages 8 & 9), followed .
. bY further development of the neurat. the
.etnbryo.n ic heart, and . Uire~ branchial arches
(Stage 10-12) . .BY ~e end of.$tage 12 .(41h week
after-ovulation}, the embryo has its characteristic
P..shaped ~urvature and the ann and' leg buds are
present. It is 4-5 mm long and the body stalk
~
. :-:S:-:-:IO::-:-L-::0-::G:--:Y""=o'-F:-:P:-::R:-::E:-::G:-:-:N-:-AN-:-:C-:::Y:-::-..- - - - - - - - - ~.
contains one umbilicai vein and two Ulllbilical ~~
arteries. When amnion ensbeathes the body stalk, ,.
the umbilical cord is formed. It is at this }>Qint
that the embryo can be seen and its cardiac actiVity .
recorded by ultrasonography. .(FigUre 13.5).
. . .:., : . . ;...~ . ... . . . ..
"-:cb
. . (6. wee~ :menttrual age} .
6 .. weeks: Ovula:tion~ Age At the end of the .siXth
. embrjo .is- 22:..:24: :nim long, the head 'is large
compared to. the.. trunk, .. fingers and tD.es we
pre~,ent . and .. external ears form def'~ltive
e~cyations on htii)i. ~de .o f .t he head (F~_ :t3~6) .
... ,,,.~ -. -- . ~-
s wee1<:s'' 0Viilaticn ~Age The embcyo!iic periOd of
early 6rganogenesis c;nds at Stage 2.3 or at 8 w.eeks
ovulatory a ge {10 gestational weeks), when the
embryo .has a .c ro.w n to rump length (CRt} .or 30
mm, ;t he head is more rounded, the eyelids have
fused, 'the ears arc fully devel<)ped, fingers imd
toes are well-foq:ried (FigUre 1-3.7) .. The fuSing of
the eyelids i~ ~en: by some investigators as the
arbitrary end of the human embryonic period.
At thi~ p6int; it' rnust be &loted that the first 8
weeks of human life in utero is a period of
differentiation, when all the structure~ destined
to be present at- birth are formed. Each oigan
system has a definite time sequence for its
appearane ~d . ~ifferentiation. In addition, the
tube; sequence 'or events ill one system is related.to the
sequence of events in other systems, (e.g. urinary:
and. internal genital systetrts). If deviations Q<:cur
from. these l)otmal sequences and rela~onships,
fetal abnormality occurs. Any' 'teratogenic
substance or event like infection cannot influence
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 c"HAPTER 13:.1=ETAl MORPF-JOLOGIC.AL AND PHYSIOLOGICAL DEVELOPMENT '211

the development of a structure if it occurs prior to

the appearance of the stiucture in the embryo or
after the structure has been differentiated and is
undergoing growth only. F9r example, maternal
rubel!a infection Will re~ult in congenital cataracts
only ii the fetus is infected at the prttise time when
the lens is developing. Table 13.2 lists certain
malformations that may occur duri..lg .specific. .
periods of a gestation.

Table 13.2. Potential malformations according to age of

gestation in which lnsult ~ (Reprinted m>m Kaiser rn. .
Fertilization .and tho phys~ol~gy and -dev.dopm~t of fetus
and placertta. 'Jn Danfct$ D & Sco~t J (ed!!): Ob$tetrics and
Gynecology, sth ed, 1986, Philadelphia, j :B. Uppmcvtt Co.')

- AREA oii' RJClf Weclc After OYUJJ,.tion Potential Malformation

VA$:l,i.~~
WPICA;JNO
PUC~HTAL_sm; 3 Ectopia e<>rdis <1:,
"-~~-r-~ AMNiON . . . ~..... .. :. ~
Omph:alocele ... ,.
:':-.=-''-:~.,;=--..y(>LK SAC !~-~\t~~~tti~-~ 1 .
~ oJ ,;;;: ' ;.A-.:~;:-~~~
Ect,romeliQ ' .. . .
. ' . 'S}'i!l,P9:(iia . . .... : _,;.:._ ...~~~.J.:i :

. . . ' . .

Figure:i.~~~. Plt!~term~-~
,~:in' tiua1
~ 6w~lcaovu}ation
agq:~dJlbcyo
yoik. and 8 aCt
.4 "On:ip~e .. :i
=Aic;ri.'. ::.
... .,
:~s.,
. . . . . ... .
-~ - - _.,
~
:.. ~'_'... : . ' . . ... Eclr,on;lelJa:.. .
. ~)?bate~U.tuta~~~' .
... ...,. ... .l --~... : .. , . .

. ' l:l~ ,. . : ::':.:;:::' .

S . ~lis~'-
Henliv~bla: '
Nu~iataiii.ct
MJffiipll~ '.
Facial clefts
Carpal or -~ ablation

6 Microphthalmia
Cai:palor_pedal ablation
Harelip, agp.athla
Lenticula:t cataract
Congenitlil heart
disease
Gross septa! and aortic anomalies

7 Congenital h eart disease

..
+-o.-J~...,....-..-,.., HINDBIUJN Interventricular septal deiects
':f-"1--.--+.--.-.... FOREBRAIN Pulmonary stenosis
Digital ablation
. UMBIUCUS Cleft palate, micrognathia
Epicanthus_, brachycephaly

8 Congenital heart disea.SeK

Epi~thus, br;tchyce~ifiriy
Persistent-o stium primuin
Figur.e -13.7. lntraute~e pregnancy at 8 W.eeks ovtilation Nasal bone abta:tion ~
. a ge (tO weeks m!!n~trual age) .~ ignifying end of embryonic Di~tal sturitlng '
period.

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21:2
--~----~~--~--~~~~~~~~~~~~~~~~~--------~~---~
. SECTIO'N 11: PHYSlOU)GY OF PREGNANCY -.~::;:

; :~ . . . . -~
The Fetus constitutes one ha;lf ofthe total CRL {Figure 1.3.8} ;;,~_
~e. ~es. .are-c.lesed, extem~ _geni~la: ate ~till not. !~.:'
...
T~e previable period of fe.t al .development disttngws~ble, ~~ .the mt.estines are located . _
{11~19 weeks menstrual age) is chata.cteriud by within .the abdom~: ~nd pf. #le' umb~c81 -~ Y .
.a rapid increase-i n t:xxiY_-l ength and
wcight. At the {a phen.omen:on ~own as the phys'iolpgical if
end ofthe 19th week, tho fetus has teacbed-a CRL hethia.tion of.the ..gut) {Figure 13.9) Tii~ inte..stiru] t:i
of lti em and weighs 'ap_proxijnate1y 320 gm.. All loops :nonn,ally b.ecb-me lo:~aie d 'Within the
fetal organs ardunctional'a:lthough the respiratory abdomen by the end pi :be J21h-l;Ilensb-ual week
system -is still t:OO irn.xll;ature f1>r ext:raut~ life. (li)'h week _.t?,yU:~t{)ry -e:~e). . . , . .
After 20 weeks, the fetus is called a newborn. It is
call~ pre~!!t:m imill37 w.e~ks, ~term .f rom 31 ~ 3 months .aY;$e.en,d .of the .12th y;-:~k ot te~~
4:2 w-.~k:S and posttenn if pregnari.cy goes 'beyo:nq the uterns-;~:usu~ f~tjustabo\Te.the s1mpb.ySis
4~~ks. pubis.:Tl?.e:CRL .oflhe f'etO.s.i~ -~7 c;m.cin~ of
oss!.fication-are:present in mosfofthe fetal lxm.es, -~

Th~ foTiqv.i:ffigbnbf s~nit#azy of Key featutesof fingers and toes_. have. beqome differentiated.,
each moiith. of' g8tati<>J).,iS .b a,sed .main'o/ on .the extern:al gefiitalla of.:rnale and_ female fetus...~ ha-..e
diseussion .~n.Williams .Obstetric-s,
.
19'h edition. become -~~il~h!+l?~~; and i-;itest:4les are new
.
in :the
abdcitnen .:Gtlfss trunk ::mo.veinents ar.e
J.1. .weeks At fl. weeks menstpJ.al~ ~e. {9 ~\a; present a~ this tkr~ - ~d . the ietu$.-' i'~M~ to .
:oviilli'tozy ii.ge)', the .toutv4 h:ead 'bt the fetus s~Wi.- e.g~-, ,strol9Iig-.t he lip:S _re~Ults. ~ su;ing
..
...~~ movements fFigp.re '13~10) . _ .

,.__.,....___._ Orb'it
'b'-"---,,-- Maxilla
&
Mandible

j
Figure 13;8. Fetus at 11 weeks. The (:rown-ruinp le!igth is
used for gest?tion~ age determina~on by Jll.t rasound, Figure 13.9. Physiologic herniation of the gut.

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 CHAPTER 13: FETAl MORPHOLOGICAl AND PHYSIOLOGICAL OEVELOPMENT . 213

.~.i3.10-TheJ'etus.at.1!Uveelcs &hoWiag:(A):Jtapro!ile; (BjAnani:;hand;-and'fingeisi (C)'Femlll~-s.ex~eri$i'ition;

(D) Stomach located withit?. abdomen.

4 months By the end of 161h week, theCRL.is 12 skin is wrinkled, the head comparafudy large,
em and fetus weighs about uo -gm~: Gross . eyebrows and eyelashes recognizable. Fetuses
examine.tion of the external genita'lla idetitill~ the born at this time -have surv;iv~d with intensive
. SeT. of the fetus: T}Je foi:"e~ and lavier:teg$ are neonatal care. Fetal lung pneumonocytes begin
crossed and the fingers are fiel_ted. OssUi;ation of pnxhiction of surfactant at this time.
the skeleton allows i.dentificapon of a1l
bones by
r--ray exarni..'1ation, 1 months By the end of the 28th week, the CRL is
25 em and the fetus weighs about 1000 _gm. 'The
5 months The end of-the 20th week is the-midpoint skin is thin arid red and covered with vernix
of pregnancy. The fetus weighs .about 320 _gms caseosa, a mixture of fatty secretions -o f fetal
and measures 16 ctn CRL~ The skin is less sebaceous glands and desquamated epidermal
transparent, with lanugo (a fine downy heJr). cells. The eyes are partially open due to tl"le
covering its entire body and some scalp hair disappearance of the papillary membranes.
visible. Feta,l brea thing t;novements bec()me Eyelashes are present. The fetus born atlhis time
regular at 20-2 r weeks. . . will most often survive with expert car~;

6 mo~ths By the end of the 24th 'week, the fetus is 8 months At the end of32 weeks, the fetus has a
21 em long {CRL) .and weighs about 630 ~ The CRL of 28 em and weighs .<!.bout 1800 gm. The

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 . {

2"14

. .
s.k in is .PtiJ.l ~d ap,q Wrinkled, toeru;ills are 'P resent
and th testu start to descend. A fetus born at
~.time wilt usually suT.vi~~ with. pro~ tare.
9 m9p.ths 'At'fJl~ .end of .36 week$, ..t..~ fet\l~ bas a
cR.L -ot 3.2 C.m and
stibcu.taneo~s fat deJx.)siti1<t:esults ,in lo~.of tikin
~ t;.nq the fingh:it~:S.~ ~.e :firtg~ps.
Fetus8 bom.at this B.me:ful.ve M aqellent~ce
of ~ur:vfval: .
m~ments:ofth~ ~;-m to rump. length(~ '
heigtlt) ~e . con:si~eted tn.:ore a~uia:te than
m~sw;eme.nt_&. of th.e 9'0~ .to .he~l (standing
hejgh~): Th.~ ~vemge -Sitting ~eights .~ weights
of the f~JU.s ai tile end of-~Ch limar :month were
w~igh~ ab9~t ~500 gm. ~bU.laredJ~yS~lI:;in 192()~ ill!d are ~.Parable
t.o 'tlie:inore,~t W.tr~~ic'tabu:la~on:,.; of CRL
veq:ms_.AOQJ.(Tabies 1a.3 & t:3:4).
. .Fht s~oi!.tha; ~ ~Qf-~ l~) .. {Ne>. ofl~~
.. ~!! me>ntiu!: ~i:tgth .OC:fetu.i {Ch'll - {H9; ~~

.. . . ..
:-..~.-:-
.. . .. .. --:-,....... .. .
':~- ,
l::' .:- . ' . - .. ...,. . .,' . .. . " .... ~ . . .
:":

; :~
. - - ;. . . .. . . 1.. ~- ': : ~:- ~: : ,
'.~-: .' .

- - .
..
--- ~ .... ~ -~- ---- - .. - -- . . . .. - ...-_.. ~- - -- - .- . - -- :-:-- -::- --:- ..... ' _... . - ~ . ...--:--#> ----- - . - -- -- - J ~- -

. Age{wk) CR Fetal Foot

Length Length Wei@lt
M~trual Fertilization (tnm.} {mm) 1g}
. .. "

11 9 59 1 :.8 Eye$ ~or.~:~~ore rounded. Exteinill genitalia

.. . atiJ.1:~9t ~~b~ a,a,~a,l~ otofema le. Int:estjo~ are
in 1:heumbiliq!}>~
12 : 10 61 '9 M ~i:.e~ :abd~tn.. 'EaPY.fin truill.u e1 t.
14 ' 12 87 14 45 $x:<#~lliiliie~: .:ri~e~ ~~~ ..
16 14 12'0 20' uo H4d e:cl..'~.linib:~ ,-wdl.dev.e loped.
18 16 146 'P .200 ~ st:a,nd 9:Utirom:qe#.
20 .18 160 '~3 .320 VctiiiX~~.Pr~~ .Early toenail development.
7:~ 20.. ~'9.0 . 39 460 f{ead amt.body.(lanugq) hili-JiSible~
24 22 '210 45 6:3'0 Slfui. ~ed.~d'red.
'26 24 230 so .820 F~gerru,.,ib prc~t. ~ lx><;ly.
28 25 250 55 lOQO Eyes:partlally.o~ Eye~~ pr:esent.
36- 23 27b 59 1300 Eyes.open.~ head ofhair. Skin .slightly w:ririlded. .
32 30 230 63 1700 Toenall:i'p~t. Bo4Y::fining.out. 1'estes d.e~endillg..
34 32 390 68 :2100 .Fingerruill~ reacliifugertip.S_.skin pirik 'and smooth.
3.8 36 340' 79 29.00 Bo<:iy usqallY, plump,. Lanugo hairs almo~t a bsentTO=ails
reach toe tips.
49 38 360 83 3400 P rominent ~est;breast pf'Ptplde. Testes in.scrotum,or
p~pable in ingUln?l caitalS'.. .F 4lgemails .extend beyorid
fmger1Jps.

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 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT : . .. 215

Table 13.4. Crite!;ia for estimating fetal .age. (Reprinted from Os._ya S. Am J Obs.tct Gynecol
1993; 168: 903).

PREDICTED MENSTRUAL.A GE {MA) (WEEKS) FROM CROWN-RUMP LENGTH .(C~

MEASUREMENT (CM)*

CRL MA CRL MA CRL MA CRL MA CRL MA CRL MA

0.2 5.7 2.2 8.9 4.2 11.1 6~2 12.6 8. 2 14.2 10.2 15.1
0.3 5.9 ~.3 9 :0 4.3 H .2 6.3 12.7 8.3 14.2 10.3 ... 16.2
0.4 6.1 2.4 ~.1 4.4 .11.2 6.4 12.8 8.4 14.3 1().4 16.3
0.5 6.2 2.5' 9.2 4.5 11.3 6.5 12.5 8.5 14.4 10.5 . 16.4
0.6 6.4 2.6 9.4 4.6 11.4 6.6 12.9 .8.6 14.5 10;6 16.4
0~7 6.6 2.7 9;5 4 .7 n.s 6.7 13.0 8.7 14~6 10.7 16.6
D.8 6.7 2.8 " 9;6 4.8 il.6 6.8 13.1 8. 8 14.'1 10.8 16.7
().9 6 .9 2.9 9.1 4.9 11~7 Q.~ . 13.. 1 6.9 14.8 10."9 16.8
1.0 7.2 3.0 9.9 5.0 11.7 7.0" 13.2 9,0 14. 9 11.0 16.9
1.1 7.2 3.1 10.0 .. 5.1 11.8 7.1 13.3 9. 1 15.0 11.1 17.0
1.2 7.4 .3 .2 10.1 5.2 11.9 7 .2 13.4 9.2 15. ! 11.2 17.1
1.3 7 .5 3.3 10.2 5.3 12.0 7. 3 13.4 9;3 15.2 11.3 17.2
1.4 7 .7 3.4 10:3 5.4 12.0 7.4 13:.5 9.4 15.3 11.4 17.3
1.5 ~1.9 3.5 10.4 5.5 12.1 7.5 13.6 9.5 ts.3 u.s 17,4
1.6 8.0 3 ,6 10.5 5.6 12.2 7.6 13;7 9.6 15;4 1.1.~ 17.5
1.7 8.i 3.7 10.6 5.7 12.3 7.7 '-.: 13.8 9 .7 15.5 11~7 17.6
l iS':: 8 .3 3.8 . 10.7 5.8 12..3 7.8 "1 3.8 .. . 9~8 15.6 . 11.8 17.8
~
I
, . r;:g;:" 8.4 3.9 10.8 5.9 12.4 7.9 13.9 " 9."9 " 15.7 11.9 ' 17.9 -:.:.~ .~~,. ~.w.; ...

..:.....' :.-- -~:pj': 8.6 4.0 19_:9 6.0 12:5 8.0 . . .14.0 . 10.0 15.9 ."12.0 lt.g,~~:l,:~!.<.- :"
2.1 ..8.7 4.1 11.0 6:1 12.5 8.1 14.}. lC.l 1-6.0 12.1 ts,.o~v,,~';i~ ..,,._,,
,_,::_;;, i _._,,

.: ::!

.jun~tioil ofthe sagittal~ the rrontai,.and the :~tonal .

The head of the fetus is obstetrically the most
important part of the body because during !abor;
it :l!d~P-l!LtQ . th~ JilQtA~r t:~ .R91!Y P.~Jyi.~,. g is
coQl.Jiqsed_primarilY-.of. th.e .skl,l.ll, .wit.'l . th~ .faQe.
occupying .8. relatively small . part .of the whole
structure.
. The feta l head has the following critical
'J'he 3kull is Il1ade up of 2 frontal, 2 parietal,
2 temporal bone$, the upper portionof the occipital
bone, and the wings ofthesphenoid. These bones
are sews..ted'rrom each other by membrru1ous
spaces called sut\lres: the frontal suture betwee n
the two parietal bones, the two coronal sutures
betWeen the fron Ul.:l and panetal bOne s, and the
two. iambdoid s utures b~ tween the pos terior
margins :o f the parietal bones a nd upper n:ia:tgins
of the occipital bone. With -vertex present~tion
.during labor, all except the tempora); sutures can
be palpated and are useful in monitoring position
and presentation o f the "fetal h ead.
A fontanel is iormed where three or more
sututes . ~eet~ forming a spa ce covered by a
m embrane. The re are three fontanels: the greater
or anterior fontanel {or b regina}"is formed by the
sutures and is diamond-shaped~ the Jesser or .
posterior fontanel is the triangle-shaped area
formed by the interse(:tion of the sagittal and
l~mbdgid sutures; the te~poral or casserian
fQn~.eJ~ ~r~ 19.Gated a t t};lf! ju_n,ction of th~
lambdoid and temp<)ral sutures.
diameters. whi ch are u;sed during labor to
a scertairi the fit of the 1lead within the ma ternal
pelvis. {Figures 13.11 & 13~ 12)
1. Occipitofron t al diameter (OFD) == 11.5 e m:
follows a lineeXteric!ing from a point ju st above
the r oot of the n ose to t h e mos t p rominent
portion of the occipital bone.
2. Biparietal diameter {BPD) = 9.5 em : the
greates t tra psv ers e diameter of th e h ead,
which ex tends .from one parietal boss to the
-other. :!~
3 . .Bitemporal dia,meter (BTD) = ~.O '~in: the
grea test dis tance be tween the two tempor al
sutures.

Seanned lly: ~
.216
........--------~~~~~----.----7-
SECTION Jl: PHYSIOlOGY OF PREGNANCY
.1.....

4. Occipitomental diameter {OMD) = 12..5 em: correspom;is to the plane of the SOB a.nd averages :,
from the chin to the most prominent pOrtion 32 em. Larger heads are seen in white infants, ~-
of the occiput. males, and those born to .m ultiparas. .

5. Subocclpitobregmatic diameter (SOB) .. 9.5 The Fetal Brain

em: follow-s a line drawn fr.om the middle of
the large fontanel to the undersurface of the
occipital bone where it joins th~ neek.
6. 'l'rachelobregmatic diamete-r (1'8D} 9:5 em: a
line drawn .fro.n1 the br-egm~ to. the
undersurface of.:tbe-fetalmentum or .man'dibl~..
~~
The fetal brain changes in appeara..."'lce and
function. as .p regnancy progresses, and frotn
midpregnanc-j onwar:ds, it is possible to identify
fetal e.ge from its ~haracte.ristic external
appearartee. Please refer to FigUre 1'3.13 for
diagrain of .t he cha.tacteristic conJigurauon of the
fetal brain from 22 to 40 weeks ofgest:at:ibn oftwcr
week intervals.

FWtAL PHYSIOLOGICAL DEVELOPKElf!'

Catdlov.aacular $ystem

All of tb~ nutrients for fet~l growth and

developtnenf. Jire,ih~lf..eted;to ~o.:fetal . heart 'from .
the.placert~ by the>umb~ vein jn tl1Cumbi1ical
com, and therefore fetal circl,ilation l$ basically .
different: fro.m that .of the .adult. One m11.jor
differ~nce is that t}le fetal. heart acts in F.ODUel
F!iJ1ftl3.:u~ f.'cW~eadshov.ing.the fontancls .suturea,. wher_~s. th.e adult. heart ads in ~quence.
qr.<f the bi~~ c!.Wneter.. . .
Description of Fetal Circulation .
. .
Sifup1y put, oicyg~riated bl90d'l'ipm the'mo1her
rs (:a:rifeCf _GY_tf1~smgie --umblli~at~vel:tl,~whiili .
enters in the. umbilicus and ascends ~on:g the
anterior abdominal wall to the ~iver, where. it
divides into $he p.o rtal sinus and the du-ctus
venosus; The ductus venosus is :thebigger branch
a.nd.it tiave~~s theJjver to enter the Weriorvena
. cava. T.herei .a. streaming of floW" :Qccun be~n
.pxygenj:l:t~d blOOd frqm the uttibilical V'in and the
deo:eygenated blood from 'the lower haJf'ofthe 'fetal
body .which courses along~ide eaeh other in the
inferior venacava .41 sep~atc streams With little
admixing. Streaming persists as the in,ferior vena
cava .enters the right atrium, where, instead of
eruptying into the ..right ven tricle as it does in the
~<!gure 13.1~. Dianietera of the fetal head. adl,llt, o-xygenate.d blQod is directeli tq t4e left
atr?.um .throug}l t he foramen ovale, speci.(iciilly
through the crj.$ta dividens which deflects blood
from the inferior vena cava to the left atrium . .
Meanwhile, t he deoxygenated .blood from the
The .greatest- circumference of the fetal head inferior'vepa.cava plus that from. the superior vena
is that which correspOnds to the plarie of the OFD cava flow .into that portion :o f the right atrium that
~~ averag~s 34..5 c~~.'I:he smallest circumference allows emptying into the right ventricle.
. . ... .....

Snanne4 8y: C
~-___:._C~HA----P_TE_R---:.13___: _FET.__A..,...L_M_oR_ P_H_O_L_O_Gl_CAL......_.A_N_D_P_H_Y_S..,...lO_LO_._G_IC_A_L,....o_EV_E...,..L..-O_PM...,.E_Nl ---...-~
_ .-: 217

r
.Jtll.._/
'
---
~
. '
32Wks
22 Wks

.,..
I .
'
.
'
/~

. '"}/
. ;~ .
..
~r_ .--:---
2GW~s
36Wks

:?-'-'~~~~A~
~/ _/ . .
38Wks
. :; .. .28 Wi<s
. ~ .;; ' ~.). I~:. - '

. ..., :,.":... <.:.~- ~:.~-

Figur~ 1'3.13. Ch~ct~ns.tie
confi&nnWon of fetal bca.iliii iiOtJt~~tP
40 weeks at 2-week in~ (RqJrinted
from Will.ia.ma Obstetrics).

:Mo: ;. : ..
.,..... - . :,. ,

Oxygenated bl()Qd d>!'ltinues .m. its journey
throughthe heart. paMing into ihe left ventricle,
is._c:j~~-oll:~ ~~~.~~-ai~~ ~4 .gpe_~ '~!! .! <>
perfuse the heart and brain~ the .two most vital
oigans in the fetus. DeoXygenated blOod i$ ejected
out from the right ventricle into the puhnonary
artery where it passes through a third shunt, the
ductus arteriosus. int9 the descen4irtg aor..a, :Md
thence into the hypogastric arteries and QU t
. t :h rough the umbili(:al 'a rteries h ack to the
placenta.
. To summariZe the differences !n fetal and ~dult
cir..:;ulation:
1. There are three. shunts, namely theductus
venosus, foramen ova1e. and du ct~s arteriosus,
which allow o,cygenated blood to bypass theright
ventrii:::le and .pulmonary circuhition and flow
directly to the left ventricle and ,aorta to supply
.t he heart and br.aill; ' by 2:.3 week~. 'I'he foramen ocivale i~ f un--nally
2. As a. consequ:ence of the shunts described,
the ventricles of the fetal work in parallel .as heart
oppo~ to that of the adult heart which worlcs in
sequence. For an illU'stration of the fetal
ciic~~~t.{9i}. P.i~~ -~mlhr 'i?i~~~l3.i4... ... ". .
3. FeW cardiac output per unit~f weight is
three .times higher :than tha t of an adult at rest,
and this compensates for t.J'le low olcyge:n tontent
of fet~l b loo d. Thi'S high ca rdiac :ou"tpllt is .
accomplished partly .by the higher heart rate of
the Jetus .and its lowperipher:a.J resistance.
Changes Afte r Birth
Mter birth, when the eord is cla.mped and the
fet al lungs e:x pa nd) the umbilical vessels,. the
.ductus arte riosus, the foramen ovlile, aiu:l the
ductus venosus normally constrict 1Uld collapse.
and fe tal circulation changes.into thatofanadult.
The ductus arteriosus is functionally clo$ed by
10-96 .hours after birth, and anatom.icaJ.ljif.tlosed
closed within : several JTiinutes .after: .,biJ:thand
anatomical fu sion ofth e tWo septae of the fdiamen.
. ova1e o~curs by one year.aftei birth. Penect closure

Snanned 8y: ~

2f8 SEC'flON II: PHYSIOLOGY OF PREGNANCY
o---- .
-{} . . . . .
- ~
. . .
+ -:--~
... .. ~ .:? . . . ~:..
i~_,n'Q.t a~~<i it?._~Ji~1!.t 2~?.-~~~!...~f.1~~
Tb.e ductus :veno~ms constrict-and it ~~t!l~ the
.ligru;nentum v..enosum. The ductu~ a ttenosus
l;>cec:oh;t~$ :the ..iiga.in.entum arteri.o:$:utn.. The
-~mb~:iut~es ~mthe uml:iilk~.:Lli~ep.ts
wb.i.le'tlie intfa4bdon:iirtahtinn a ntof-theumbilica1
vdr:Cbe?~es -th:e-llga:entum. ter es.
.
: Mainter~ence .of -t h.e p~tency 'o f the th;l~tq:s
ar:ter:iosus shunt .depends on the difference in
blOQ. prissur.e :betw.~en. the-pulmona.t.y:artery.and
the ~otta and the. difference in o~g.eil t.eri$lon .bf
tli-e. blood--p~ssipg:.t:hrough the ductUs. Jily alter;ing
th~ _p0., ,o( the blo-o:d {'increasing tl).:~ p0 2),
i.nv-e stigator.s have ben able Jo s to_p du ctus
~etiosus -~ow. ,
Thes~ . effeots ..of;yaria,tionin oxygen tension i.p.
blood .flow. furough :the .ductus-::ar.e believ :toi.be.
m e.diatedthrough
. . actions of.p rostaglandins iri the
d:Qctus:. Prostaglandin --synthetase inlu'bj.tor.s {e.g._
m efenamic acid -given to'thepregnant woma:n} may .
re ~mlt in premature closur~ of -the d'p.ctus
Scanned By:
1 .
arteriosus. Posthatally however, prosta,gla.ruim
inhibitors are used to effect closure of patent
ductus arteriosus ill syn:J.P.tomatic newborns.
.Hematopoiesis
Formation of bl<>Pd is first:~mqnstrable in the
.Y9~ sac duri.ng the em btyonic periOd, the
meS:O~iastic period.. In the fetus, the UVer takes
over up tb .n~.r term, the hepatic period. T):le bone
:~ marrow starts its hematop oietic function at
ru1_>~ fo~ mouths fetal age, ii:nd is the major
site of. b1ood formation du.ri.ng adulthood, .the
myeloid period.
The:.d:ft~""Oc-jtcs' :f lrst fo~d by the f etus :are
nucl~t~ hUt grad!l'~Y "QeG6l:neti9h-:hticleated as
dev.elopm~nt .progr.esses .. Bloq'd volume and
hemoglobin C Oncentratfori inc~s~ _p.r ogiessivdy.
At mid-pregnancy; hero9globin is .abOut lS .' gm/dl
, ~~,a_t-.~t:Did~- is:about.-l~"gn~:/<d)'.i~...:: ... .
. . .. . . . . .
. .Fet.al. tcythrocytes ha."'~ -~ sb~rter life :~
..._ .(aP.:<;>ut ~<H:f1;irclsth~t. :of'a'dulf.:e~) due
. tQ their -latge vo'l ':ttile .and are ..fuor.e -e asily
..d.efo~able,. which: _Serve. ~to . :offset!. theii .lllgheJ: ,
viscosity...;r'h~y..also.,contai."l....s~v_era1:.ebzym.es)hat. . .
have appreciably different activities. They are
~fe!T~ to as ~stress .e:~~s.!'
.f>iiii:Iig..states _or Jew a;nenwi:i-~ ~:tn~ :~iaJ lifer
syritl;l~izes erythropoi~tirr and ~eretes~ it:in.to~
ail:.L..:U.c;>tic fluid. Ftal ecyth.4:>poietil) plays a role in
ery.throp<>iesis in \,ltero. ~ .
~oFJ;D.alter:m ..uua,I1ts liav~ ~ a,veragev:olume
of 80 ml/ kg boQ.y weight immediately after aird
cl~ping. The p lacenta likewi$e contains fetal
blo-od in a.mo~nts of 4 5 ml/k;g boqy weight.
Ther~fore, fetoplacental blood volume at te(Ill is
about _125 ml/kg of fetus .
Fe.t ql Heroog:lobin
.i n th~ :e~bryo and fetus, the globin moiety of
.the: hernqglobin.rq:olecule- differs :from. that of ~
n ormal adult. Three major fbn:Il.s of~hemoglobin
are 'formed .i n th~ emqtyo, differing i n their globin.
moietie~. The f~tus also el<iborates th~e types of
Jlemoglol?ins, which <;liffer in their globl? moieties:
C
 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT 219

-f.\,.
1. Hemoglobin F (fetal hemoglobin or alkaline- hemoglobin is hemoglobin (\. During the .lifst 6-
.r e$istant hemoglobin) - 2 alpha chains and 2 12 month$ a.(ter birth, hemoglobin F continues to
gamma chains. decrease, eventually reaching the low level found
2 . .Hemoglobin. A ladult hemoglobih) - is formed in e~ocyt~s of nonnal.. adults.
startmg at 32-34 weeks .g estation and te~ults
from methylatiQn of the gani.IIla globin.chains. Fetal Coagutation Factors
It conSists of 2 alpha .<md 2 beta cluJ'ns. .
.3 . Hemoglobin A2 - contafua 2 $1pha an.a21lelta Fetal blood contains lower levels of the
chains . It ~s presertt .i n the matu.tt fetus infollowing coa~latlon factors: II,. VI, IX. X, XI,Xll,
small amcurits that increa~ after birth. XIII and fibrinogen. These are vit:an)in K dependent
factors, so the :neonat;~ is r-o utinely given
As illustrated in FigUre 13.15, at -~y- giY.en prophylactic vitamin K. injections tQ prevent the
oxygen t~~sion and at Jdenti'cal piJ. fet~l development of hemorrhagic disease of the
erythrocytes' 't hat contain mostly lietriagt6.bin F newborn. Platelet count~ ru-e within the notmal
bind tn~re oxygen than the beJI).oglo'i>in A . range-; .tlt.rombin time is somewl)at prolonged;
-e xythrocytes. Themajor reason i~ that h$oglobm factor XlU (fibrin stabilizing .fa..et-or) .an.d .
It binds 2-3diphosphogJy~te mo.-e tigl:ltly than plasminogen are 1ower t~an in the a.d.ult.. A low
d~ ~e heniog19bmF _containing..~oyetes, level of factor VIII leads . to a dia,gn~~ls of
ana thl:i . bip.tlipg lowers tl;l.e a:fijnt.~ of tbe hell)Ophilia in ale infants. -Gontinuous ~g of
hemcglobin :mol~ule for- .o:x;ygea 1;hc_in'-~sed blood frotn: the 't,urtbiliciU -. stump itt .tl'le-neonate
oxyg~n af,fih.ity of the fetal e~s- r~sults may lead to a clin.ical diagnosis ()f factor )Gil
fr6ili: .'ii ,: lower concentration of 2~3 deficiency. . ,, . , . ,, ..
djpbosphQstycerate in the kW:s. 'llie.affinity of fetal ..: ... ':- :~~ .....!.,

blood for oiygen decreases,_on the ~thj:r hand, at Fetal PlaSma. Proteins and Blood Yrscoiity, "' :
higher te.aiperatuie:s, as in :cases -of JP.ate:mai :.

h rthennia. The mean tot~ plaS'It).a protei,n atid :plasma

~ :- -~---~- '
albllinin-concentration in maternal and fetal:olQod
.. __:_-.A s ~p,t;tgn~bl.cy appr.oacpes te:rm. less are:,similar; The .same is-:tnie -of ViSeosi1y>.( )t.bOod-
hemo'g1ob1n F and more heltlogloJ>in. A are in both matenial and fetal blood. Th iricrea~d
produced. Atterm, about ~fourths:~! the total viscosity in fetel.blooddue to a higher hematOcrit
("thicker blood'1 is offset by the lower k-veis of
o. fibrinogen and IgM, and by the more deforma ble
. . ,0 . er;y:throcytes.

eo Immunocompetence of the-Fetus

-To For years, the human fetuswas thoughtJo be

incapable of producing specific antibodies, and the
60. immunol<1gic defenses of the newborn {essenti~
.,
~ iri the maintenance of body ipt~grity in the
~ ~0
.._ extra.uterine envitonm(mtl were thoUght to ha.ve
.
:>

~ 40
beeh derived exclusively from the lnotber. Without
.
!I
c:
aprior antigenic stimulus.i11 the fetus such asan
~ )0 inf~ction, the immunogiobU:lins present are
a. consistently lgC from the mother, transferred to
20 the fetus across the plac~nta by receptor-mediate d
processes in the trophoblast -a s discussed --in the
chapter crt the placenta lgCtransport from mother
to fetus begins. "at arOurid 16 weeks-and. ~S - most
eo z6 )() . Q so 60 pro~ounce.d during the last fo.u r w~:ks of
p01 mmHg pregnancy. A pretermileonate . therefore ,~ not
Figure 13.15; Oxygen dtssociation curve 9f fetal and have -significant "liimountsof matemal .an~bdies~
metarnal human bloods at pH i .2o. {Repnnted from Newborns begin to. produce Ig.C and actult"values
Williams Obstetrics.) are reached only a t three years o f age.

Seanned 8y: ~
220

IgM is produced by th~ fetus .in response to
congenitatinfections 'li:ke rubella, CMV. and
toxopla.$mosis. Adult levels are attained by :fl.i!le
months of age. :6 lj.friphocytes appear in Ule liver
by rune week!: of gestation and .a re seen in the
blood and $ple~n by 12 weeks ge,stai.ion. T
lymphocytes are produced by the thymus at
.~tind H "f~ks. Monocyt~s cfneviborns areable
.t o proeess and. pr~sent antig~ri. whep. tested with
materr...al ,antigen-'speclfic T::.ceus.
Nervous System and Sensory Organs
FleXion .o f the fetal neck and ~nk is'ob~oj
by .the eighth WCfek of gestation, sign~g
sufi;i.cient.develcrpment of synaptic functions. Ifthe
fetus is remoyed from the )...lter:us. duting the 104
w.eek. spontaneous movements may be observed
aithcmgh moYe,ma1t~ ll.t .-ti:t.~ro are npt felt by the
mother unq! :about.lS-~0 week$ (qukkeping). At
1:0 weeks, local $timuli n:i~Y evoke .squinJ:,ing,
opening the .!lloU:th, :incomplete finger-closure, all!}
plantaJ:'fl~n ()fth,.e toe~. Cbmplete finger closure
is $een.d.Uring.theJoiufu ~{m~ m91~ ~
an<l, :.ttsp~'tion..axe :~so ..see.n a\ ,fui:;; time, :The
~:b~tyoto ~~Cki.S.present only ~t 24 o; m~reweeks
~>:.estati.on. . . .
o . -. :

... ...-.. . .... ...

~...1.!! -~~~;Q{g~~m!i.9!1. _f:h.e .~t!!e!J:.m.t~
~- ~ ~

-- .. ....... . . .. .....
. - .. -- --- ..
Thenewbom:responO;s poorly .toim.ro;unization are capabl~ of peristalsi~ and cf tran~po'rti.ng
especj.albr to bacterial capsular polysapChari4~~; glucose actively. By 16 weeks, the fetus .is able to
and -this may b~ .du:e to a~fici(mt ..te$pons:e .o.( sw.allowru:pniotie flui~ absorb much of the water
l'l.ew'born B cells to :PQ~ydonal a~~~ts 1ak ot or from it .a nd propel ''Uii~bso.rbed .matter to the lower
T cells that proliferate in respPnse :t o :s.ped.fic colon. Hydrochloric acid anci other '<iigesti.ve
.stiriuili, Cll;Z.YJlles az:e.pr~~t m.~:veiy si:nallamo'unts.in the
'fetus, &'l:erefore premah:!.rely bern infap.ts have
. Qnly :lgA :t~ge.ste.d in .coJGstr:Um!,m.!'ly -prb.viqe transient dC:fici:encies o~ t,.'J.ese enzymes.
piotec'tioi,i against'enteric infe_C ijon:s, si:ll~e the
:antiho'dy r~sist,s digestion. and Js effective .on t erm fetuses are able t o swa.Uow as much as
mticbsa1 .surf1;1.ces~ Th.e same ~s poss ibly tr~Je 4!SO xriJ. ofan:iriioticlluid .i n 24 hours.-Attl'lis time;
for lgA in,gest~d wi,th. ~mri.io,tic. flui'd before fetal swallo~g of ain.niotic .f luid plays a role in
delivery. . the regillatioQ. of apmiotlc fluid v:olume: when fetal
swallowing is inhibited (~s in fetl,lses with
. .. In the fetus a nd. new.born, IgM -i s esophageal .atresi~) . po ly hycir.atnnios results.
prQ.~:i.DtJ.Y. :Pt70:9.Uce.d ~ resP\?n~e. tq antig~.~ic 'Furthe~ore, the act of .swallowing may enhapce
stbnula#on, :wheFeas in adults., ~gM ,ptodUct ion is gr.o w$ and. development Of the gastrointestinal
.superseded" in 12 weeks .. by-the ' predo~i;qant tract and t~~ndition:>iHor aliplentati6n'aiter birth:; ..
production ofigG. Sen,1m ~evels.oflgNi'in umbilical Swa:llowlrig, in adaitiqn, removes s ome of the
~o:rd 'b lood .and.iden~ification of the .spec,ific insolubledebris that is shed'into the amniotidluid .
a:ntibody in.a y p e of aid ,in. the diagnosis of or abnornuiliy excreted
inlo it. This deb.rls cail be
intrauterin~ infection. . identified in the m econium after birth.

Snanne4 8y: C
 CHAPTER 13: FETAL MORPHOLOGICAL AND .PHYSIOLOGICAL DEVELOPMENT
The amniotic fluid probably contributes little
to the caloric requirements of the fetus, but it may
contribute some e.s sential nutrients: about 0.8
gram of soluble protein is ingested daily by the
fetus from amniotic fluids, half Qf this albumin.
M~conium is passed by the fetus after birth
and sometimes during labor, and it consists of
various products. of secr.e tion, excretion and
desquamation by the gastrointestinal tract, in
addition to the undigested debris from amniotic
fluid. The daFk greeni~h--black color of meC9JVUm
.is ~u~ by bile pigments, e~peciaily biliverdL.
Meconim:h _pas.s age duririg 1~.bor is said to be
cau~d by ~ypoJda, which stimulates the .smooth
muscles (>f the cohm to contract a nd result in
intraamniotic defecation.
Small bowel .obs_tr..lc:tion may lead to vomiting
in utero .F~elti$es who suffer from congenital
chloriaeru.&rmea may have cliar:rhea in u.tero. Both
conditioil~\"roay result in polyhydramnios and
pretenn d,6)ivery.
.. ~ :: f:. :.
Liver and Pancreas
FetaL'h.epatic function is different from the
adult in.,fhat ,.m any.. enzymes of the .fetallivex
are r~du<fea : in amount. The fetal liver has a
very limited capaci~y for converting .free
bilirubin to conjugated bilirubin. The more
irn:mature the fetus, the' more deficient the
cortjugatih~ system~ .
The fetus produces relatively more bilirubin.
because of the shorter life span of fetal
erythrocytes . Only a .s mall fraction of the
bilirubin is conjugated an4 excreted through the
biliary tract into the fetal intest~ne ~n.d
-ultima:tely oxidized t() ~iliverdin. Much of the
bilirubin is probaply .transf~rred from .f etal
circulation to the placenta and to the maternal
liver where it is conjugated and.excreted through
maternal bile.
The fetal pancreas responds to hyperglycemia
by producing increased insulin. Insulin-
. containing
. granules can be i dentified ii-1 the.
hutnan fetal pancreas by 9-10 weeks gestation and
insulin in fetal plasma is detectable at 12 weeks.
Insulin levels are high in serum fr<;>m newborns of
diabetic mothers and in other large for .ge~tat.iortal
age (LGA) infants, but1ow hi in:fant~ who are small
for gestational age.
Scanned 8y:
. 221
Urinary System and Amniotic Fluid
Formation
The Urinary System
In t.he human embryo, two primitive urinary
systems, Llte pronephros and the tnesonephros,
precede the development of the metanephros, the
definitive 1,1rinruy systetn.. By the end of the flrst
t.ritriester, the nephror..s have limited capacity for
glomerular filtration. The' fetal kidneys remain
functionally in1matul'e throughout fetal life. The
abilityJo concentrate and modify the .pH of urine
is llinited even in the mature fetu~. Therefore, fetal
urine is :h ypotonic relative to fetal plasma :because
of low concentrations of electrolytes.
The fetal bladder can be identified by
ultrasound as ~y as 10-12 weeks when .u rine
producti~m is thought to begin. Urine is found in
. .... . .
. the fetal bladder iii varying amounts throu&hout
the day. Urine production has ~n _estitna~d to
be 10 ml/hr at 30 weeks, and aJ5ouY2?:>inlZf..r at
t~nn. with a total production of:6$~)}~j~ay~ 5
Administration of di~retics to tlie' motlier.wm
res~t in increased fetal u$e prod1;1ction. F:etal
glometmar filtration .a rid fetal tubmar reabsorption
of water .was . shoWn. .to .be,. dect;ea.-se ct in.'3m:ne
gr~wtb r~tarded tnfantg an<l in infahts :~i:dfubetlc
mothers. 6 , _,..._
~
Urethral obstlllc~cn i..1 the fetus re.~m~ the m
di.Ja~~on of th~..l?~JiCkr.\l.rete.r.s, and~~ pelv.:e.s,
a phenomenon that is easily seen by
ultrasonogr~phiC examinations as part of the
.. prunebelly ~<;lrome.rr
Kidneys are not essential for survival iii :utero
but are important in the control of the composit::iOn'
and volume of a.mruotic fluid. Abnormalities that
cause chronic fetal . anuria result in
oligohydramnios, which in turn results in
hypoplasia of the (e tallung.
Amniotic Fluid ( V1 C. Tll U"'J)
Amniotic fiuidserves several functions in utero:
1. It proVides .a medium in which the fetus can
readily n;1ove. ~-
2. It cushions the fetus against possibJ.~:injury.
3. It helps ~aintain an even temperatuf.e.
4. It provi,des a mean~ of testing for f~tal well-
being and maturity (amniocentesis) .
r-..
~
 222 SECTION .ll:
5. It enhances visualization .of the fetus during .
ultrasonographic examination.
6. During labor, it acts as a wedge in dilati,ng the
cervix.
F-ormation of the amnion begins at about the
12th day after fertilization a$ described .earlier.
Amniotic fluid, initiaJiy produced py the am;niotic
mem1:kan~. averages 50 m1 in volurneat 12 weeks
gest:ati<m and 400 inl b m.idp.regnancy at whlcli..
tim.e:it;ls mostly offetal ori~ pririlarily.!eW. u.ri:Q.~.
-By j!S:38 w~~s; it r.eaches its ~ 'V~h.tme .at
arouh<:l 1000 ml, after whiCh it gradual!y
dirrrib.ishes in volume (Figure 13.16). Prolon.g.ed
pre,gnanCiesresUlt in markedly red.ucect..ap.d Sbant
airiri:iotic fi'?id.
. .. .~ -~ ~ ...
.
''
.,
i
-
l ,...,r,-~-------.,..""'---------.
Figure 13.16. Range of no"rmal :volumes. ~f amn1otic .fiu~d
plotted against we~:;ks pf gestation. (Fiym Queeimn JJ,
'PJ.orp.psonW, Whi~eld CR, e.t al..Amniotic'flu:id_ volumes fu
nonn~pregnaricies:AinJ Ob~tet'Gyt1ecoll972; 114: 3_4) .
..
More recently, .in an attempt 'tO quf,lltitate
aniD.iotic fluid. volume, sonographic ir)..vesj:iga.tors.
h ave ~Jonnulated the amoniotic fluid index (AFI}
wh.ereby. the uterus is divided into four equai
quad rant s and amniotic fluid is measured
:>vertka1ly in the single d.~epest pocket ill eah
quadrant The four values are added to give the
AFL Figure.
13~17 gives the results of.a lo~ study
ofAFL
1'he composition of amnio.tic fluid, in ~ddipon
to voluine, ch?-nges as pregnancy p_rqgr:e sses.
During the qrst half of pregnancy, it the is
Scanned 8y:
PHYSIOLOGY OF PREGNANCY
a$ the extracelullular fluid of the fetus and devoid
of particulate matter. ~y the 4u, m.O:nth, the fetus ~.
is 03;-pable of modifyi,ng amniotic fluid composition
and volume oy urinating and qy swallowing
progressi-vely large .amounts of fluid. Fetal
breathing movements also 'britlg ahotit further
modification of amniotic fluid composition and
volume.
Febll. :urine is hypotonic rel{ttive to mal:ernai
or tetal pla$ma.. u contains less ~odium.
p<>t;a.ssi'U.m, ~nd cl1iorlde but mo~ urea, ct.eatinin,e.
an.cl uric add.. The net effect is a decrease of
osm~lali~ of a.mni~ti.. tiuia aa
pre~a.ncy :~
progr-es~es, when Jeia:l -urine ~a.ke!S 'an
increaSingly. imp()rta._"lt 'bontfibution to amnloS.c
fluid. . . .
Cbntributions frO"m es:cursions of .a mruoti<:
fluid.:in -and .out offeW l~n~ 'reswt.in -~of
g~ycet<,rpho,s_phclipids ~d. pl:fhnonaty cell~ as
gestation ar;hrances. 'Further contributions of
p~J.cula:.te matter come from.deS@a.rt~.aicil fetal
cells, I.anugo, sc;ilp hili, and -v.emix~
.....
J..l":t
(-/ ,;:;s
.,..
FigU.re 13. i7. A:mniotic fi~id indic~s ;u:n~IJ.g norm.Bl
pn: gnant wom'ert fu Mcu~FD'i1;!F }lospital,.(From Sui:npa.ko
WW and Qlvis J. P.hilJObstet Gyrtecol, 19'9~ )-
Fetal swallowing of ~niotic fluid plays a major
r ole in regulation of amniotic fluid volUme (Figure
13.18). In si~uations where t~~ fetus cannot
'
swallow, a~ in esophageal atre.'sia, .p olyhydra.mnios
(ex;cessive .amniotic flui<l.) results. Conversely,
when uri~ation ca,nriot tak~ place, as in renal
ag~nesis .. or
utethnil. atresia, oiigohydt8.mnios
. {diminished amniotic fluid) ensue.s. This lci.tter.
same condition. invariably r.esults in fet?.i pulmonary.
~
 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT 223

. hypoplasia and sometimes, abnorci..a l fetal limb After birth, with the flrst breath, the w~t~r.-to
development and skeletal deformities due to tissue. interface b converte4 .to an . air-to-tissue
e.boonnal fetal positions. interface in the..alveolus of the newborn. Thls
permits the uncoiling" of surfactant from the
Re'J)lratory System lamellar bodies and this surface tension-lowering
material then spreads to line .the alveolus and
Fetuses hom prematurely m()st commonly die thereby prevents alveolar collapse during
of respiratory distress $yndr-ome (RDS), which is expiratior.. Therefore, it is the capacity for fetal
due .to functioDEll .im.Q1aturioty Qf t.."le fetal lung. Jn lungs to produce surfactant and not the actual
1957, Clements found th:at a surface tension- laying .down of this material in utero which
lowering material was present in mature lungs and chararcterizes lung maturity before. birth~
this was.responsible.for preventing collapse of the
air-contlitining lungs during respiration. .This
m :a teriai. was given .the name surfactant.
Subsequent stud'ies established that a lacic of
surfa~t In preteJ.:nl fetal ~d neonatallu.ngs led
to RDS and that surfactant synthesis nonnally
followed a developmental timetable, increasing
towards tenn.

Fl~rt: 13.19. Type II pneumonocyte. (From .Wiiliams

Obstetrics 1993.)

Composition of Surfactant
Figure 13.18. Schematic illustration of regulation of ,About 90 percent of surfact~~ - is lipid,
amniotic fluid volume and compos ition. (From Williams
Obstet,rics, 1993.)
specifically glycerophospholipiQ, .and 10 percent
is protein (ap<>.proteins). Of the tipi<;l component,
80 percent are phosphatidylcholin~ (lecithin), o f
which 50 percent are dipalmitoyl-
phcsphatidylcholine (DPCC) or disaturated
Surfactant is a complex lipoprotein fanned lecithin: 9-15% are phosphatidylglyceroli 5% are
specifically in the type U pneumonocytes that line phosphatidyleth~nolamine; 4% . a r e phosphati-
the aveoli (Figure 13. 19). The type II cells a re dylinositol; and 4% others (Figure 13.20).
characterized by multivesicular bodies which are
the cellular progenitors of the .lamellar bodies in Phosphatidylglycerol (P.G) is the second most
which surfactant is assembled. The lamellar surface~active glycerophospholipid component of
bodies are secreted from the lung; Le., they are surf~ctant but more i.nlportantly,. it apwrs to
swept into the a,.nmiotic fluid during fetal breathing con(er a certain unique: stabilizing featul'fJo the
movements. Thus the appearance of surfactant in St\rfacta~t .moiety~ ?hfs is a prop ~h of
amniotic fluid signals the start of tile functional . phospl)atjdylglycerol whtch is ovet and abqye that
maturation of fe ta,l :lungs. which can . be attributed to its surface ten-~ion . -

Seanned lly: ~
 224 sESCilbN li: PHYSIOLOGY OF pREGNANCY

lowerin.g proPerties wone. This action is. ?elieved organelles. Phosphatidyl~holine, phosphati-
to be iniportant in the .prevep.tion ofRDS '?ecause dy~glycerol, and phosphatidylinosftol share a
infants born before the appearanee of common initial pathway involving the acylation
ph<)S!)~tidy1glyerolin SlJ.liact:.a,httire at increased of glyce'rol-3-phosphate to phosphatidic acid, the
risk of d.evelopbg R:!)S even. when DPPC content common precursor {Figutes 13;21, 13,22 & 13.23}.
is normal.fot matur lungs. With fetal iung maturation, there is first a surge
in PC and PI synthesis followed J:>y an increase in.
Gluckand associate~. from a ~-es of studies PG tvgether v.'ith a concomitant de<::rease in PI
t.rom I%7 tc t 974, ~owed tllat eviclence of fetal . 1Figure 13:24}-lt is interesting to n:ote that:fetuses
hmg maturation.rowd ~ seen wii4 '9.lJ.. ihcreasing bcm of .d iabetic women d~velop RDS d<!Spite high
roxp.position of l~.{DPPC) in BJ;ilnibtiC Uuid coticent;r ations of' D:PPC in their amniotic fluid.
I, ' relative to sph:ingomye1in. Thia ls the ~JS rati~: This 'is due to th~ common occurrence of
~.: ...
~. :; ~,;Spbing9myelin "{$) is a tu't;U'ker for inositolemia ~d in6's itol int61eran~ in persons
t.~. glycer6phospholipid $ynth~sis py the lU.n~ in with d~abetif:: nieU!tUs. :A t the same time,
genera!, wheteaa ~saturated l~thin {L} is a hyperinsuiln.emia of'the fetus may se:rv.e to inhibit
~pecific index of s:utft(<:;tallt :$Yn.tQ:esi.s in ty~ II the eynt:hesis of the 'iipoprotein of surfactant.
... . La~. in l:976., Ha.il.mari, et q.L
that.identlfi<::atio.p. .o r'PG in m:hliotic
ia al~ :an: ~&e:awr 1-p!'feta't~lungniaturation.

Fi~ 13.21: Bio'syn.th.etia:pathway for-lecithin synthesis

type celL:; (From Willirui!.s O b s tetrics, .i993)

.Figure 13::20, Ccim.pQsition of. mature sut factant. (From

William~ Obstetri.d, '1993)

R~gu.lation of Surfactant Fo_rma.tion

Surfactant biosynthesis i'Sc9nfmed Jo .thetype .

n eells of the lungs. 'fhe'apopr<'ltei,ns.a.re-produced
in tire endoplasmic retic:uluin ; wh~reas the
glycerophospholipids are synthesiz~d through the
cooperative interaction of several cellular
' IP"HOYW.ron.curooy : :
Figure 13.2;i.. Bio'sy~thetic pathway for sy:i:l.thesis of
phosphatidylinositol and phosphatidylgly ce:rol in type rr .
'j
cells.. (From Wil\iams Ob stetrics , 1993)

Scannec18y: ~
 CHAPTtR 13: FETAL
.
MOR~.HOLOGICAL AND. PHYS10LOGICAL
.. . .
DEVtlOPMENT 225

in the end-Ocytosis and recycling of seca;ttd

surlactailt by the type II cells. SP-B ~d SP-C are
smaller molecular weight proteinsand are belli:ved
to be important in opfunizing the surface-active
properties of surfactant.

Hormone Regulation of Surfactant Formation.

1. Cortisol - Based on studies initiated by

Liggins in 1969, cortisol produced in tb,e fetal
adrenal is the natural st.i.mulus for augmented
surfactant synthesis. When a'(!Ini'n istered to
20 .:rs. ~ ss .. mothers i.'l preterm.labor, the incidence of FDS in
~s Of':c tsuno.. their newborns wa;J lower .than tha~ of newborns
of Untreated mother$. It is usually given to
~ l;J.a3.RelatiOn betWeen lhe 1ev-e1s of lecithin, PI, pregnant wom~n at 28 to 32weeks <>f:gC$tation if
. 'and ro inamniotieflu:id -.a a function of~tion age. \From they are expected to deliver prematureiy. It is
W.illiams Obstetric~. 1993) howev.er not t'he only single stimulus for
augmented sUI:factant preductio~ as eVidenced
hythe non~;.tevclopll)ent .of RDS in infants U!Uble
to sa.~te cOrti~l, namely anen.tephaly. aili"enal
hypoplasia, and c ongenital ~enal h:YJ?etpl{isia.
It tt1ay be that
.
cortisol
..
i3 o ne. i>f severiuiionn9n~s
. . . -~ .':..><..
that act coopetattvely to effect .J~ta.l .. ~lJ.p.g
tnaturation. . ~-

.2 . Fiprobiast rf'neumb:ibcyte}acklr...;this fa.ctOr

produced ln stromal. Clls.:of .1\lngs .~ay;..se~e., ~s
an intermediate .ni6dulatQr !or type llj:ell .
maturation. Purified t ype n cells .resj5o'hded poody
to glucocorticosteroids, but in the pre~11~~ of
f ibroblasts or pai1:iaily. purified .FPF, tHe cells
.res~~~--- .,... -~~~~:~. _: . . . .......... .
3. Prolactin - . Mendels~>n .and co-woricer.s in
1981 found fuatoeortisolplus prolactin {Put neithei
rigure 13.24. The propose(! CMP cycle-for .t he regt1laticn hormone alone.) cau~ an :a cceleration in the rate.
of the q:latiVe.mtes .of $)1lthesis o(PC~ PI, and PO~ {From of !>YJ1thesiso f phospbatidylGholi,."'le by human fetal
Williams Ob~tetrics, 1993) lung tissue in.organ cultUre: The~ two hormones
may be the lead boqllones in the 9rchestration of
a multihormonal s.timulatio.n of surfactant.
The apro.protein moiety of surfactant is biosynthesis in fetal lung. .
prodl.!ced in the type II cells a."ld is ofthree type.s :
surfactant protein A, a. and C; SP-A is the major 4. Estrogen- Estrogen .affects phospholipid
apoprotein and .it increases in amniotic fluid as . turnover in nr&:ny tissues, act to .promote prolactin
does the L/S ratio as a function of gestational age release from the anterior pituitary, and may be
~d fetal lung maturity. Its synthesis is increased involved in the. synthesis of _prola;ctin receptors .
by cycli_c AMP, epidermal growth factor , .a nd Many of the tissues that h ave prolactin receptors
triiodothyronine. lt i~ inhibited by .also have estrogen rec~ptors~ It -appears tl!at
glu<;:oc.o rticosteroids and insulin . . SP-A is estroaen .dil."e<;tly or indir~ctly re~ula~..the
important in the structu:rattt:ansforma tion of the numb.er of prolactin receptors. In adgrEion ,
~ecrete4 lame1:far bOdy into tu~ular myelin within ~strogen, an anabolic s.teroid, regulates lipo~ro~iri
th~ .lumen ofthe al\Teohis. It m ay also be involved' synth(!sis :a nd lipid metabolism. ......~..

Seanned lly: C
 22-s "SECTiON 11: PHYSIOLOGY. OF PREG!ilANCY

s. rnyr.oxin:e- A po'ssi:ble role for:throXine in Respiration

siufactant synthesis has be~n .shown in :Sevetal
animalres:earch studies which'demonstra.ted that At the end of the second trimester, there is
adinistration of thyroXine is assoeiat~d with develop!llent of th:e air ducts and alveoli;
accel~rat~ ma turation of tlte fetal1ung. pulmonary vasculature, muscles :of respiration,
and coordination of their activities through the
6. (]rowth Factors.,.. "E pidermal g rowth :fac,:tor central nervous $)'Stem. Ho.wever, it is not enough
"{EGF) acts to proii).ote surfactant secreticn a...<d for fetal s urvival if bom .at this time. Respiratory
specificallY to increase the 'syP.thSis ofSP-A, the mov~eAts a,re s een at the beginning of the 41il
.majvr apeprotein of -s unactant~ .month. Progres-sively larger volll.r:.les of ainlliotic
. .
ilu:id are noimally in~pired ~d expir.t4 by the
; 1. Ftdte.let Acitipcding.:Factor :(PAP) ..... tncr~ .fetus. This ingestion of anmiotic tJ,uid into the
:PAF coucentta:fiot;L "ih fetal ltUlg ~urs lungs mii...y _further promote gro:wt h and
.. ~eonc:O~tantWifu-aecr-eased'gly6Qg~tent. p~ differentiation by way of growih factors in the

i$ found 'in the. a.'ri:w,ioti fluid il). fis$.9clation With amni.o:tic "fluiQ:. Feta.r breathingm6vemen.~. when
the surtactant. obServed .during .t he biqphysiccN -p~,!il~ .f.es~ a,e
considered a positive sigt1 of fetal weil-,bei:ng~~
Sll.IJllll.8.cy
. . ,
Crying .:mutero {va;gitus uteri) is rare b:u.t
hiccuping .i n utero is m ore co.Dl..--r1or...;
. Pre$ently, tt is :reasonab1~ to ~IiCIU.de~ the .
hotm:On.Eil~ulatlon o!
~t-eyn~s in .
ilid>ty~?j~pp:etimc.riocyteS'.f.~f~:.tkv'eJnpm,g ..:!eta.l:" . Ei:ld~rlne System
.. . ..
:Iu~s iaJ:.>~t ~bouti~y;=~;~_p~,;;itit:r.ation"-' Anterior :I'ii.Uitary.
.Q( several hormon~s. Ju~f as -iaetii.t.{on:~s a
p retreatment cf brea-st tiss.l.le w;ith !estt<>gen~ .. . .Recentwor:k:by Mulc;ah~y and ass~-~
..:rouo~ed.; P.:Y c~r-~s.Ql~ . pri>l~~tht.," ;~d ..W,$lin, to .indicate .'that ,the :Je:ta~,~,ent4<cr:4le "~$~ :is
. p;tb.a-ps .il,.~sini:i!f!r.,;~equep:~ -rif-';ev.-~,r,iuNe&a~ t9 :functio~ &en;~fore the ~ntrai-.rvou~~
:attfl~rated~urr~ct.ant,:fo~ti9~Jxi~turinif'eW . acliieves:full:maturity~9 J.1ie fe'W.a:ntemr pituibuy
:lu.ri_g~... .. . , : .. . : . :_, .: ....:.: -~ . . . ::.. . . .. , :.. . dii'ferentiat~s; into,:;S -.~ell,type;s-which~.~te 6-
protein h ormones by tl:J.e end of the l?n week.
Moreover it. :~.Ppe:ats :~at ~g ;W,wt)i. ;and These are: : .. ,.-~
.m S.b,u:ation ru:e not syno:hym:oil.~t.: :P.ethaps th:e (
two -eventlr a:terrot --everr com:pletnen~ i~e~ 1. . Lictotto~s:... secrete prolactiii (PRt}
1v.n-g gr,~wtn ~<t:Y -involV:e pr.ocesse~ j~bibit
:that 2. S om.atotropes - secrete growth hormone (GH)
fun:ctiona1 nrat~rati<in. -,..a
:~ ~e~$ple.., :th~ 3. Ccrt;icotr.q~ - . secr~te cort;icotfopbin (ActH)
a .d .ministnrtion o'f .:gluc:oc-oftie9$ t-eroid tp 4. Thyrot:i-opes - s ecrete thyroid s timulating
,pregnant"w~meh to ~rr-ecr feta.Flung ;t:h-a~iation n onnone {TSH) . .. .
Js ..g~n.e.r.:tll:Y ~ffee.tive op1Y,. ..q..,uj:p;g one ..bri~~ 5. Go nadotr~pes - secx:ete .folJ.icle .s?m.Ulating
wiiidow in ge~a,ti<:ni (ft:o.m.:28 'tv ~2 "wee~)~ trus hormone (FSH) and lu:t~in.izing .hoi:ql.one .(i;H)
~ay indi:ete -that .t}ie -$.e~~u,t}c ..'~ll:!;"fit$ of
stetoid at this ti~e 'ar:e '.derivd;l ''ft.orh. :i?t<>.Ce.sses In ,a ddition, t,h.e .fetal ~pituitary prbdl,lces and
1arge~y ind~epep.d ent of.aecele:r:ate.d 'S~'rlax;tant rele~ses beta.:epdor'Ph ins which decrease with
:for.n.ia~l.on. It rr:.ay be . :due to !Uteratlon~ ln declinjng feW-.pH but inc<easa Willi fetal PCOJ
e:~tra~.ellu1ar matr"ix tb.at f atcilitate l'L].ng Jevels.
-~xpandabilio/.

It is probably approp:da te at. thl$ .ppint to

m .~n.tion the cu rre.n.t use ()f suda,.ctaT).t By 10-12,-weeks g~ station, oxyt9Cin and
r~placen;lent ther~py. in p6s~ibly -pr~ve:n$g c>r arginine vasopressin (AVP)" aresecreted by tlie fetal.
tr~.ating respirato-ry distrdi"'s";. .sy:.l};d-tom:e -:.;in . ..neurohypophysis. :In addition; it sepretes ttrgiP.in'C ..
.preterm newborns. In ~tU:dies of'~i:ep~<?em:ehl .vasotocin.(AVT), which is presentoru::;<duririg fetal
th-erapy~ nat-ural surfact;:l,iit -tha.t,. c9 ntajn life in the' h\lman -and is known to promote sleep
surfactant proteins a:re mor,e effective than and s tiii).ulat'e prolactin r.elease. Oxytocin and AvP
synthetic lipid riiixtures.. act, to .c.onserve wa ter at the level Of .lung and

Scanned By: C
 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT
placenta; rather than the kidney. Fetal stress
(hypoxia) U1creases AVP levels in cord and fetal
blood.
Fetal Intermediate Pitr..J.itary
The human fetqs has a weU~develop.ed
intermediate lobe of the pituitary which :begins to
disappear before term and is a bsent from the adult
pituit:a,ry. "It secretes alphameli:mocyte stimulating
hormone (a-MSH} and beta-en.dorpbins.
Thyroid
Total thyroid hormone levels increase
considerably a!ter midpre~'lcy. The fetal thyroid.
.hormon~s have a ver;y limited action during fetal
life though. Only brain and lung tissue .may be
res1>9nsi.Ve to :th~se honnones. The fetal thyroid
c"Oncen~tes k -."Ude more a;vidly than does lh~
matemaLthyroid. Therefore it -is dangerous to
administer radioactive iodine .or Iger amounts
of ordinary :iodides (a.s that .f dund in cough
preparations) to the ~other.
linni~~.tely ~ter birth, n;a.a.jor .c h.anges occ:w-
in thyraid:function and metabolism. A sudden Or
marked iii~se in thyrotrc>;pm secretion cccUr$.
which resUltsin a progressiY.e increase in ~erum
thytoxine d triiodothyro$ levels, reaehll\g its
pesk at 24 to 36 hours after birth.
A(lr.erud.Glands
Tbe "fetal adrenals are very much larger in
relation to itstotal body size, compared to..the adult
ad.r enals. This is due to presence of the fetal zone
iil the adrenal cortf!lt of the .fetus, which involutes
rapidly after birth. The functi()ns of fetal .a drenals
are discussed in detail in th~ section on the
endocrinology of pregnancy,
. The fetal a drenals synthesize aldosterone in
addition. However, the renal tubules are relatively
insensitive to this hormone in the fetus and the
newborn.
Seanned 8y:
._ I ~
. .. !.~..
Gonads
The fetal testis synthesizes testosterone from
progesterone and pregnenolone by 10 weeks
gestation~ At this time that the fetal pituitary is
still not functioning, hCG acts as an LH-surrogate,
stimula:ting the Leydig cells to synthesize
tes;tosterone and promote male sexu-al
differentiation.
Fetal Leydig cells, in contrast to th~t cf adults,
are not desensitized inspite of repeated exposure
to hCG i..& utero. This may be d'Ue to 1) abfience.of
estrogen receptors in the fetal testis, and
2) proll;lctin stimulation {)f hCGfLH receptors. in
fetal testis. During this time of intrauterine life,
hCG stimulates the de\Telopment of Leydig cells
in fetal testis, stit:nulate testo~teron:: fomi.a.tion,
and increl;lse receptors for LH/hCG. The:re is
absent .down-regulation Of. the.s e receptors and
. continuecl fetal testicular testost~l70Qe." secre,t ion
inspite of high hCG product,ior.. .. . ~ :.~ ~ .,
Fetal ovaries prodqce estrog~~~ bu"t":this
hormone is not needed .for femt!.le phenotypic
:development in t_l}e fetus. . .,... . : . . __.;
Genetic sex is established atY.l he time of
fertilization, and s exual development of the male
and fe.m ale embryo i~ identi~ up to 8 weeks. At
tlris'time, in :t ttel)'rMtrrc:cn:;r tlie:Y Cliroiiiosome,
gcm-c:raa.l devel:c>"pmeffi "proea~as aioiig-lf!sHcu:rax-
lines, whereas, in the absence .of the Y
- chromo.so~e. the prim6rdial gbnad develops into
an ovary.
Phenotypic male and female sexual
development .-a1so is the sameuntil.8 weeks, after
which, .the presence of testosterone and mulleria.IJ.
inhibiting factor from .the fetal tes tes d etermines
deveiopment .ofinternal and external genitalia into
that of a maie. Absence of these hormones will
cause development into f emale internal a nd
external genitalia. (Figure 13.25-.)
~
228 SECTION II: PHYSIOLOGY OF "P.RtGNANCY

GENETIC SEX XX XY
."" (i)/
PftrilofloiAI. GONAD

G()tV.OA~
, QRGANIZATION Su~eai.:~ ~~
- :.~
HY Ani~A -9ne . . - o f
:i.'f Ant~~ o -
. . .

GOHAOAL SEX
om
OVARY ~
~.

Sd'TDUC~Ui

l
li!UIIefi&tt !:Net
~~ol _le~t~
PHENOTYPlC SEX

i.I:NI-~
. ......... . ~-i~

l
.Jri~t'a.2S. 5e<rual.diiiet:e~tiation: genetic, gonadal an4 phenotypie. {From Willliuna Ohste~ 1993,:)

POINTS TO REMEMBER

ihe.embryonic peri0d stc\rts at .the beginning of the 2r-.a week after ovulation up to10 gestation
weeks.
The previable fetal period Is -from 11 to t9 gestation weeks.
. .
.The viable .felPIperiod -is "Jr,om ~20 .to 40 :gestation weeks._
Gestation age .in weeks .is ~;ilso known as menstrual age and age of gestation anq is ~lculated
from firsfdayof -lMP. ltis used when describihg the fetal period and in clinical practice.
Ovulation.age in w.e_ eks is.c_i31culated from the day ci.f ovt.!lation (al~o known a$ conception) and
romes 4 weeks after .
LMP .
.and its.used .vhendescribing the embryonic
9
penQd.
The tncee trimester.s of.pregnancy ( 111, 4nc1 and 3'~~) each last for 3 cal_
endar months.
The embryonic period has 23 stages of development bas.ed on specific external features of
somite development and crown to rump 1ength (CRL).
Potential malformation can he .associated.with the ovulationage when:the-inst~lt (teratogens1
infections, etc.) occurs.
is -called :a newborn. lt.is preterm until -37 weeks, full t~rm from 37-.42
After 20 weeks, the fetus _
weeks and postterm beyond 42 weeks.

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~
 CHAPTER 13: FETAL MORPHOLOGICAL AND PHYSIOLOGICAL DEVELOPMENT ' 229

For calculating age, fetal crown-rump lengths (the sitting height) are considered more accurate
than crown-heel measurements (the standing height).
Fetal weight is affected by several factors. A fetus in the 3~ trimester gains about 30 grams
~~ . .

Fetal weight of 2500 grams or less is considered "small for.gestation age and 4000 grams or
.
more targe for:gestation age: Filipino values have still not bee,n established.
The fetal head is the most important part of the body during labor. Its landmarks and
diameters determine the course and management of labor.
Fetal circulation is basically different from tllat of the adult. Change occurs at varying times
after birth to effect a chat'lge in.to the adult type .
. Fetal.nervous, digestive; -urinary, and respiratory systems continue to develop, with milestones
marked at various -points until term.
Amniotic fluid is mosUy from :fetal urine after the first trimester and serves several functions in
utero.
Fetal surfactant production is !mportant to ensure lung maturity and functior.-....~t birt._..
The fetal endocrine s_yst~m is functional even before the CNS achieves full maturity.
GenetiC $ex is estaoiished during fertilization whereas phenotypic sexual development is
!nfluenced by intemal and external factors.

R!<FERENCES . .? : G.-annum P. The ge~tourinary tract. Nyberg, Mahon ey

l. Day S , Acctira.cyof gestationruage estimation by means
Of fetal crown-rump length measurement. Am J Obstet
Gyne~l !99_ 3 ; 168: 9.0 3.
2. Hendricks.CH. Patterns of fetal and placental growth:
the.second hair of normal pregnancy. Obstet Gynecol
196.5;24:357.
3. .Al~h\llerG. Immunologic competence of the immature
human fetus. Obstet Gynecol 1974; 43: 8 11.
& Pretori\!~ (eds): In Diagnostic Ultnisou:nd of Fetal
.Anomalies, .l 99-0, St. Louis; Mosbyyear-Book
3. Vintzileos A, Campbell S , ~ngardia L. The fetal
biophysical profile .a nd its predictive value. Obstet
Gynecol 1983; 62: 271.
9. Malcahey JJ, DiBlasio AM, Martin MC, J3lumen tritt Z,
Jaffe RB. Hormone production and peptide regulation
of the human pituitary gland. Endocrine Rev ! 987; 8:
406.

4. StabJ!e I, Nicolaides K H, Bach A, Teidner B, Rodeck C, SOGG I!: S~D READIII GS

Estergaard.JG, Grudzinsl--. as-JG. Complement factors
in fetal and maternal blood and amniotic fluid durir.g
the second trimester of'normal pregnancy. Br J Obstet
Gynecoll988; 95: 281.
5. Wladimiroff JW, Campbell S. Fetal urine-produ ction
rates in normal and compli~ted pregnancy. Lancet
1974; 1: 151. .
6. KurjakA; Kirkir~en P, Laten V, lvankovic D. Ultrasonic
a,ssessment of fetal kidney function in normal and
complicated pregnancies. Am J Obstet 0ynecoll981;
141: 266.
1. Cunningham FG, MacDonald P, Gant N, Levero KJ, and
Gils trap LC. (eds}: William's Obstetrics, 19u..edition,
1993. London: Pre n~ice Hall In ternational Limited.
2. Danforth and Scott J (eds): Obstetrics and Gynecology
5'h edition, 1986 , Philadelphia: J .B. Lippincott
Company.
3. Dolman CL. Characteristic configuration offe~ brains
from 22lo 44 weeks gesta tion at 2-weel} interval. Arch
Pathol Lab Med 1977; 10 1: 193.

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23{) SECTION ~1: PJf(SlOLOGY OF PREGNANCY

4. Kalousek, Lau and Baldwin.. t>evelopmc;:nt of the embtyo 6. 'Romero, Pilu, ~ Jeanty (eds): Prenatal Diagnosis of .
fetus and placenta. In .Dim.minck & Kalousek (eds}: Congenital Anomalies 1988; Norwalk, Connecticutt:
Developmental Pathol~gy :of the Embryo and Fetus, Appetcin & Lange.
1993; Philadelphia: J.B. Li,p'pincott Co.

5. Moore KL. The Developing HUman: clinically Oriented

Embry~logy, 2...1 ed. {1977) and 4u. ed {1988).
Philadelphia: WB :~aunders.

., .....

.......

: ..

: ..
. .

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 14

lVIATERNAL ADAPTATIONS
TO PREGNANCY
MA. CRISTINA PELAEZ-CRISOLOGO, MD

ReproductiVe Tract

Cardiovascular

Respiratory

Renal

Gastrointestinal

End_
ocrino!ogic

Metabolic

Hematotogic

Musculoskeletal

Integumentary

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 - ..,,. _ _

------------:'":'~-::--:---:-:-~-:---::-"':""":"-~--:-------------- :
'-'"-'.
.23:2 SI:CTION II: PHYSIOLOGY Of PREGNANCY .~

JNT~ODUCTION 3. An internal layer, c onsisting of sphincter-like ~.

fibe~ eJ."'Und the orifices of the fallopian tubes [;f:
.An appreciatibn of the mate.rnal physiologic and the internal ps of the cervix. "~1-
.a daptations that occur during pregnancy is
:;fUJ;ldiunental to the understanding and proper These layers are so arranged to act as a ligature
.clinical management of normal pregnancy, and 'its to the penetrnting blood vessels afte1 delivery.
potential complications. Adaptation to pregnancy
-~ .h:um;ans involves major anatomic, physiologic During the first few weeks of pregnancy, the
. arid m~tabQlic cllanges in L'le mother in order to uterus retnairts as .a pelvi.: organ. Subsequently,
.support and provide for the nutritional and the increase in length entails upward _ groWth out'
..metab9Uc - Jl~eds . o( the- gt'O\Ving coACepfus. 1'h~ of the ~lvis... Aa it continue~ t o enlarge, ~ t
pregilant woman tinderg~ :Pt.Pto-und anatOmi~ .d.isplaces the mtestfues. and' ev~tuallyuliderg6es
. and. physiologic iharige$ in .almo$t every ,organ . dextrorotati.~~ ,! ikdy cauSed by the preSeJ,lte o(
_~#emL.These ad~Wta~ns to th,e pretnanf.tttate the ~to~~cid colon ()n the leJt pelvic ~ea. .
'~'ju,sf after conception and evolve L'lrough . .
. ddiveiY) after-w}'IJch theyaltnost completely r.ev~rt Flow to the uterus inct~ase$ i{PJn about' 50 to-
'ba~:~to the non-pregnant state ov-er a period of 100 mL/mili in the midluteal_-phase. of the .
~~~ menstrual -c ycle to more th.ah 1 L/min 4 the third
trimester. At tertn, uterine blood flow. of whi,ch
-~PRODUCTIVE 1'~-~ - more than 80 petcent is <l~c;ted to pladmtai. the
l-.~
implantation .site, a~ounts for about 15 to 2.ci
percent of tne cardia~ output.. Increased now .
begins.shortly,a.fteT--,i:niplantati<m)~before-fot:mation--- ...
The ute.rine mu$Culature lx:comes thinned out of t..~eplacenta, is complete, a,nd rise.s progres$i'!:ely.
t:Q ~~JIUX!.odate: tbe e.nlat:gipg fews; placenta.a..nd in parallel with expan~lon of -the uterine mass.
-lit.nnio,Uc fi:uid. The total volume .p f the uterine
: ~ts at .term is abo"Ut S Jite.rs; - The- ut~ri..'le ..
;~ty- ~ttenn n.ls.yreaclj appromnateiy.soo:to .
l :QPl:flinles :us n on-pregnant'state;;"such;;tha:t!_; ':at'.- . The- cerv.ix-undergoe3.- sohening .and--cy.ano$1~.-: .._
-~;. '-thi$ organ may weigh a-s much as 1100 resulting from increased vascularity ~d .edem.a,-..
. ;~~--- The -me:jor .-p hy.siolPgic ~~~&e~ -~ the al~:mg with hypertrophy and hyperplasia oC~e . ._.
. :..,-u~s.during. pr-egnancy_involves. str_etcbiP.g -~~ ceniici\1 g!ahas. The endoeemoo --cellspi'9duceca:
;~ed hypertrophy of tQ.e myometrial cells. -On niuc()td-plug,' rich iii fftlmunogl'Ob-utirrs -:-~d '
~c pther hand, -there is limited increase in t..l-ie cytokines, which acts as a barrier with41 th .
-"' -~Umber of the .myocytes. In addition, thete is an cervical canal soon after concep~on. The.cerocal
~Ulat,ionoffibr.oustissue~. particUlarly in the muc1.1s of pregnant women typiCally shows. a
~trMJ -musele layer,.as well as an increase in crystallization or ":Qeadin.~ pa.t tem,. attributable.
. .. :the ~stic tissues. These cha.pges are thought to to progestetcne.
p~ result fro~ the effects of estrogen, and
'to.a certain ext:ent, :progeste:rone, ~specially in the Placenta
fri'st 12 weeks -o f pregnancy, after which time,
mechanical distention is the main instigating The placenta is a com~lex organ that selVes
-.-factor. to anchor the developingfetus to the uterine walk
to provide for the exchanee of nutrients;
The . muscle layers of the uteru s during respiratory gases and fetal wastes, and to direct
. pregnancy are arranged as follows: matern.al homeostatic adjustments to mee_t
changing fetal needs by secretipg hormones ~d .
1. An . outer .hoodlike layer which arches over other substances into the tnatemal circulation. It
... .t he fundus and extends into the various is a disc-shaped organ that measures -;.bOut 2-i
ligatnents. em in diameter and has an average thiclmess ~f .
about 2.5 em at the end .of pregnancy. The s~a~ ..
2~ A middle layer. composed of a dense network facing the developing fetus .is called the chorionic
ofrnuscle fibers per-forated ill all directions by plate. It is penetrated near its center by.the .
. . blood vess.
e ls. umbilical ar-tery and v ein s, which branch .

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 CHAPTER 14:'MATERNAL AOAPTATJONS lO PREGNANCY
:repeatedly . to perfuse the functional units, the
tteelike placental villi. with fetal blood. The villi
are rooted in the chorionic plate and extend toward .
the basal plate, which i~ comprised of maternal
decidlJ,al cells and e:r..tra,vi!lous
syncytiotrophobt'ast. The mature placenta
contains 60 to 7.0 vill.Qus trees, each of which,
through repeated branching of the.secondary and
teqia.fy villi, gives rise to more than 100;000
intennediate ahd tenrunal villi; The villi, whose
~nibined length is estimated to .be 90 km, co~tQ.in
increasil}gly ijn.er branches of arterioles ~nd
venlJles tba.t termin~te as clusters of :grape-like
outgroWths comprised largely of $inusoidaldllated
capillari~. The entire villous t:re~ is ensheathed
in a .continUO'!-lS layer of SyncytiottopboblMt,
which overlay'$ a discontinuous layer of the
~
cytotrQphob}a:stic ~ells. Tl:le chorionic p late is
~ fusecf,at its edg~ witll the . ~ pla~e 'tb form a
ho!lQ;w aav.ity.: ,the intertil.Ious space~ which js
i
.::.. perl\l$ed-With ma.terrialblood thatentet'S through
f mullipJe ..sp!..":al .arteries that brancll .o if the radial
!~ arteries~ the trtyometriuill and ~vits by ~y of
~
! the ~place)l'tal vein~.
j
. ;:.
' Maten:Utl. and fetm blOod :do not .miX. or CQ!lle
1t in~;cOP.~t..ExeM!.l~ .ofnutrin_ts,~d gases
.. ir
-:
._ ~ p~ prlrtcipauy
. a~dit~us'ion
in,_the termin~ villi e,cro$s
b~r.riei' :CQni;prised of a layer of
1
syn~tr(}pbobJast. basal J~mina, andendothelial
l ~ B,y~te p~cy.the <llff'~swn barrier th.iris
f ~ .~~J.~_!'PE.J :tmd.Jl.~~. :~ :.~Utfac. ~t~L .o f aoo.Ut
. 12.Jil~ .~ounts..o!.pmgeste,~ne,.~trogens~
.
hutilan thprionic gonadotropin fhCG), human
pi~eentai lactogen (h'PL}., and other secret<>r:y
';:
products ~ rele~ by the sy]lcytiotrophoblast
directly into the 'i.nte'rYillous $pace and hence the
mat.erruil circulation. These placental hortnortes
are latgely responsible for orchestrating
adj'Qsbilents in ll}~t.emal physiology as p~gn~cy
progres.s es.
~reast
The nia.nmlar'y gland~ .b ecome enlarged soon:
after the first missed menstrual period. This
e nlargement results p artly from hypertrophy and
hyperplasia of t~e glands in preparati0n for
la~tatiOn and also from an increase in the bulk of
fattY tissue. At ..the. end of the secon<t .m onth .of
gestation, the nipples become enlarged an:ci
erectile; super.f'ic.ial veins -beC9~e prominent; and
the ar~ota wide:n s and becomes more deeply
pigmented. The sebaceous glands of Montgomet}r
Scanned 8y:
233
become enlarged and more prominent. 1be first
evidence of secretory activit-y appears at the end
of the first .trime.s ter when colostrum ,m ay be
expressed from th:e nipples. Several weela later,
the d~kened areola spreads out, fonningamottled
secondary areola.
CAROIOVASCULAR
Normal pr~gnan,cy is associated with marked
hemodynamic alterations wi.thhl the maternal
circulation, mcl:uding increase$ in cardiac output
and. plasma volume and x:.t:Puctions in vascular
resistanee and .a rterial 'J5ressure. Assoclakd with
the$e ,chap.ges are :markeli alterations in .t he
activity of various neurohumoral systems and in
va'sclllar ~d -endothellcl function. Stiml,'i1ation of
volum.e-sensitiv.e .cardiac mechanor~poo may
e4cit ~ attenua.t~ refleX effect -on bloodpessu.re.
and r ena} tu:~~tion, as well a~ a reduction in
baroreceptor afferent and cardiac .affe.r ent
dise~ge during pregnancy, all of which:lile1Ve ,to
allow for plasma vohtme ~ansion. ,J~ .' .
. Adequa~ pefills.icm -of the . pla~_en~.:~~ ~1,111
iridispei:lsable.,:cpndition.for .normal gro.-.hr;And-
. develop1nent of the fetus. Any.r. su~j~d
redud,ion in placental perfusion resuif.s;fu. a
ccndltiOn -c alled intrauterine :growtll r~ction:.
(iUGRJ~.and.. mf;ly ~causi' preinature--dellweey -or .
. d,e livety -of ...gn:-undersized~ babyc"'8.1- t.ert:'tr.
Adjustments in the maternal cardiovalcular
system enable this cr:itieal need to be m ehritho'Qt
COt;Ilpronusit).,g itS cap11city. to respond .t o the
changing demands. arid challenges of theJDb.ther's
day-to-day life in an often taXipg enVirooment.
To ac~o;illmodate the required . high ntes <>f
placental petfus ion, .ma:terr.al cardia~ t>utput .
increases JD.arkedly during pregnancy. A striking
increas~ in ~diitc output is seen within the first
6 weeks of pregnancy. Cardiac output in a typical
55-kg woman increasc;s from about 4.!S L/min
before fertilization to more than 7 Lf-niin after
the first trimester and remains eleva:kd until
delivery. This initially results from 'a n increased
heart rate, soon followed by an increased stroke
volume. The increase in cardiac output is .
accompanied by a modest decrease in m~ blood
pressure resulting primarily from a d~ine in
diastolic, pressure. This deereas.e i;~, blood
pressure is .seen despite a 50 percent ~mcrease
in blood volume and persists untn al><)ut the
~
2'34 SECTION II: PHYSIOLOGY OF PREGNANCY

middle of the second trim~ster when blood
pressure gradually rises to about or perhaps
slightly above the prepregnant level. At term, the
blood pressure normally returns to baseline
lev~ls. The increase in cardiac output and the
decrease in arterial 'blood pressure result from a
pronounced decrea-se in total peripheral
resistance.
progesterone. The- increa~e in prelQ~d, which
develops in .concert with the-increment in' blood
vo!urile,:leads ti> an increase in left atrial diameter,
which also begins -during early pregnancy.
Increased aortic distensibility coupled with
decreased peripheral resistance r~Uces afterlocld.
During labor, both cardiac o~~put and blood
pressure i.."'lctease. After .delivery').. cardiac QUfJ>ut
j, -

initially increases~ but begins :to. ~ within

v ascular Reslstaru::e the ijrst hour to reach baseUne -levels 2 w.eelcs
postpartum. J~ost -car.<;lio~sc$r pa,.'llt!lCterS 'show
Periphet"al vascular resistance is reduce~ their grea~est changes \'4thin -~ weeks postp.rtum.
througho.\lt pregnat)cy . .The .~ecrease in tol;~l Five months postnatally~ only _a -mild residual
~ripheial reststancl! 1s far ~ter than can be ventricular hYpertrophy persists.
D.Co~n-ted for by the JQW resistance of. the
utei:Oplacental irculation. There i~ a lVidespread RESPIRATORY
c;l~~ in tpp.e of ~~riQle~ ap.d .l~er arteri~s
of the l'lle~~~ri.c, Jin1b,-euttmeo us,'lm-d ~speel:ally Res:tin~ pulmon-ary -venb1atj_on is h.l~
the renal .citel,ll~n$. It ls im.p ortant to note, throughout pregnancy. In -the ineiU>tnlal .Cycle,
howev'er; ~at--despjte the overall deorea:~e in minuteventili;ltionis.~ter _inthelu~~-P"~tban
vase\,i-Iar ton:e'l~'lo:cal and _ sys:t~l:p.i~ va:sculat" the:.follicular .- ph~ ~ , ~ ~dily - Nter
regull;ltory-"'responses.r~tnron:oper:ti:ve;;<;}ieflex concepti.<m--un_til de~" . ay ~' end -of -~
a.djus~ept~'; t~'c.han_ge-sJ:p.:p--ostU'i'~,;and'-tG''the - l'ilvoolar:ventiiatidn is abc:>ut 40!percent~1J]an-
r~q'uirements ~- of P,xercis.e " are only:,miltUy the_prepregnantrate. This'citS;nge ciS'~about .
cori).promised. The ~asis for ~h.e-~~cree::Se . ill . by a 20 _perc-ent increase ~ tidal voluti)e-W'it.bo\it a
va;SCU!ar resist.imee is a -t(:ipic' of-aeti\!e research. .chan_ge- ;il) ::frequet"__ey .:of~spi:tll.tiqn.'~ -PlPid .
Cl~ly}.-the~.4wel6.pin~embey():,~must'tsnd~;o.~t: . growth -'~fld. int-en-s-e nt~~bo:Uc ;Q.ctlVity -:~f.-the
sdm'tWsignalsr..to:,btirlg:<a.:bbut ''th~_s-e chan-g~s~in -- p_tacl!rtta,~.'uttte: b1.cr~~~e in-...:1ll~:temai - o.~gen
v.e:~iilar'tone-; !Jnfu'sien:::oft -estrogensvin ~- non" , --, con$U!Ilption is ~d~t' be(O'f:e--~e.-:e;nd 'O.f'1be ;iirs.t
pte~t b,'"man fU\d flnim:ai subjebl,s ae~telY tritne$~r. ~~tb.~~P~taJ~i$$),Qilt
-de~as-es -v~cular te.sistance -a-nd ~roduoes Ther'eafte(' O:._~con~rt~-~-.--~
ciiintei~thiit_mi~;~UiQuihl~siprP.M:Ufu.:_ti. .uiC.fti~~~~aui--iii~~ii iilit1n<itiiii)ir:iii
to th~ee seeo 'in .n ormal .pre_gt nincy. Hu-m:a,;n mass to -reach 'alevcl tba,t'i$ il\:;out.~() J)d'tent~e
vascular endothelial c~Us expre$8 estrogen. the non.p regnant level, but hy_-p ervt,ntllation
r~pt6ts and, 'i n 't'e.sj>onse to -e:stra(;iial, -r apidly continues -until tl:re baby i~ddiv~ ~ 1he rate
me-tease their :production: of vasodilatin~ agepts t:>f alve<>Uii' ventilation ~s the m.tabolio_tate,
such -as nitiic oXi(J_e :and POI~ . Other ~tudies alveolar PC02 declines by ltbO~t 25 .percent and
sugge$t -a Sii:niUU' role -ft>r progest~rone, ~one ()r relnains at about .~o fum Hg f9r the ~ or
m~e.pre~nce .ofhi$h levels of estrGg~n$ . .Studies gestatio11, ~d .P 02 in~se$ by abo\lt ~ percent
innxt~ts :ha;ve- b:nplitated th.e pqssible role of the Consequently, arterial P02 d~ -from abut40
oV:arjart hormone_, relaxin, to aceounUor the many mm Hg tO' about 32 mm I:Ig.
changes in the r~na1 and mesenteric blood flow
seen in early pregnancy. However, <there -are n 0 The plasma bicatbona:t-e concentration !alb
cotnparable dat.afor human subjects. fro m about 27 to about 21 m~L, while pla,sttla
pH. increases :from .7 .40 t(> a bout 7 AS.. Arterial Po2
MyOcardial contractility .seems tq b e increased increases slightly fr9m about 103 .to 107 mm Hg;
during ~:ll trimesters of-pregnancy, thusgradl.lally As pregnancy progresses, growth Of -Ule uterine
pr.ovoking .t he development ofa mild ventricular mass .might be expected to in tenere with the range
'h ypertrophy. Compliance of the heart and aorta of motion of the. diaphragm and to interfere with
inct~ases because of changes .-i n physical expansion of the-lungs and pr_eatn-ingmovements;
properties o( the extracellular matrix, a however, thoracic volume is mainwned ataltiiost
p-henomenon . c:a~led . remod-e lling. S-u ch th<; preptegnannevell:>y a .c nange m ~hape -c?f-.the .. .
rem<>delUng is thought to occur in res ponse to the chest. Even before the uterine: volume has fullj
-h igh circl,J.lating . leveln of estrogen s and expanded, the angle of the ribs 'qegins -to.widen,

Scanned fly: C
________c_H_AP_T_E_R_1_4:_M~A....,.JE_R_N_A_L_Ao_
: A_P_t_AT-'-IO_N_S_T_o_
;- ,-
possibly because of relaxation of the costal
ligaments, so that the diameter of the chest
increases by 5 to 7 em. In fact, total p~onazy
volume is decreased only by about 5 percent, and
the vital capacity is unchanged, The sttlall
decrease in total lung volume is ~ccounted for by
a decrease in the functional residual volume that
results from the upward pressure ex~rted by the .
abdominaLcontents. Thi~ change in functienal
residual vohlme increa.s es the efficiency of alveolar
ve.ntilati<m because inspired air is diluted. with a .
smaller volume of residual air in the alveoli. ,I n
line with their effects on the va.scu.la.r smooth
muscle, .\ he hotTaoneil' o'f pregnancy -also relax the
airway smooth. muscle, .w hich :incr.ea,ses the
functional dead space but significantly decreases
airway resis:tance.. The hyperventilation of
pregoaney .i s attributable to the high circulati.P.g
concentrations of p~gesterone.
Velitilatozy 'dri'<le is also increased Within .a few hemoglobin.loadmg -of.maternal. a+td fetal.blood . .
hourS a'ft.et:progesterone is given to .nop..,;pregnant
subjects :of~either sex. Progesterone increase.s
ventil.S.tory. ative _by increasing the sensitivity of
.both ceJltra! and peripheral chem()receptQrs to
CO;~ :Alt})Q~gh pregnant women are hyper-. i ntervill<>us: :space;-. u;mbilical ve~ous .bloOd has
. re$}>0mW~;tQ'-increases in-inhal'!d CQ2 , pregnancy
doethlfui?.~uce .. their ability tp adjust alveQlat
~titatfon-iuj>'Weid or qown~d in response . to
change~ in artetial or inspired PC02 , ind.icatfug
that normal feedback regulatory mecbanisms
-r~m.mn. :~~.a.1iv_e,. Due . .to the. heightened
_sen.sithiity_..cf..the.~cbemoreceptcr.s, . ECOz-at..Ievels- -venous-"blood--~be-accounted-:forin--pattb}rtlte
tbaJ prevail in the n:on-ptegnant woman relatively high rate of _02 extraction and co~
$t}mula.tes ventilation until enough C0 2 is
efunlnated to establish a new st~ady state -at a
lower set"'VOint. Progesterone also increases the
sensitivity of .the chemoreceptors for P02, .b ut this . that de-spite the low PQ~ and the . metabolic
chi;Ulge is o!lly evident in intense exercise or in
hypoxic conditions such as high altitude.
Resetting th~ steady-state level Of :PC0 2 in
.matemal blood ben.efits the developing fetus by
facilitati.1g tha transfer qfC0 2 from tjle fetal to
the maternal circu~ation. PCQ2 equilibrates rapidly
across the placental barrier bydiffusion of C02 in
theJorm of the uncharged, dissolved gas. Its rate
o.f diffu.s ion depends the steepnes~ of the
conc~ntration gradient between fetal olood in Ule
umbilical artery and rnat.ernal blood in the
interv-illous space. By lowering the PC02 ._.in
maternal blobd, a steep cpncen.t ration gradient is
cr~ted whiie allowing fetal PCQ2 M.ci blood.- pH to
be maintained at a level that is favorable forrapid
cellular growth. and dev~lopment.
Scanned 8y:
_ ____.:__ _ _ _ _ ~;, 235
. _PR_E:_G_N_A_N_cv
'The small increase in P0 2 is of;little
consequence for oxygen delivery to the fetus,
because maternal hem~globin is already virtually
saturated at the PO~ that prevails in liOn-
pregnant women. However, tbe rapid rate of C02
transfer across the placental banier and the
resulting transfer of hydrogen ion increase the
rate o.f o~ygen delivery to the fetus through .
oper~:tion of the Haldane ~d Bohr effects~ 1'he
decrease in PC02 in -fetal capillary blood a$ it
traverses the terminal villi inc reases the affinity
of hemO.globin for .o xygen, and hence its degree
ofsatux:ation at the low paitial pressure of I)X]gen
of intez-villous blood. At the .same; til)le; the
incr~ase - in PC0 2 in the Intervillo~s space
facilitate~ the unloading pf oxygen from 11)alernal
hemo,globin. Simul~eously, the d.iffusionmC02
. across the placental bartier raises the :pH of
placental capillary blood and Iowe.rs. :i.hat of
intervillous blood to provide a similar efred: on
Gas ~chan,ge acros~ the placent{l.,:i~.::~~~us
to~ exchaJ}ge in the lungs;, the..~s\lP.ply
to the.p1ac~nta is low in .Q 2 and hiM~f:;~~r
eq;tilibration w.itb materual blood' !n,,fhe
taken :pn:.0 '1 al;ld deliver~ C()~. Al~q.~@:~J;'.Q~;.~d ,
co, .-equilibrate .quickly - across~~tli~ P.4i.tal
barrier, .partial pressure~ .o f the.s~~;.~V;le
umbilical vems diffe:t radically frcm values3n:fue
ute-r ine artery ..and even the uterin-e veirts.
.n irfe.tences. be-tweeilUterine... and~- nn,;bWcal
production by the.syncytiotrophobl!lstand~the
relatively large areas of the placenta. that are
unavailable for exchange. It is i~portant to note
activity of the syncytiotrop}1oblast, the o~gen
content of Umbilical venqus blood -is quite similar
to that o f maternal arterial blood. This is possible
because of the higher content of hemoglobin in
fetal than maternal blood and t}:le g:-ater.affi.nity
of fetal hem oglobin for oxygen. It' is also
noteworthy that PC02 , bicarbonate, and pH in
umbilical venous blood are all in the same range
as found in arterial blood of- non-pregnant
subjects.
~NAL ......
~.
:~
. Both ren. a l plasma flo'?' and g_loqterula,r
filtra tion ra te increase to 40-80 percen~~above
n ormal in huma ns. Mechanisms under(y1ng the
~
 . ' f
236 SECTlON II: PHYSiOLOGY OF PREGNANCY

marked renal vasodilation duririg pregnancy have Ureters

been a subject of intensive irivestigation. Althou-gh
numerou3 factors may be inv.olved in this renal As the uterus .'enlarges and r ises out -of the
hypercm~. recent studies have implicated nitric ffi'atemal pelvis, it rests upou the ureters, and
oiid::: as an important mediator of the renal dispiaces them laterally, giving rise to the .
hyperfutration -during pregnancy. Pregna..11cy is dilatation of both the renal pelves and the ureters.
.l ilssodated v.-ith enhanced renal eApr~ssiori and the so-called "hydroureter of pre~ancy. This
acHvation oCNC synthase. Nonselective and dilatation -is also .accompanied by hypotonicity and
selective i.nl:"Jbition of NO sy.cthase isoloims also hypomotility of.it:B musculature. The ureters also
attenuate the-renal herriOdynamic change~ durirfg- tend to elongate - and become more tortucus~
pregnancy. Recent studies have s}lggested 'that predisposing them to partial opstr.uctibn.
.t he hormone rclaxiJ?. -~ ru'so
an important factpt
that medfates,.th.e enharu::ed Tenal hype~!D.iaand 1Jrlnar-1 Bladder.
production of-NO durin,g p~cy. In -addition,
it appearS t..~at r:elaXiti .e nhances NO 'production There is elevation and thickenin:g. of the
py an:~ridothe!inB re~ptor-meGis.tedmechanism. bladdertrigone andi:hickeriing.of theintenireteric
The in t:racti.on b~tw:e~n t elfudn -and tlie renal margin~ .At term~ the \lrinary bladder is pushed
.endoj:helinsystem retiiains.to pe ~.xrimporb:l.llt area antei:-io'rly and superiody, with r.e_sult<mt ed~m~
-o{inve~fi.gation. and hyperemia. a:s well a.s marked
. ' .: hypervascularity.
~1\ffedfit:Wid'~fferent- glom~J;Ula.r artenole;s :-are
th;"fua.fpr'"~tes ~t::i:.esi:s~ce.~to"-bl9oo::ho.\V:m tlie_ Seniril;-Electroly;t~f!- .
.kidll~.Y s; ..nicreas'ed!rresistatrte..m'the~e ve'~'sels' ... -. .. : : . . ... . . ~ .. ~, .
.iei\itts tri-a: gi:eat._e.r.::tha:ii so:;~_ie61t: increa;s&m. panrig.-'ri.oroia:I gest<l,tion,:s<!ic.m .osmolality
.~tte'ctiVe -t.enal pla,sjifa flow (E~FW Glonierulai-- .de~tee.ses by- 1Qm9sm/L'-and s eru-nr sodium .-
._capill.ary 'pr~swe charig~l! little rr.:~mdhe ::Q.on- decr.ea:c;e;sty S in<E'q j:L: -~:A! r.e~ett~g of the .
pregn.ant:state:becau~:.-r~ist~neei$ . redu'ct<i'in . osmorece-Mor;:system :occur:s; witli=cJ,e<;rea.s.ed. _
:l:>otli the: .afferent. artd the :efferent::gicmert.i!ar osmotic;fur_esh~ldS. f6I~ betli' thh:fst-an'!:fv-a:soptessiil '
tea6le~>-[fl&ea:sctrnow 'tl;ifOli-gl(tlie':~~ri.lenuk rel~ase: ,.Serum '<$Iofide tevd~' :a te ~~'sentiauy.
-~pillarl~s ateonstan.t-hydto~t~tic: pre:s$U:re .and unGhangectduringpregO.gncy. :o~.?P.~~:Si~t
deereased-eolloid-osl:n-otic...preSs.ure~results.~in -a . ip:cr~s!i."'l.<!ldo.stex:oric..le:v:els:d'liring"pt.tgnahcy,_
.gr~ter~th~O~~~~creaS:e-lli-ihe:glm~~ -in;most'"woen,-se:r.UnLP?fassium:level~:are..either.
.filtration n;~.te (GFR). TO.e .a.dl:i.ptive v;ilue of the normal, 'Or on the a-i,,~fugi:;, 0':3 "mJ?qj~ 1owcr ihan
ihcrease mGFR is u~own, but it m~yTaci)itate ih those women who -.a re ~not p~egnant. : The, ability
cxcretior~ offetaf'wastei and -dietarY .'f oxms: to ~~riserv:e potas#~m m~y r~sult ftom .the
elevated progestet.one in pregnancy.
The_'!'iverage crea~~ lev_e l and ur.~~ nit;rogen
cor.ce~tia;~ion :are sHghtly .tower in pr~-gnint
women~- fu those 'wnu ',r.e, :uot ptet~nant (0.5.
mgfd and.:g mgjdL, respec;tive~y). The increased Preg-nan:cy has little, if any, e'ffect .i:)ri
filtered loa4 also -r~sults in increased urii,lary gastrointestinal secretion or al;:lsorption; but it
.protein excretion . glucosuria, apd amihpaciduria. has a major effect ~m gastrointesti.rtal motility.
The uri<>acid cleillance rate's 'increase to. a greater Changes in motility a're present tp.roughout the
extent than GFR.- Jiyperci.lciuria .is a r esult of gastrointestihal tract andare: related to increased.
increased GFR and of inc reases in circulating 1ev.els of female sex, hormones. In a4dition, the
1 ;25-dihyd.r.o xy-vitai:nin D 3 in -pr.egnancy. enlarging uteru~-displaces t he bowet'.and thus
(absorptive hjpetcalciuri'aj . The' ren1ri-- affects the presentation of disorders such as=
angiotensinsystcm is .stimulated during gestation, appendiCitis.
and cumu1ative retention of :;tpproximately
9SOmEq of.sodium oc~urs. This sod.1um -retention Mouth 'a rid .Pharyri
r:~sult_s from . a col!lplex interpllilY between.
n:atriur;etic and ap.tinatriuretic stimuli. present The incre;;tse in estr.ogeir during:. pregnancy..
,during '~est~tion. contrjbutes to increas.ed vascularity ~f the gums

Scanned lly: ~
 CHAPTER 14: MAT:ERNAL ADAPTATIONS TO PREGNANCY 237
------~-~- .........-~-..:....,....,---------~--,....,-------------.,;;;,.

and proliferation of gqm connective tissue. Thus, adaptations may manifest as spider angiori);ataand
gur:rt bleeding is a
eominon finding during . paimar erythema. (<liscussed under Integument),
pregnancy. Likewise, notable dp.ring -p regnancy which can mimic' liver disease. Albumin may
11re gingivitis characterized hy spongy swollen decrease by as much as 20 percent during
hyperemic gums, and epulis of _p regnancy pregnancy, whereas alkaline phosphatase and
cha.-acterized by red Tajsed nodule/son the g\lms. cholesterol can increase by 2 to 4 fold and l.S to .
Pti'alism, excessive salivation, cart . also be a 2 fold, resPectively.
resultant effect of the hypervasoularity;
ENDOCRINOLOGIC
Esophagus
Placent!l
Progesterone ctmtributes to ihe decreased
lower eSophageal ~phincter tone which can lead The placenta is the main endocrine organ
to ei!iophageal r-egurgitatioh, manifesting as during -pr-egnancy. !t secretes Ule following
heartburn. 'there is al:someehanical pressure from honnones: 1) human chorionic gonadotrcphins
ihe upwardly displaced stoJ::Q:ach dUe to the {hCG), :2) hu.trlan placental iactogen .{h.PL),
enlargirtg uterus. 3) e strogen, 4) progesterone, 5) chorionic arid
adrenocorticotropin (ACTH), 6) prQppio~e
StC)iilaeh lariocortin (POMC)," 7) human -cho.r ionic
.thyrotropin (hCT) .8) parathyroid hormo~e :__
~. prpgesterone is tlle causative factor . related proteins, 9) thyrotrdpin releasinghonnone
CQnb:li>.ufiP.g to dect:~sed motility, which in tUrn, . fi'RH.), 10:) gonadotrop1n relea~J.ij:g_J~o~()B-C _
.!ez,d~ ~0 e~pha~ ~gtlrgitatiort; slpw emptying (GrtRH}, 11) luteinizing hormone..-""~r.eteasin-g.
pf .the stOffiach and reverSe peristalsis. Estrogen, hormone (LHRH),l2) gr<:lwth.hotm()!;!~_;;.~~~~pg
..op the <>fh.er hand, contrihufe~ to a decreased hortnon~. 13) other protein . suostantes~.h~e
~ti.Pn,..Q(..hydrochloric acid. Again _due to the somatostatin, activins, and pregnancy specific
m~.:9isp1acementby thee~guterus, protein~. - -
..-thde.ln!\Y...ar~ be bemi.atiort of the upper stoxnach . . . .
~~~:_ ::;,: \i~JL~--
iii" a$ mJny~;is :
1 s t() 20 perctntcf pregharit womeri. The human chorionic gonadotr_p.P.ixJ.::..~Fl~Je
principally' - in"' ~;';tfie
, , . .J- . .
is synthesized
Inten.hte syncytiotrophoblast and is detectable in the
. p~a~xn,~. ~~-_p_~! ~~X:U~~. ~~- J~. !Q.:J.Q.-~.Y~
WiUrdetteased viseeral motility' ahq: proJo.n ged ._ ~~~-r ..fu~_.m:lx~J~. -~Y..tJ;~--QUYt~~g..~onnone.
tiiiliSittrme -or gasfrom.feslincll confei1S:, -tliese {LH) that precedes ov\llation:.'Thus, it is poSSible
pro~de a good avenue for better ferrous and that hco <!nters Iilatemal blood oa. the day of
calcium absorpti<:m, water absorption, but blastocyst implantation. Thereafter, the1evcls of
inc1-ease!d flatulence and constipation. In addition hCG in the blood increasempidly,lll8.Xinial1evels
to the hortnonaHn:fluences exerted by pregnancy being attained at about 10 weeks of gestation.
on the intestiil.al tract, the mechanical pressure Begi.nnin~ at about the lOth to the _12111 week of
exerted by the en:lar.ging abdomen to tl:ie gestation, the levels of hCG in the maternal plasQ:la
rectosigmoid area <::ontributes to constipation and begin to decline; a nadir is reached by about 20
hemorrhoid formation. weeks gestation, which persists during the
remainder of the pregnancy.
ltepatobUlla.ry
Human placental lactogen (hPL), also called
With decreased muscle tone a nd motility of chorionic growth hormone or chorionic .
the gallbladder attrlbl}table to the' progesterone soinatomammotropin because of its potent
stores of .ptegnartcy, there is delayed emptying lac togenic and growth hormone-. like activil;y, is .
thne and thicken~g of the bile, khown as biliary detected in. ~e trophoblast as early as the.Sc:cond
.sludge. This predisposes pregnant women to an a.n:d third-week after fertilization of the ov.wn, and
increased risk of gallstones, as well as cholestasis is concentrated in the syncytiotrophob!i.t. The
of pregnancy which manifests as intense pruritus. concentt~tion . rises steadily up to the S~:to the
Esttogeri alters liver enzjmes; pla:sma prote.ins, 36th week of pregnancy, .and reaches eve~higher
bilirubin and serum. lipid concentrations. These levels later in pregnancy. HPL serves to ~cipate

Scanned 8y: C
 l ; .
(
238 . SECTICJN II: :PHYSIOLOGY.OF PREGNANCY

directly or ipd.irectzy in: a number -of metabo-lic trophoblastic cestrogens and pro_gester<>ne. The
processes, namely: .1) ~poljsis and an increase . ovaries .are also the source of relaxi.n.. .
in the levels of circulating free fatty acids; thereby
provi4ing a source cf en~rgy. .for maternal Th.yro.id Gland
metabOlism and fetal nutrition; and, 2) anti-,insUlin
~ctlon, :lea<llilg to an mcr~se in matemailev.e ls The. th:y-roid giang. uop.dergoe:S hyperplasia, fls
-of insulin w.hkh favors protein.synthesis, in turn well ~s hypervascul.aritY and a'-'gm.ented functicn.
en~uring a mob~ble -so~rce -a mino adds for Hence, normal :preg:pancy may ~ consid~d as a
tr:arisport to the fetus. physiologic manifestation of a mild hyperthyroid
state. Biochexnically, there may be ;a ~light
Pregnancy, especially n ear tero, is a increase in circulating thyroid hormone levels.
hyper~strogeillc state. Bio~ynthe~i~ of eStrogen
takes place in the plaeenta.~ be41g .p .roduce.d Parathyroid Gland
. :::.
almost ~cl~si;v-eJy in the _syhcyti..ot:r.ophobl~st.
. Production ~f estrog~n ~epntinu~iricr~as~s m The.ie is hyperttpphy. :and.. hypetl)lasia of tlie
ma,gnjtude~s:pregl)-!Ulcy pr(?gresses_ , ter:nUnati,ng para:~,hytoids . .durill._g pr~gi).~hcy, cim$ing
a ."bruptly aft-et the delivery of the fetu-s and . enla~gement and increased c-ei:h:ila:r ~~tivity.
p~fenta. .: The .fetal.a.dte:Pal g~d has ,a lso be.e n Parathyroid lrormone c<rp. centtaiio.as .i n the
th~r;ib:.~d ...tn~e .:a.,. sit~ -of: origin. .of <::strQ~e:Il p-lasma decrease :d~g the ~t .t::illp:ester. and
;pr.ecutsbl' ~uhstaes 't?-at ser"'e to. pto-!n~te tben p rogressiVely :i..-"'lcrease throughq"\}t the.
p.la~W :e$.1;:dlgeil: f~riil.8.tio:P.- . . remffiP..der Dfpre_g n'$cy. ln.c~~ing pamth.ftoid
' :.!:.~, .. . .. "~ ~..: . ,. , hormone levels .after thefrrsf: trimest1- resultfrom
.... :.i~9geste~~~;s~.~~~I?J.i~4~9-i~$~~ :m~~ ~;~; ~~1~~~-- - ~~~~-~~~
utlli~tion:.,oi! ma~~.:hp.tas;rp,.a~low, ,qe.n:sitY.r. :filttation andmctea.sedfe:tal:.tra:nsfet :of. calcium.
liJH)p:rot~in .(bD'C} : chples:~et;.Ol; .in.- ..-th~~ :All -t:B,~~ f~ci<>rs. ;~tili.:k,~ ~-s:_u~on
sy.ncytio"tropli~,\?J.ast 1i,ft.er..the:lil:St 6.;w .8 ~~~s of_ Of palqium. ~ncen~~;ip. #.i p~<fp.t:~:
g~~tiO.n. V.er:y;.l~ttle:pt;e$~ro.ne. is 'P.t:n.dP.~.by. . . . . . . . .. . . . .
tlie~9~e8: b)r::~~~~t~.:~k::ofp~in:cy., :: .: .::. ,: .;;~t;r9~~$~~~; ap~_:to lti~bk..$e a~tiol{ of
: . ..._,. . . : ;., .-.. : ., ....: .. -~~~~uil6Pe:on.P6fie~fPU.on; :res\uti.llg
.Pifuit&ty; Gland'"!.'~'.. ' = .. :. in a.phySlol<;>gic~xi:)etpa"iath.yri?ia:sW.t~'/' which
., serves~ supply=thef~tus with ad.equate Cglcium..
. T-ht ::8!1tenot :lpbeo;f :fu:e - pituitacy-.g~ax;i.d
h.:n;>erno-pW,~tWii%it:nx~a)::~an.d-;:th~,is A:d,re~-G4n4s ..
in.crea.~:cellular activitY :9.{ the ~p~ancy-:clls..
a,$ ~ .e"ffe.ct.of e...~n.. :i'b<* "i$ . eV;iden:.~. th;a,t .Alth~ugh tb,ere . is yety little morphologic
pifuitaty. go.nado:trapln _ptodus;tion ce~~es cl;l4nge irl' the ~C;li;'enal glands ,.d~g prCgna.ncy,
rompletely.dur.'ing:-pteg;l~. .In.: the po$t~ribt 1o~ .t here is. ':\ Jlia:i:~ed ..~e'q'u~ion o:i ci.r :cuJating
of th~ pit\,litaiy, Uiete is an ..~~ea.sed...pro.i!."uctio.r:l adt~.ilOFQ~cotropin horip:on.e.s {AcTfr) ,early ill
of .o~Oclt!.. espec1-a:I.ty c}Qs"e.'to,..tertm, whltl)_ .. :is pr:egnancy, l:ru,t,as .p~gnancy.pr:q-gFes$es; tJie l~rels
.~e-ce ssaty fo_r :~he s:ti):~1~-tio:n of uterift.e ()fcorli~o_trophlli .a;nd.fr#~rtisol ri;se, 'm:~e~po~~
contracti.)lty. to the nee<,I.for hom:eqs{asis:

Ovaries .M ETAB0LIC

. During.ptegnancy, notmaluvarilffi,JUnctioh is As implied earJ..i.er, the metab9lic. a~ptat,ii:>ns

s'-:lpptesseQ.. Follicular maturatiop. is s uspended encountered .during. pr~gna.P.cy' serve to ensure
and the .t heca intema. eeJls underg9 hyperpl~s~ fetal growth. a!J.d developm~nt., to .prov;ide ad~uate
wi'th. lutei.i:iizationl .which can
give rise to the fetal stores; tO meet i:hcr~sed. in.a:ternal needs and
luteoma-s otpre@<Utcy. Thereis:ipcrea_s ed corpus to provide the nece~saiy .en~w, Pregnancy is
luteum activity: up to :t he .1'2~ ~~ek of.g~tation; . irt.iti~y. an.:
~np;bOlic. :state,. Ai.th9ugh fqod int.q_ke
thereafter t the .'cor.p-us lp.teum o'i .pre~ancy and. appetite .aie increascl; actl0,1;y i\l de<;:r.ci.se.d,.
gradually. ~gresses, The jUnction.-p.f .theovafi<?~ thu!> ..as.m.\lf~.as -~. 5 :kg .of.~t t;la)' b.e ad~t,ionally
in: the secretion of e.s trogeris .and pr:ogesterones-is deposited .du~g- pr:egni.cy; .a,nd-?09 ~s.of.new .
taken .over by the.p lacenta,' which se~r~tes protein synthesized, thu:s lea4ing to
m at~mal
'i

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CHAPTER 14: MATERNAL ADAPTATIONS TO PREGNANCY . 239

weight.gain. In the second half of pregnancy, it is effects that promote greater use of alterffiitive .
mQre . of. a catabolic state, with .m ore stored fat fuels, .especUUly"fatty acids, by peripheral tissues.
being utilized, increase in . ins~lin resistance,
decrease in serum glucose and adcUtional weight Llpld Metabo&m
gain from the growing fetus and pla<:enta. These
metabolic . pro.ces~es are .influenc~d b y hu.~an Changesin hepatic and adipose tnetabolism
placental lactogen . (h:P.t), estr9gen and alter circulatirigcoricentrations of triacylglycerols.
progesterone, with the end-~ffe.et. b.eing an fatty acids, chQlesterol, and phospholipids. After
alteration in gl~cose metabOlism to favor incr~sed an iJ;litial decreas e in the first 8 weeks of
de.m and. pregnancy, there is a steady .inctease in
triacylglycerol~. fatty acid:i, cholesterol,
a
. Incr~ levels of WL lead to Q.iabetogenic Upoproteins, and phospholipids. The higher
state and dec.reatte4 gtupose ~olerance, most conc6lti'ation or ~gen andinsulin resistance
pron:ili:\ent betWeen i:he .241b to :t4e 28a. week o f are thottgl1t w be respcms ibie fot "the
g<fstawn. .In addltiol1t JncreaWi.g :p!Plactin level~ hypertri$1yceride1nia of. .p regnancy.
a.l$0 :eontri'bute to .ixl~eased insulin: resistance.
lncrased eS.troge.n an4' l>ro.ge-sterone 'l ead to Cholesterol is used by the placenta for steroid
incr~ t~t. ~}"tlthe~is, , fu,t. cell bwerttophy, -Synthesis at:l9 faf:o/ acids are us.ed for placental
lipolyfds ~iUtm .a nd artabplic fat st()rageearly oXida~on apd m~Q)e Jo~n. Change.s ..in
in. pre.gnariey. . . . totcl ~oles~l t:PncenQ:atitm reflect - ~ariges in.
. . -the-various :li~protem- .fractions. HPLcliolesterol
~ohyd~t~ . ;__ ..
M~~boliism inci'eases b.Y 12th week of gesta.tio~ Jn.x:esP<>n~
.' . : - . . . . ~~->.- . ~ . . to estn~gen : and :r.en1l$_:;J e~vated tfi"ro~~9iit<
. 1>U$g:~W1Y pregnancy, EJ.:uoose ,tol~cc is pregnancy: Total and : Lt>L-qho~"st~t.ol- .
nor-in.t4 or.sJ!ghtly improved and . per"ipheral -epncentrati'o ns 4e"ci-ease . initiaUy:~:buL'tiien;
(PP;tscl~) ~lj~i,tiVif;Y t:o i:t'lsuliD mi(lh:vatic basal mer~ itl the '$.Q~d and.thlrd trim.e~t~.:VLDL
."glu"c()St:_p~uction _ia normat ..s~die$ mcijpate and :qiaytglycerols''decrease.in tl}e-.fii1t:8:.w~l{s: . .
gf.~~ter.:th~JJ,t~ior~at ."$:erisitiV:i.t:Y tQ .. tbe ~blood oi gestation andthencontiriuotisly-iii..ey~~til ~..
gl\,l.coa$:1~'9i~ri~$ :errect . ot -exogenou~.ly temi. In the 8CCQnd half of pregnatl:cy .;:v LDL
administered in$\illn ~the fin;t "t rimestet.ths;n in -clearance ia alteted because o'f .the : decreased
the -~~4.an<i tl#.rd ~e~te~ 4,18~~~-~ppn~es activity -DLpqpmteip .~J>ll~ . (W>l-} in the~-~
to~@~~~m:~-gr~~rfuP!.~".!i.!.:t~~t!' mtd ijyet md ~Y~ .O.f.the. in~.actlv.ity: in
U1an befo~_p_mm_an~~The ~D&Q.(th.e_i.Pha,n.ce.d . . th.C..plaeenta~.IP.-the~ta:te,~hepa;tic..LRL..i~lo:w.,- .
iPstllln secretic;mis unciertain ~use perlphehu but increaSes ~ith fa;sting, whiCh increases .fatty
insuliil J!erisitivity and hepatic glucose pfoduction acid.an.c;l ketone production for the fetus while the .
rates are not ditrerent from pregravid values.This supply of glucose is low.
metabolic milieu under ~e i nfluence of cortisol,
.e strogens, .antl prog~stins favons lipogenesis and C.hangeg in lipid metabolism promote the,
fat storage. Althou,g h .t he preciSe mechanism is aecumuhition o f IJl9,ternal fat stores in early .and
uncertain, alte~ations . in the ho.r tnonal milfeu" mid pregnancy and enhance fat mobilization inlate . . .
durirlg pregnancy are probably .resp onsible for the pregnancy. ln early pregnancy, inc-reased
reduced .i nsulin sensitivity. Changes in f> cell estrogen, progesterone, and insulin favor lipid
respcMive_p.ess oceur ln parallel With growth .of deposition and 'i nhibit lipolysis. LPL a;:;tivity in the
the fetoplacental unit and . its elaboration of adi~se tissue from the femoral region, but not
hormones such as , ,human chorionic at
from the abdominal region, is elevated 8-11 wk
som.~tomaminotro.pin (HCS; another terril forhPL), of gestation. Lipolysis iri response to
progesterone, cortisol, and prolactin. Prevailing catech"otamines is markedly higher in the
insulin res.i$tarlC.e P~-~uces . exacggera.~ed chq.pges abdominal than in the femoral region. The femoral
iri postPrandial concentraU~ns of m~~bblic fuels cells are virtUally unresponsive to catecholamines
(eg, gl~co~e .VLDt, and amino -:acids). Insulin in pregnancy. ..;t
resistance serves to shunt lngested nutrients to . :~.
the fetUs a,fter feeding. In late gestation, rising In late pre:gnancy, HCS pro.m otes lipoly~s and
concentratioris. ot HCS, prolactin:, coitisol, "arid f~t m obiliza tiori. The increase in plasma fa tty acid
glucagon exert antiinsulinogenic" and lipolytic and glycerol concentrations is cons istent with

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 240 . SECTION U: PHYSIOLOGY OF PREGNANCY

mobilization of lipid stores. This shift from an pregnancy, so that the set-point for regulation of
anabolic to ~ catabOlic state promotes the use of red cell forma.tion is adjusted downward.
lipids as a maternal energy source while preserving Expansion of the blood volume also dilutes the
glucose and amino acids for the fetus. With plasma proteins. The concentration o f albumin
prolonged fasting (48 h), as wellas shorter periods declines by about 30 percent. Since albumin is
of fasting (18 h), the:re is a rapid dive.r s.ion.of the most abundant plasma protem and~ major
maternal metabolism to .f at oxidation, wit.'l an colloid osmolyte, plasma oncotic pressurt atso
elaboration of ketones. Decreases in plastn.a de.c reases by a bout 30 percent. Synth~sia of
g1ucose, insulin, and alanin~. a,nq increases in albumin and . sotne other hepatic proteins is
pl~ma fatty acid and S-hydn;),cybut-;rate are seen thought to be regUlated by plasma oncotic
in pi'egnartt women hours before these changes pressure; a decrease in oncotic pressure sensed
. .are seen in nonpregnant women. The e:ihanced by hepatocytes :~ctivates transcription of the
lipolysis and ketogenesis allow pregnant wom~n album4 gene. Once ~gain. it :appears thatthe
to utilize stored lipid to subsid~ ener&Y needs ~nsitivity of a rgulatdcy mec,htrni~ is reducee
and m.inimiZe protein catabolism. by . some action~ ~f pohno.llt;$ of pretnAficy.
Hepatic protein syhtheti'c capaCity b nM
HEMATOI,OGIC . comprom~sed, a s :e-vi.deticed by intteaaed
production and. $ecretion C>f some globulins,
Blood volume .starts .to ~panel before the fibrinogen~ ancl ,'clotting.fact9n- . 1h~ tbf!ri~ L"1
four$ week .of pregnaJ:lCY and .( :ontinues to vascular volume and in levels 6f ted blood ICClls
in~ iuitil.the middle of the third triniester, and albumin woUld be considered.patboll)gieal !n
whett-it :is -~boUt 40 to ;;$0 prCeilt ~l:>ove e .pre~ non-pregnant women, but ar~ ilOI'JJU\1 in
pregnattt'.'leveh.ldtht>l.lgh-~Ule', ~o}tn~--i'JI:.a4pe(\,c;. pregnancy.e;md e:p~ totesult .fioni adjustments
.
volume vanei-widcly-. fl:Om wo~ to woinan~ .the.' totl1e. set,-poill.t~-ot~ormaJ.Iy .<>~~.g foe<l~ck
ine;tease is Consistent. for ~h WOn:lil)l fu eaJ:l;of . reg-~taw,ry : syst~ The adaptht.ad~tagea of -
herpteg4UU1c-Jea -firtd ia greater ;n twin than in, decreaseg. cirC$.thl,g lev.t.ls .or :ellnurili.i ~: red
amgl~ pregn~;m..cie$~, .aou.t ~plasPl-a:.oiuldd;ed, -:c~u.. . bloc~ --us: ~~
. . """'1" ......
. .... c~..., ~-.Q.t ,..,;.;.; wn~ .'ho--- ~~;.;.,............b. ed ..
~.,Q._ . , _,_. . .,.~~~- ~- .....- ..m
'Y'ofumes~, ,bliulie:plasin~iv6l~e:-~d~ . effeCt; of. the .tow.et.t'eQ ~u ,m:Qa andllse .lower ..
a:
by 50 ;-~nt.;-.whQ.e;:the..~ .~ell.J#.as:J,.. irtci'ea$ep~ . prQte4t centettf l$ d~~~ ht bloQ<f :visOOsity
by 'i)Jl\y ; ~O to ~0 percen:t.:.;C (mseqliently, the : which-contribu~es ttJ. at~ta~ol'wayt.Q the .
hemat~t decllrt~$ - fioni about 45 ;per-t~nt ..tQ ovej;:all dett~$e iri~rlpheri.il:, reSMance. It shoUld
~:bCiilJ 3S~_~f~prodild.hgthe~:scF~ailoo"'t1tletnia be: -~IitPh,!l~~e<t- that;~ altt.pugh-the. .heJM.U>crlt
Qf p~cy-. IfiS:n9fKiiowii:wn:y ::expa.IlsiOrFof de:cliit~lFin-;Pr<;gtr~(:y;--the toW red-"eell--mass ..
the red cell mass fails to keep ps,ce with the incr~~s. significantly. and m.a:y theref'Qre lessen
increase in plasma volUJil.e. . . the postpanum imPact of the inevitable loss of
about soo -n iL of bl<;>od at delivery..
Erytlrropoietic capacity of bone. marrow i~ riot
th~ limiting .factor. Further enhancement qf red MUSCULO.:SKELE1AL
blood cell prOdu~i:ion. is seen after .l:lemotz'hagic
injur)'. S\JilUariy .red blood c~ll production
inereasesfurther in pregnant w<>meil in resp<>nse
to the decrease . in o.J tygen ten sion (POi ) The. hor:mones of pr.e gnanc y ha'le b~en
encou.~tered with a change in residepce from ~ea p<>stulatedto soC.ten thedense.ligaments ohlmost
level to high altitudes. Pregnancy thus does not all body joints, although joint laxity did not
inted'ere with -th.e ope~ation oLbasic regulatory co!'Tel\'i;te w:ith maternal estra,diol, prt>ge:sterone;
mechanisms tha t govern erythropoiesis. or. relaxin levels. Nonetheless. the pelvic bones
C9ncentra:tions o(ecythropc>ietin in blood.plasma become mos~ Vlilnerable to_this joint laxity fu allow
inQ"ea~ only 1110d~st1y dudng pregnancy. It is for expansion during childbirlh. The ~crolliac,
possible t hat increased renal biood flow partially s a-crococcygeal, and pubic joiritsthus eXhibit
compensates for decreased hematocrit in increased mobility duririgpre~ancy. Joint ~tY
~airibiining renal interstitial P0 2 so that and mobilitY triay c<>ntrlbute to the lower back
erythropoietin-secreting cell~ are only mildly dis,comfort expedertced by lil<>st women; especially
. stimulated. Alternatively, the P02 sensitivity :of late in pregr1ailcy. During labor and qelivery, th~
these celts may be decreased by the .ho rmones of n a tural curve of the tanbone flatt~ns and is pushed

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 CHAPTER 14: MATERNAL ADAPTATIONS TO PREGNANCY "241

outww :a s the baby's head passes through the Compression of the medial nerve as it passes
pelvic outlet. Not surprisingly, the str:ess of through the wrist, the carpal :tunnel, a.nd into the
delivery commonly results in postpartum tailbone hand, .Jl1ay cause pain in.the hand, wrist ~d ann,
pain. contributing to th~ Carpal Tunnel Syndrome.

Round Llgaments lnt~gument-

The round ligaments, found on the right and The rouow ing are the cQinmon integumentary
left sides of the uterus, .attach to the pubic bone system ~hange$ encountered during pregn9.Ilcy,.
and help support the placem~pt of .the uterus in most probably attributable t<Hhe hormon,.al effects
L"he abdominal cavity. As the ute..-u-s expands, of estrogen, progesterone and relaXin.
these ligaments endJ.l.re ~ontinual stretching ~d Linea nigra : tr:ansfonnation,of the linea alba -
arcia cammon source or pain in the latter part of the Il1i4line of the abdott)lna] skin t() a markediy
pregnancy. Pain, either a sharp- .spa:stn or aun pigme~ted brownish-black color.
-~che, i$ felt or:1 one, or .s ometimes both side$ of
-the lower belly. Chloasma or melasma gravidaru~: irregular
browni~h
patches ofv..aryint~s on fue face and
tUb-cage .neck. Similar byperpigmehtatiPtl or dark'!nbg
may also be noted 'in the areow~ -~. ~d
.The ribcage ..expands enormou.s~y durjng- genital regions. This hypeipjgpientatioll i~ said
pregnany.::to>help make -r oom for the -expanding . tt> be cau~ed by a meia,n oc yte-$timtilating .
uterus -and '".t.Q niaintain adequate lung c apacity. hormone which increases fuwati!~/itlle.:second
Matiy pr.egJUmt women experience rib discomfort
from this ~sion, as well as the occasional little month of pr~gnancy until terni. -~-~.r''/:,;t~ ~~~:~ .'
foot or knee that might habitu~y press against DiastasiS !'ecti.: separation tlie. 't~,dus ot
the
. ":-
ribs. - -
. --~_;._r:=.:-
ab(iominis muscles at. the m idline due to the
tension cieatecrbY- thegmwij)g uterus.:;,', ' .;:_, , .
sJ;l,ouldel"fi_;M.: . . . . ... -. : . ..... ~~~t~~,:.r.. -~~-; -. --....~-:~:-;_~? _.- '
Striae graVidarum: also kno~l~:f::"#tr~tch
The sho\llder a rea is -e lso a stress area for the .marks; these tU"e slightly d~sed~*whlch
pregnant womatl. The shoulder girdle niusdes ~ay range in rolotfrtun s~to red,di$b tp brown,
tend-to-be>me inlbalaneedt;uuiinhibit-tood body . and-appearontll.e- abdomen; breasbt-~d~thighs.
m:echanics;'Thei ntemal'rota:torsovertighten..imd
~xtern.al rotators weaken . . The musCle~ that Palniar erjthema at1d v~ular spiders: The
elevate the shoulders tighten, while the mus~les ~ttet are minute red eievations on skin of the the
tha~ depress the s houlders w.eaken. face, neck, up~ chest .and arms, with tad.icles
branching out from a centi:'311esion. They are also
_Upper ~emities known as nevus, angioma ortelaflgiectasis. These
.c onditbns are attributable to hyperestrogenism,
Swelling, fluid retention; and increased bloQd- and ma y be mistaker. for ::n.anifestations of liver
voluine .c an restriCt and compress tissues in the disease.
extremJtks, particularly in the third trimester.
thu~. many pregnant -Women ~ay complain of These integul:nentary changes commonly
.hand pain and numbness ' upon waking. regress after pregnan-cy.

POINTS TO REMEMBER

Adaptation to pregnancy "in humar'i~ rnvotve-s major anat<;>mic; physiologic pnd -metabolic cha!'1ges in the
mother in order to support and provide for the nutritional and metabolic needs of the growin_ g conceptus.
The uterus undergoes hypertrophy and hyperplasia to accommodate .the growing products of conception,
re~ching a weight of as m uch as 1100 grams at term. It likewise undergoes dextrorotation..

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242 SECTION ll: PHYSIOLOGY OF PREGNANCY

The plaCenta 1s a complex organ that serves to anchor the developing fetus to the uterine wall, to
provide for the exChange of nutrient$, respiratory gases and fetal wastes, and to direct maternal
r.omeostatic adjustments to meet changing fetal needs by secreting hormones and other substances
into the maternal Circulation.
Breasts undergo hypertrophy and . hyperplasia of the glands in preparation for lactation and also
from increase in the t>vlk of tatty tissue. The areola progressively darkens, enlarges and .forms a
secondary mound.
Carcliovascl11at changes 1ocus .on an increase in cardiac output and the decrease in arterial blood
pressure .resulting ftorn a pronounced 'd~rease in total peripheral resistance
There is increased pulmonary ventilation attributable to ,progesterone pro.Ouction, as a consequence .
of increased tidal votlime~
Oxygen ~nsumption and C02 productipn increase steadily in parallel with increasing fe.tat mass to
reath a level that Is about 20 percent above the non~pregnant !eve!, but hyperventilation continues
.until the ,baby is ~elivered.
Renal plasma flOw and glomerular filti'ation rate increase to 40~80 percentabove normal in humans.
. Motifiiy oHhe gastrointastlnalorgans
Tne .placeri~
.
are generally
.
decreas:~!i during pr~gnancy,.

prroueticn'many:hormone$;.tO'Jtnait1taln:no.rmal , pr~panc-F . . . . . . .
.

serves. as the r~ain endocrine .organ during pregnancy, .being responsible for the

I
Relative in$ulinresistance develop!r'igin .tt)e late secon.d'triinester serves to shunt the.nutrients to
tile .fetus after iogestiQn of meals.
After an initialderease in thefitSt:S..we.eks,of pregnancy, there,is a steady inerease in triacylgly~rols,
fatty add~ ChbtaSt.ero~ tipop,.otelns~ ar'ld phOspholipids. The higher cor.centration of -~trogen ~.nd
Insulin reslstancearethought to.be respcnsibl~. for the hypertriglyceridemia of pregnancy.
PlcJsma and red~ vOlumes ~nctease. but tha plasma volume expands by 50 percent, while the red
cel~mass-~a$$by only20-to'Sff.percent:Gonsequently,.the-hetnatocrit-declinesrrom -about45-
petcentt0-abotit~5percent; producing-the so-called"anemiaofpregnancy'!.

MuseuJo.skeletal changes focus on lordosis and joint laxity most .probably attributable :to relaxin
and J>rogesterone effect
Common integumentary system changes include hyperpigmentation, diastases recti and striae
gr.avidarum.

3. Ferguson M. Ma temal Ada ptations in Pregnancy.

1. Volman MNM, Rep A, Kadizinska I, Berkhof J, Van
Geijin HP, Heethaar RM, de Vries JIP. Haemodynamic
changes in the second half of pregnancy: a longitudinal,
. non~invasivc study with thora~ic electrical
bioimpedance. Br J Obstet Gynecol2007; 114 (5): 576 -
581.
http~/ fhowto.fm/e./ a/title/Maternal-Adaptations-in-
Pregnancy. Augusl2007.
4. Granger JP. Maternal and fetal adaptations during
pregnancy: lessons in regulatory and integrative
physiology. Am .J Physiol Regullntegr Comp 2002;
283 (6): Rl289-Rl292.

2. Weisserberger TL, Wolfe LA Physiological adaptation 5. Aug~st P. Kidn ey disease and hypertension in
in e~ly .human pre~ancy: Adapta tion to balanc e pregnancy. www.kidileyatlas.org~
maternal-fetal demands. Appl Physiol Nutr Metab
2006;31(1): l~il . . .. 6, Bianco A. Maternal gastrointestinal trac t.adaptation
to pregnancy; www.UpToDate.coill, Decernber2006.

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 CHAPTER 14: MATERNALADAPTATIONS TO PREGNANCY ' 243

7. Petaglia F, D'Anto.n.e. D. Maternal endocrine and 9. CuruUngham FG. Williams Obstetrics. 22nd edition.
metab<ilic adaptation to pregnancy. USA: McGraw-Hill2005.
WWV! UpToDate.com . .J;me 2006.

8. Sumpaico W. Textbook of Obstetrics. 2nd edition.

Association of Writera of the Philippine Textbooks of
Obstetrics and Gynecology,lnc. Philippines. 2002.

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 15

DIAGNOSIS OF PREGNANCY

IMELDA S. OCAMPO-ANDRES, MD, MHPd

Presumptive Evidence of Pregnancy

Presumptive Symptoms
Nausea W:th or Without Vcmltlng
Disturbances in Urination
Fa'tigue
Materna! Parception of Fetal Movement
Breast Symptoms
Presumptive Signs
Amenorrhea
-Thermal Sigr.s
r '
_Anatomrcal Breast Changes
Skin Pi~mentation Changes
Changes in the Vaginal Mucosa

Probable Evidence of Pregnancy

A Enlargement of the Abdomen
lA Changes in the Size, Shape and Consistency of the Uterus
(_ Anatomical Changes in the Cervix
Braxton-Hick's Contractions
Ballottement
Physical Outlining of the Fetus
Positive Results of Endocrine Tests

Positive Evidence of Pregnancy

Identification of Fetal Heart Tones
Perception of Fetal Movement by the Exa miner
Recognition of the Embryo or the Fetus by Ultrasound or Radiolog ic Methods

Differential Diagnosis, Pseudocyesis and Identification of Fetal Death

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 I . ~~-
- ~.
248 SECTION Ill: .CLINICAL APPROACH TO PREGNANCY . 'o.\t
--~~----------------------------------~ - ~ ..

. The diagnosis of pregn-ancy is often a Presumptive Symptoms -.-_

- ;, .

. re.lati'~ely ea-sy task. More often than -not, the

patient comes to the cliniC with a strong
,s uspicion that she is pregnant. Frequently, she
has already done a urine pregnancy te.st, a highly
r~liS.ble test that is commercially available over-
. ftli~unter. Also, there may alrelldy be certain
.. change~ she may feel or observe as a result of
anatomical, physiological, and endocrinological
alterations that support tbe presence ()t
p~'lcy; ln:abou~ athl,rd :9f iil$tane!i tho11:gll,
.tl:ie(Uagno$18 .o( pregnancy- may:not be that easy.
lt ia Jn these diffiC4lt Cllse~ :mat t}le need::for
.~pim)priate c~icai md t.abi>ratdry :teets ~ be
most;.belpiul
. ..
Nausea with or withOut vomiting
About fifty percent or pregnant women
experience a peculiar distaste for food, food
idiosyncrasies or certain 'cravings' even for non-
edible material (as in pica) anci other
gastrointestinal disturbances during the first tWo
to three months of pregnancy. T his often QCCUta
i+t the tt}oming (thus, :is _p opularly ~-me<l ~
. s ickness1 thhugh it tilay al$.() p e\lr i n <>thet tiniea
o( the Qa.y. .
Stte8s and ,e motional tensii)n pJB.y aq
impoita:nt f9le in -~c seve:rit;y of the nm1sea..and
votJiiting~

, ~The i-mprovement of more . sensit.ve Extreme nausea and votnitiilg is assoda:~

~ji~oeti'ne tests of pregnancy and the advent .of with hyperplacent-osis as in :auultiple pregmmcies .
. Ul~Qund have been of great help in such and molarpregnande~ ..In some~ses, ~t
. d :Utm.m.as as viabiU.ty and localization Of vomitL'rtg aggravated by inability to take .iri :food
pregn9.ncy a~ . well as th~ir corresponding may re~'!i!Un severe deby~~_un and ketoJ'lurla.
.,~gement.. ,T ht:$e techno~ogies. (ll"e..aveilable . th~t may necessitate hospj~tion (Hyperemesis..
. ..~~;~.st.:.~rban~andmost. a.ffiuerittn.~nicipalities ~- . ,.gra.v.idaro,.J.m)
.
. ~d.-barrios
. .. .
,.~..;,!,..'
... . .
~-.:;_ ''
~:~ This disturbhl'g symptom corr.c bltes
. .:YJ~!Jowevert itt ~s where said te.c hllo.ogy is not sig:n.in~tly with the -am~Ufit of.-CitcU11lt:ittg :~ .
. -~accessible or.on.occasions.tha~affordability.:. . hCG..- levels in the. ~tie'(lt~- ,s ystem. It.u~ulilly
-is;ja.~blem,. the.various basic. manifestations .. of .. , appears at six weeks,.~!ID.es a peak at abOut 6Q. :. _ _.
. ~CY:::$tillr:~,o~4,P.la.Y.. ~;;itn~~t.:,role : in -- . to. 70._d_ay~ . and may_.dl~p~ ~n. thereaner.
~ping the clinician diagnose pregnancy.
M9J}a_g ement cQnsblts -of sm~!l .freqU!.n~
-. . :. ... the' nw.nifeste.tions of pre~ancy have bee~ feedings, ayoidance-oUauY~foOO.a, and in itS:atead.
-~-~~81f1ed i~to tnree groups, nam~ly a light; dry,-low-fatdieUs recommended.-Ice ChipS. --
-lL.J )reaumptiv.e , 2) probable, and 3) positive may also help. A lot of eJIIOqonal support from
- :-.~ences or
pregnancy. the f~y; mostespeciaily,froiil the busbanc:4plu,s
reasSurance !rom her obstetriclart Will J>e :most
. ;~UMPTIVE EVIDENCE OF PREGNANCY useful. Occasionally, tnere b:.a.y_ be a need :tQ
prescribe antiaeiQetics. ForWlc6ntrolled f(>miting
Presumptive evidence of pregnancy is based . especially :Cor; those p atient,$ wpo are unable to
l>n~igns -and WJ:nptoms that may involve different take in f09d and or-c:J anU~.emedcs, _ hospitalli.ation, .
:c;>tgan systems but are most prominent in the may become necessary ror hydration 'and
. repf()ductive tract. correction of fluid and electrolyte imbalance .

.Presumptive symptoms include nausea With Distu1bances in Urination

-Qr . Without :vomiting, disturbances in urination,
'!a.tigue, perception of fetal movement, breas t The enlarging uterus causes direct presSUre
8YJ!1ptoms. on the urinary bladder resulting in frequent
urination, bladder irritability, dribbling, nocturia
Presumptive signs include. ce.s sation of and even susceptibility to \l.lin;:uy tract infection~ .
.. menstruation, anatomical breast changes, This is most marked durlngthe second andthird
. :changes in the vaginal mucosa, skin pigmentation months when the uterus is still a pelvic orgruum4 . . .
. .cllanges and thermal_ signs. . is quite adjacent .to the b ladder. These sympf:9ms .. .

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 CHAPTER 15: DIAGNOSIS OF PREGNANCY
---'------~-'----------------------------- --
gradually disappear as the uterus rises from the
pelvis to become an abdominal organ. These
symptoms may reappear again at or near term
w~en
. .
thepresenting
.
part
.
engages.
. .
Fatigue
Many pregnant womeh expenence lassitude
and easy fatigability :especially in
the first few
weeks of prgilancy. This may be attributed to
the L"lereased me4tbollsm d.ur.ng pregn_a ncy.
P~tiott of FeW .Movement
The pregnant Pa:tient may -~rience _a slight
flutter or . brl~k ~nvemertt Withm }ler abdoinen.
This awareness of ll}e fU'~t movement is terined
q\i,i~. f'or_pri:tl:Ugravidas, this is U'sually
expen~ in the lSih-~()th w~k of pregnancy .
while in i.".l.lltlgravldas, _oti the tfth-1SU' week
ge.sta~?t:t; .:::.r.Pe~ fet;al mov~ments increase in
intensit;Y'iili.'d 'ftequency as pregnancy prc;:Jgresses.
'These movements may be mistaken by the
prinllgtavi4as fo'r :peristalsis or spastll ()f the
gastn)intestinal ~.stem.
, . --)..;..;., .
Bieast '$Yifi' to1M
. . ,.:,4f . .
l3reastibnd.emess or mastodynia may. range
rrom .tingling Sensation to frank pain during the
first few weeks of pregnancy. This may be
d~sttjl,>ed by $~me patients as tightn_ e ss or
heavm~ss-of"1:h~---bre~tsrs-resulttng ftcmi :Ofeast
e~mefic Tfiis:fsbroughfaooufby~ilie effects
of estn;>gens which .stimulate the mrunmary duct
S)'stem.and,l>y. the.progesterones which sthnulate
the .alvedlat component.
These breast symptoms are more pronounced.
:mthe prirp,igravidas and may be less ob-viol;ls in
multiparas whose breasts may still contain little
amounts .of milky material or colostrum: for
months or even years after the birth of thdr last
child especially if breastfeeding was undertaken.
Presumpti-ve Signs
Cessation of Menstruation
. During the reproductive years, cessation of
menses in -art otherwise pealthy woman who has
-heretofore regUlar menstrual cycles i~ one of the
earliest sigris of pre~tnancy. A delay of ten( 10) or
more. .days will _make one strongly suspect the
Scanned By:
: : 249
presence of pregnancy. A ~d missed,period
will make the suspicion even stronger. However.
amenorrhea is not always a reliable indicator as
delays may be caused by other factors like wom:en
with irregular m:!nstrual cycb. emotional stress,
chronic disease, drugs, er:docrine disorders;
lactation and other genitour-.......ary tumors.
Occasionally, uterine bleeding tt1ay occur even
after conception in some 25 pctten t of cases. T his
is often described as lesser m amount and paler
in color. This is interpreted as im:plaJ;Ltation
'bleeding as the blastocyst implants in the uterus
s.nd will re8o1'11e itself spon~U:sly.
Anatomical Breast Clianges
Hormonal stiml;llation that acc~mpanies
pregri;:tncy causes . breast enlargement ~;tnd
va~lar engorgement makio.g. delicate veins .to
appear -visible just beneath the skin. Th~se
changes: become evident at about ~'Sbt~ -toJ\e:ight
weeks; after c ont:ep_tion. The cfrb.tmra:a~itl- .
_s ebae!eous glands of the a.retila {Montgomety_?s:
tubercles) b_ecome hypertrophied and ' very
prominent. -- The a:recla ~ broader, daiker
and "more .-pr.o triinent . .Tile nippl~:s:;be~ome
considerablylarger, ti:lOI"e deeply pigiilen:tedtt;~.
increased erectilicy of the nipplesi:r; tikeWi~
o:b served. ,.,,_.,.,, _.,. _
. ~~ l61h..yee~~-~~~-!!m9.ml!~
_t:J::e. ~JQs~~-~y ~-~~l!:om.tM~. - ..
bY gentle massage. If the increase in the 'breast .
size .is extensive, striae simnl:ar to the striation~ ,
observed'in the abdomen tna:y appear. However.
breast size before pregnancy does not necessari,lji' .
correlate with volume of llli!Jk: production during
lactation.
Changes in the Vaginal Mucosa
About the sixth week of pregnancy, the vagiruil
mucosa becoin'!s oongested 8!!14 violaceous, bluish
to . purplish in color. Origiinally described by
Chadwick in 1886, it ha1 been known as
Chadwick's sign.
Skin Pigmentation Changes
Increased pigmentation of the sldnroccurs
during pregnancy_though not neces~ylf.!pecific
for the condition. Ctttain cutif'neous
manifestations a s chloasma. linea. n.i gra; striae.
C

250 SECTION Ul: CLINICAl APPROACH TO PREGNANCY
gravidarum, and _.spider telangiectasia appear
during pr~cy.
cl;lioasma ~r <m;a sk of ,p regnancy' or melasma
gra~um refers to the. darkerii.ng of fue skin
over the forehead, .b ridge of the noSe, che:ekb9nes
and neck~ . Thse changes are:more prominent
in os~ wi dark complexion and become more
intens~e~ . with e;qlbsure to sunlight. . These
findi'rrgs may disal;.pear .or at leas t r:egtes s
significantly -after.delivery.
Ther.mnL.Sign~.
A ~rceptible" t;:lev:at.i_.On p f bQd_y temperatuf~
fqr :l onger :than thi:ee :weeks is . a ..pr~~umptivc
eVidence .of pregnancy_ This is attribu:~ec;i .to the
thert)lpgenic effect Qf pr ogesten>.lle. . Lh,tnng the
luJe?} pha5eofthenieD.s . tiual:cy.~e; th~ ba~ oody
c
tel:nptrature .rise.s appro:;cimatdy 6.3 to'O.S .. ov~r
the basal.OOdy t~peratilie .o J.t he follicular-phas~.
PROBABLE EVIPENCE OF PREGNAllGY
The probaQle evidences o(pre.gqancy consist
of enlargement of the abdomen, changes in the
slz.e, shape, cqnsistency ;.ouhe ~utex:tistanatomical
cli~g~s in the;cervl.X; Bfaxt.on.:.fJ1ck~ contracti 0 ns ,
. b<;tilo"ttement, physical outlining of .the.f~t:us and
positive resul~s -o f endo.crille tests.
Scanned By:
- ~----~- --- - ---- -------------
l -
.A bdo.m inal Enlarg.ement
There- is progres~ive in.crease in abdpnllnal.
enlargement from 6 :Week!; onward to near-,talli..
By the end of the 12th week of gestation, the uterin~
fundus m ay be palpa ble. a:t the level of Lhe
symphysis pubis. At 16-22.wee.k s, growth a~
to ~ more .rapiq as the uterus rise.s .out .of the
. pelvis and "in;to tJ::te a~ome.n. . . . .
The uterus increases iii size to a ccoiD.moaate
the grawin.gproducts .of cor~tio-q. hiitia1J;y, .the.
growth "is w ithin the. anteropo~crioi- .:diame~er
which e:>q)lains the urin:aryfrequc:ncy.ari"d bp.dder
irritability :often e..~perieDced .during this time of
infauticipa tion.
By the twe1ft h week, the uterus somewhat
'beco~es globula r with an average .diameter of
abqut 8 em all ~ouod .
Bimanual exa mination reveals a softening of
the corpus as comp ared to the firm .to. doughy
con s istency of the no n-pregnant uterus. This has
led to some of the following recognized si&Jl-S;
1). H egar's sign: Tpis i!! .the softening pfllie
uterine :i sthmu s:resul ting 1inits.i::O:mpress ibility:
. on b\man_ual. ~xamination: This .~~ of~en
. obser ved by .the 61h to B~ week of_.preg:n.an,cy.
(Figure 15.1).
C
 CHAPTER 15: DIAGNOSIS DF PRE;GNANCY
:2 ). OOocl~W~ SigTt; This refersto the cyanosis and
- Softening <if the cerviX ~;hie tb the mcr~ased
or
' vascularlty tbe cx;.rvic~f tissue. This. may
occur :asearly as four weeks. (Figure 15.2)
Figure -is.2. Goodell's sign.
Changes in the Cervi;.;
Softening of the cervix occurs at about 6-8
'f-eeks. Frequently during pregnancy, the cervix
ip likened to the consistency of the lips while in
the pregnancies the cervix is likened .to that of
the nasal cartilage.
Cervical muc.u s during pregnancy has a
characteristic ~eaded celhdar. pattern .when
viewed under the microsco,p e. This pattern
characterizes the progestational effect on normal
Scanned 8y:
251
cervical mucus which replaces the 'feniing'.oo~em
characteristic of estrogen predominance seen on
the ftrst half of the cycle.
Braxton-J{ieks O.mtractions
These are painless, irregular contractions
which may be both palpable and visible as the
.pregnancy progresses. These cont...--acti.ons begin
early in pregnancy but become more perceivable
towards the 28'tli week. These increase in m,1mber
when the ab.domen is massaged or stimulated.
These ut~rlne ccnb:actions may be do-cumented
during second
. triplester
. . ultrasonography.
Ballottement . .
!'l-( fi.Ml t.H!U- lwJ tf 41-.~ ""'";hLUJ
By the 20"' week, th~ volume o!the fetus is
small com~ed ~o Ule ~iqtic fluid. When the
exa.."lliner move$ the uterUs !tom side to sid~ With
both pai'ms qn ~ach s~e - cr ~the titeitls, one
appreciates that something hard is bouncing
inside again~t th~ palms of'one~~ hands;:! Similarly,
.in an internal ex.am:inati9n; the-exainiitet'-~rfeel
the 'boun<:e back' of the pre~ntirrg)part:o'ii}t})e
examining.finger. {internnl ballottement)..(Figure
15,3} . .
: :_~_!-;~:. ~, .: .. ,:..:-:.:..;::
, ~-L' ~ :> ' _~_::_.: :~~:::
~ ~ - \ . , ' I 1 : ~ 1'"l i" '~
Figure 15.3_ Inte mal ballottement.
Outlining the Fetus
With the fetus now becoming biggi_t, it is
possible to feel parts especially if the m5ther is
nc:>t obese and. is. cooperative. Occasionalhf, huge
masses as myomas -or ovarian newgio~,s may
be mistaken for the fetal hea d.
~
252 SECTION IIJ: CLINICAL APPROACH TO PREGNANCY

Endocrine Tests sensitivity of the tests is attained. if the dete<::tion .

limit is lowered to 100 miU for a 95% accuracy.
Recent dec~des showed the development of
various very sensitive .an.d very specific hormones Though rare, .f alse positive !'esults can occur.
parlicularly, human chorionic gon.a dotrophin This happens since som~ wc.-n.ea Cave circub..ting
(hCG). These assays .P,ave .revolutionized the b.ctors (e.g. heterophilic antibodies in animal
mana.ge:m~nt of abnorynal :p~egnandes .speci,fically handlers and animal lab tethnicHm.s) 'in ~eir
ectopics and g~stafio.O,ai irophoblast1c d.~sease . serum that interact with' hCG .antiooey~ c aution
resulting in, loy.rer m~temal rates .due 1~ these should be exercised 'whe~ever c;iinical and
diseases. laboratory r~sults are disco~di:mt. R~pe&..t a~y
reruns or utilizing other tests m!lJ' :help. If
. Th~ pre~ence of ilie ,giycoprote.in,. P.un'l.an unrecognized, t his .m(.l.y le'ad to unwarranted
c.horivnic ,gonad_qtropiri {hCG) pg>duced by the clinical inten'entions .for:...condltions such as
fetal trophoblasts is & e ~asis of mostcomn10p1y persistent trophoblastic d.'is~se. One .should ' .C.
used tests all over the w,orld. This glycgpt:O:teir). judge the risks of wruting".for corifu:mation 'of
has hlih c arix)hydrate :ci>ntent (nearlj '30%); result.s the risks of 'failing to take :im~.ediate
The molecule h .a s two dlsslmllp.r subi.tnits, the action.
alph11 {92 ~jrio .acid'$) ,lQ:fd bet;:l. (1:45.:~no
a~.ds) sub~ts .. 'fll_e.WJ?):la~utn~rtit is :~~rnilar Sev~r~l.commercj:d}y :t;e~:t;~ .inv:qly~. t,he
to thoS:<; .q fthe hitdx;i!J"!;ip..:g );i:onnop.e {~li:), tl").e. principle cf <;~:ggl'lftfn_a,tion~iqnib1tio.n'" :raG.:'o-
fqllit!e .stilJ'lul~ijzrg. h<;>I:mpn:e :(F$H:), a,nd th~ .~ul1oa'Ssay, enzy~e-l.inked ci,psoibent assay
thyro~d~~uwJing~;A:o.r#ione.~f.tsl;i}:~ -~~~.-he.~~ (E~SA), anddinmunochr9ma,h;~~phy.
su_J>:J>o.r..t-s~~~!:lY.~\,Jit~~tn~.:~p.)':.-.::~$r.:.;.p;ce.V.~;n't.i:r:lg.,,, ... ' . : . .. . , .
',invrih.itioiFof~'the.;.eor.pu~,-4-rt~Ulp.,: :th~ ;. prin_cip.al, ..POSITIVE SIGNS. OF :P.REGN.A'NCY
s ite or..' ir-oge~t~f'bn~ ..:fpi.m'ittiu:n~~b e;fci_i;e: the ' '
placenta~~es over the. ro~~: . The .pr~_sence.-.of_-~nyc~e .of.the foli,owing .
' . positive signs .o f ~pr,egnancy :gila.I1lhte~s :the :
Wifu'-reeogriiticn-~~.t .Lll"arid'.J::!CG.' both .. pre.sence .o(p~&h.ai;l9:':; ...
coritain .~e:alpha. sp.!f:.,be~:~J,lbunits. ~d the ~ct
.that alpha and beta sljbu.n it$ are .s tructurallY, 1) Iden!ificati:on .df.Je@ h~ action separately
.Q{f!Cr:erit .With .differ:ent ~mtn.9 ~h:~~s; ~t:l~es .ana> ~Ma;~ :~m.:l~~ ::mo~et, . _
:Very~c~!or~ure:-,betij.>-:;;ru: bu:ri,itwere.:.devcloped~ 2) FeYceptiO'if~oractive:fetal: movement opy the
~;-s
l.L:.. .l-s:--"T..-e~-:q.:::ror:+~-......,.,
u..; .!Ji:L'> ~ ~ .u.""~ . tloiLof'hCG'"'in-:-tlre -~~ ...:. .:-.. - - ---- - ...- .. - -
..exaJp.mer, .!
maternal ~~in~. :fi:na{.o~ .hJO:o:d . N:uP1erou!> 3) Reco_gnitioi+ of tq:e embryo or fetus by
~bii:l.l:n~y>avcilable G~~fh~--0ante~-J.ests use' . ultra,sound. . .
various combinatiohs,_ofdiitereilt hortl:lones wbich
explain 't he Aiff~rent: .~si~Yi~.~~ 6r thes.~ tests. Fetal Heart Actf.on .
Although' the'se t~;;.ts:-lifey. At;"IP~nstr<;te different
mi.~~ of ho~o=i_i~s, _,.ail~of Jhese b.n,nri.moassays The auscultation o'f .diS;tinc:t fetal hCt tones
,a_~ apprqprlate-:~or tes$g. notzl?:al 'pr~~a.ncy .. (FHT) tep~te from:the .m<?tlu~(s.own. Pu,isds.an
assurance ofa viable pi:eg!Uihcj: The fliTis:faster
Human ch~ri'onic gqrta:dotrophin can be than that of the mother .ai:td: t he usual rate is
:d etected }rom the rilatema.r tii9~ogical fluids like 110-166 beats .p er min'].lte compared to 60-80
serum ari:d UriJ1e .as C,~ly. as B:t<;> 9 .pays ~ter beats per minut'e of th~ mother.
ovulatiqn oependmg ~)n: t.t'ie seh'sitivityof'the tests
used. Leveis of.hCG increase from the day of Special precal,ltion .m~st be observed that the
i.n:;plantation with.peak levels .of about '60.-90 days FHT and. not .we. mat~r.P?J pul~e is. he;ard sin~e ii1
with .s~rum levels of approXimately 50,.000 miU certain m~temal co~hcliti9ris, the. p~ ~rate can
and decline s'lowly ,thereafter until .a nadir is be increased likewis.e . These :cond.itions .a re
~eached !J..t.about.14-16 weelcs.o f.pregnancy. mater.nal .fever for whatever reason. .d rugs (e.g.
tocolytics), :aird -thyrotoXicosis.. Frequently~ the
. :Most . co~ercia1ly available tes.t s will. show .FHT-is. heard with the ordiriary;stetho~.oope by,th~.
pOsitive results in only-44 pcrc~nt.of.cases, with a 18u.. week on the .av~rage. 'With a more 'set)..sitive
detection limit of 12 ..5 miU
per 'ml. lrtcrease.d inst~ment using theDoppler.principle, the FH'f

Stanned ey: ~
 CHAPTER 15: DIAGNOSIS OF PREGNANCY
can be detected ftS early as 10-12 weeks .i n almost
all cases.
.Fetal echocardiography can demonstrate as
early as 48 days from the last nonnal menstruation
i.e. 6-8 weeks gestational age. Real time
sonography cah likewise demonstrate fetal heart
action and movement by the second month of
pregnancy.
Other rounds that may be audible through the
abdoin.inal wall other t.M,n that of the FliT ar~ as
follows:
1) F\lnic souffie or umbilical cord s<;>u(ile
~) Uteri'le souffle
3) Sound from movement 6f the fetus
4) Maternal pulse
5) Gurgllilg ga~i in the mother's gas.t rointestinal
' -. tract
' Th,eftih12'roumeis produced by the sound of
the blood:iusbingthrough the umbilical arteries.
It is desCribed a~ ,asharp whistling sound that is
.synchronous -Witb the fetal beat. The. uterine
ao~'is'a .~ft bloWin,g sound that is ,s ynchronous
With th~'l:Dafemal pulse. lt is usually appreciable
near bo-tli;)!iiypogastric areas.of the abdomen.
Th~ $riwtls are due to maternal b~ood rushing
thi-o'Qghthe dilated uterine vessels. Sometimes,
it can be heard with conditions resulting "from
in~ now through the uterine vessels. Also,
the~ ar.e .oo~e woirien whose aoruis ere unusu-~y
tou.a:--oilier-s-oun'ds lliaf"iiiay resurcm:~n:o-r-s
would be fast.in.aternal pulse (a~ in fever,
thyrotoxicosis and drugs}' and other gurgling
sounds of the gastrointestinal tract.
f'erception of Fetal Movement by the Examiner
After the 20th week, active fetal nJ.Ovement may
be seen and actually felt by the examiner. On real .
time sonography, actual fetal movements can be
observed much earlier.
RecQgrtition of Embryo or Fetus by Ultrasound
. Techniques
The advent of transvaginal sonology in the past
decades has .revolutionized the recognition and
management ot ~:rarly pregnancy as well as its
growth.and devdopmeri.t. The use of the vaginal
probe gives the opportunity to assess early
pregnancies better and with more accuracy.
Scanned 8y:
253
A gestational sac may be demonstrated by
abdominal ulltrasono~phy after only 4-5 weekS'
menstrual age. A gestational sac as sinall as ,2
nun co~ponds to about 16 days from ovulation
or 10 days ~~r implantation. . By the 5-tb -.veeic, all
sacs should bevisible and by the 6tlt week_ the
fetal heart beat must :~;>e detect~. Up to 12 weeks,
the crown-rump length should be predictive of
gestational uge Wjthin four days..
Other information about the pregnancy that
could be verified with u1trasouhd and thus
become vr;ry help~i in sub~ent m~eJX1ent
include presence of bli.ghted ovuni~ n umber of
fetuses, Cf;t:Qpie gestatlon. presenting .part. .fetal
a.not:na1ies. hydramnios and detetion of
intrauterine growth restriction {IUGR).
Difier:enttal Dlagn~:ob
There. are. tUne's , whell. pregnant;y U!i-Y ' be .
mist.akeri.- for. ,()ther c~hditions.. t,l'~~ ~-~~ul.t. _. in
enlargem ent of . th~. ,..abdcmen .. ~,_;g . ~;tp~a~ .
(especially fund9.l solitary .subsexp:U$ 't~~9'h
adenp~yosis, sOlld ovarum~s.;h~tom~.tra
.and th~ iike. Howe:v.e r,. the mote sensitive :hCG
te.s ts and Ultrasoun(l shouid sett)e.the problem-
easily. - - :/f . .. ~;j,)~ .. ~- .
...-. lr.t., . ' . t f, .\; : ~.' ~-= t ~ .:,
Ps~docyesis . .'<... .1: ~ .~ .:.,;: .. '
:~::e~!:t.?~.-~~~-~.! .~.~~~~~~
spunous pregna,ncy .
p~~~~J:.~r .
occt1t m women l).ea,nng
.~
pienopause or-~m- those w.o~n-who are strongiy-
desirous orp~~ey. The patient p:iay actually .
feel o.r .have some o.r ~ority .or .t he signs and
symptoms of pregnancy with-out re~y being
pregnant at Sll. A Careful assessment including a
bimanual pelvic examination will lead to a correct
diagnosis since the uterus will .be evaluated . a:.
small and of course none of the positive signs
enumerated 3:bove will be present. Ultrasound
_v;ill negate the presence of the pregnancy and
more importantly, will convince the patient that
she is not pre.gnant. Sometimes, he\p from a
psychiatrist will make it easier for her to accept
the situation.
ldt:mtification. ofF~al Life or Death .
The diagri.osis of fetal demise is oftentimes a
difficult situation . espeCially in patients who are
very conscientious irt coming !or regillar. prenatal
chec;~-ups. In about SO percentoftases, the cause
~
 254 ~================S:E~C~T_'"'".:-Io:~:-1:~- =C=LI=N_.-tC=A=L=AP~P~R=O=A=C=H=T~O=P~R=E_-G=NA =
1=11_:..,. . ---~- ----------~~:~~
:N_C-_v-_-_- _-_-_-_- _-
---

of death is unexplainable but it is important that Tobacco-stained amniotic fluid obtained by ;~:';
every effort be e>-.hausted to establish the cause arnniocentesis of amniotoll)y strongly suggesu . .
cf the demise . Most will resort to sonol.ogy fetal demise. Ultrasound can also documento~
whenever available to es~blish that the fetus is or anhydramnios as well as particulate .m.aftera .
non-viable. In remote a:tea$where ultrasound is floati~g in the scanty a mniotic fluid.
not available, -liccessible or ~orda:ble, the clh<ician
must ,relay on serial bima."lual ~lvic examination Radiographic evidences of fetal demi$e are
and a th~rou.gh search of the FliT with the rarely used at this age of ultras ound but" they are:
ordinary -stethoscope. 4'"1 cases of fetal demise,
the uterus may cease to grow or evert become 1} Overlapping of the fetal skull {Spaldings sign)
s~aller due to shrinkage or collap.Se fetal of
. due to the liquefaction of the brai,n.
skeleton and ~kull with liqufaction of the fetal 2) Exaggeration of the fetal spine curvature.
br$.i.tl. ~~cy tests tnay not be of much help'
at this pOirit since trophoblasts of the placenta 3) Demonstration of. gas bubbles in the Jet>..1s
continue to produce hCG f<i>r several d.ays or weeks (Robert's sign).
after the fetal demise.
SUMMARY
In the latter half -of pregnancy; when the
.patient has already ~rieti~~ ~qu1ckeJiin:g' the The .availability of commercially 'over-the-
typicalstpry iscessa\..~n of.ietal movements~ .S0rne counter' 'do-it-yourself pre~ancy kits that' are
{~ mother m~y ertoneoU)ily inte(.pret positional sensitive enough to diagnoSe most pregnan<;ies
r-; ~~for fetalmov~~hts ,as the retus.fioatsJn. and the adve~t Oi_ultr~souild have made .the
~J. -~~i~~~nmtt: "Ifthe~fetu:s=-ha.$:.:been~tleitd..for.~ diagliosis: ~f.pr:egnancy."a.;r~liv~ly.;..~_ ~Jo~::
~-~. ~"Cd'tilin:clues:.ma~:be obtitined froDL.t he..~ .. Llte , clinic ian. ._llowevet..on OCca'$iC.ns where: .
-~ pbyalcal~tisn.; Pati~rtts. viithhypetinnesis availability,. acces$ibiUty ,or.:afl'crd:;:.bility Qf. these
.; -mY-?.riet.~.v.omit anymore; p~tients with testsb~omeac<>.ncern..~ goa<:i!rustory. ~~d .
"' .h~n. iAilY...:...~f!~~wAJl!~-i~l~. p~~~W,:~;. . physi:cal. exan.llnation"inclu.~;a:wcll-4ot;te pelvic.
tl\.f;lr~e-aita rn.ay lose their turgor . and evaluation.a.re:im:portan:t 't~ls'on -han4 Tbi~iis
~i"gePPent;,-and .t he patient's weight.may .start where the pr:esu.tnptive. probable and Jiitive
to 4~~ A decrease in fundic height may be signs and s:Ympto.1Jl$ of pregnancy will :b e most
a~p_recl_J1ted. Oil in.
- tetiial exan:lination, a soft use{~l.
~-ua~re~m~y-l)e :celt lruougri:a. --son
ceiVix 1har iiiilfliiive:arreaa:y-srartecf lo . . anale~ Once p-regnancy 'is establlshed ..a:s-~blewiUt
Efforts to hear -the ?HT with. 'the st~thoscope .or ptoper age .assigned, . proper. ina;nagement and ..
~en the mo~ senSitive Doppler are unsuccessful. monitoring q:m be :started:(prenatal ~) to a.s<iure
Ultrasound should settle the issue <>f..life anddeath a good healthy fetus. to .be bOme at the most
Withd emonstration of fetal heart activity. a ppropriate time.

POlNTSTO REMEMBER .

The improv.ement of more sensitive endoc:rine tests-of pregnancy and the advant of.ultrasound
have revolutionized diagnosis and subsequent management of pregnancy
Tne manifestations of pregnancy have been classified into three groups, namely 1}presumptive;
2) probable; and 3) positive evide.nces of pregnancy.
Presumptive symptoms indude: Nausea with or without vomiting, disturbances in urination,
fa~gue, . perception of fetal movement, an.d breast symptoms

Presumptive ~igns inCiude: -Cessation ~f men-struation, an~tom1cal breast changes, changes

.In the-vaginal mucosa, skin pigmentation changes, and thermai.Signs .

Scanned 8y: C
 CHAPTER 15: DIAGNOSIS OF PREGNANCY -~' 255

The probable evidences of pregnancy consist ot Enlargement of the abdomen, changes in

the slze, shape, consistency of the uterus, anatomical changes in the cervix, Braxton-
. Hicks contractions. ballottement, physical outlining of the fetus, and positive results of
endocrine tests
The positive signs of pregnancy, when found, guarantee the presence of pregnancy.
Positive si_gns include: the identification of fetal heart action separately and distinctly from
the mother, perception of active fetal movement by the examiner, recognition of the
embryo or .fetus by ultrasound.
There tnay be other sounds that may be audible through .the abdominal wall other than
tho.se of the Fin and thus, may mislead the examiner. These are: funic souffle or umbilical
(X)rd souffle, uterine souffle, -sour.d from movement of the fetus, matemal pulse, and gurgling
gas In the mother's gastrointestinal tract.
Pseudocyesis or 'imaginary pregnancy' or spurious pregnancy may occur in women nearing
menopause or in those women who are strongly desirous-of pregnancy. A carefulassessment
and ultrasound easily resolves the dilemma.
the diagnosis oi f~tal <temise is unexplainable in about ~9% .
... ,Oiagnos:s of fetal death is oonfirmed .by sonography.
- "t . . .. -.7:tj ,' ~ . . ......
.-~;':Radiographic evidences of fetal demise are rarely u~ed at this age of ultrasound b"oftliey::1.:~ "~ .
are: . overlapping of the fetal skuii .(Spaldlng's sign) due to tbe liquefaction of thetbr.aln;. \~ ,: ;_ '
exaggerEtion of the fetal spine curvature, and demonstrati_on of gasbubbles in th~fetus---- ~ ..;..: .. :.

- '2~:.IRobert's sign) .
. ...:.

.. --~ .. l - '-.
--
. . ~- . - I.
. . ,, ' ~

:. .

American College of Obste~cians and Gyneci>iO&i'sts.

H~ej rut-Nausea and-vomiting in early pregnancy:
Its role in placental development. Obstet-Gynecol2000;
95:770.
CUnningham, Leveno, Bloom, Hauth, Gilstrap Ill,
Wenstrom: Williams Obstetrics 22nd edition 2005; 204-
207. . Taipale H. Predicting delivery dat!: by '!.ll.trasound and
. . Gabbe Obstetrics Normal and Problem Pregnancies 4th
edition. Churchill and Livingstone. 2002; pp 10-15.
:American College of Obstetricians ar.d Gynecologists.
Avoiding inappropriate clinical decision s based on false-
positive humtln chorionic gonadotropin te~t Tesults:
Committee Opinion No. 278 November 2002a.
Mariagement ofreco.liTCJltearly pregnancy loss. Practice
Bulletin No. -241 Februa.F)'-2001.
American College of Obstetricians and Gynecologists:
Physiology of fetal-h eart response. Pi'actice Bulletin No.
9, October 1999.
lastm enstrual period in ea,dy gestation. Obstet Gr-~1
2 001; 97: 189.
Scott JR, Gibbs KH. Danforthae's Obstetrics and
Gynecology, 9th edition August 2003 Lippincott,
Williams and Wilkins Publishers.

. ..
-~
_,

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. r .
..... .. . \. . , . . ', '' ' , I

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 16

PRENATAL CARE OF THE

HEALTHY WOMAN
ARETAs P. SINGSON-ALDAY, MD

Definitions
- 6(.-1 cMt"\ ~C)'l GtJ(N (_ __ _)
Estimation of the Duration of Pregnancy
- Cb\tf ~,1\f)A;rrf
Initial Comprehensive Evaluation
History
-HrI - Hl1~'\j Clf /ta4tf Jlfw 2
Physical Examination - ~~{).IJ ot f'jlt~J
Routine Ante~rtal Tests -famf\':1 hiJi\}ll:j : Ot.A,Hff:J,J<-i""to.Mv, CAl
Prenatal.lnstructior;s il.t.Mf Ill )UI )\4

Subsequent Prenat2l Care "fAJf 1'1\.i..klA\ !1JJh'j ( 1-1'\A]' ilhttaJ-4)

Maternal valuation .l-1~1 /Jl:I..M"
Fetal Evaluation- -vii W v\11 1'14-v
Subsequent Laboratory Tests -Joo~t-t~u lv~
Nutrition During Pregnancy . -Ott..-'} ll ttll.ci1cl - FAr'""" \MI~W.,...-.; 1/\1~ 1~
Recommended Dietary Allowances . kfrA~~ qr~~ JUC( , ~bA (~C.)
Calories ~ doJ<-_'! Utv.. -~ ~ . ~.
Protein - t- h wt!J(.J (~~~ c( Ot7f1J ~pv,-ill)
caibOhydrates Muu \1-'\-\"1 /11J~"j 1t11-1l~, UJ..f,tW
Fats -f(l.(( ~ ~tJ\1 .
Dietary fiber -Jr~'J ftlrt1~ ~JLmj
Minerals 1tA rl11'":1
- O)fJJ-ctv.Ht't\ WJlll"j
Vitamins
Breastfeeding "(/(/1 '~ .
-Nt1i 0( d..U1~ -NJOi V~A t (~'"111'\111
General_Hygiene
0 ,,rfl.1 tl(tv wc...,"l1) - tb
. tl.-*~r1-J.. .
Counseling
'' ~ ,./ JAI.l..i (lrttr.,LAI'-'1'-')
Prenatal -toMr1ttt1,,..A,
trv
:
u...- U'.. 1
Drugs, Medi~tions and Immunization During Pregnancy
Employment
Travel
Smoking/Alcohol .
Caffeine

Common Complaints During Pregnancy

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 SECTION Ill: CUNICALAPPROACH TO PREGNANCY

1<>d;ay, th.e con ce-pe of prenatal c -a:re Pregnancies may be classified according to ..
.encompasses risk ass.essment, medical care, -~al v:iability. or duration of -p regnancy:
. serVice's; nutritional ..counseling,. pati.e~t
edu~tion, and
_psychological support; for many, A non-viable pregnancy is one lasting ~O
it_aCtually begins. before conception. 1 ~enatal.care weeks {140 day~) -~d ,can res ).lit in .a ~pont:.aneous
is :the-r efore, a planned prograrii: of medical miScarriage, inducedabortion. ectopiC pre:gn.aD,cy
. evaluation and management, observation, and or bydatidifQnn mole. Viable pregnancies -are
,cltidition of the pregnant wmn.an directed toward further classifi into 3 types:
..,:~~g pregnancy, labor, delivery, <>.nd th~ A~-n.H. :!:.w ..:. :.
..pp1Jtpat-qrm recovery, a safe ~d s:atisfying A .p retenn pregnancy lasts >20 weeks to <37 ~;}$.:
.. ;expenence~2 !n.vud~ b]'LAmcrhKtlt~
. ~ . . . .. .
. '.:
. . . . . . .. . .
w~ fl41 ;~2.~9..days~ ._(D'h _ Jft ~h ':J
. . . : . .. . . .. . . . . . . . ~~. ; _.
'
. . ;
.. , : Awell4iesigne~:prenaW $
program . ;;hould A 'teTl'r.. : p~cy ~a-sts :fro"Q;J.:.: 31 week~ to 42- :~
'-~the opportuhities 1) .for the phys!ciah. aria weeks. .{759 ;_ 294 days) . -.~-
,.
)tn~ patient to become betteracquainted! ~) f 0r ;the
:~,Ysidan to .lea.rb. sollie.~g about the ~tient's A p<J,st.;.term p,regn.ancy ),as~ >42 weeks ~(2:94.
. etniooai attitude toward prcgtJ.ancy and laP6.t, d;lys). . V.~'>JM A-...., Akl't--~ -- ~~ 'H'fl'lik .
- ,~}:i~:ixi~trUction of-the patient her h').lsband and FPAL
.:r :- ~.#(~S.l care forh.et~1fartd t:h.!! Cbillir)g ):>aby; a has"be~n :cu$t9mazy. t c sUp:unaiize 'fue
~*.i. ~. :.,~n:~ '~)!vptima\ in~ttuction .of the patient a:hd her obste~cai. histoty ~y ~ ser~-. c;)f ~wts -~-it,ed ....
::: ... -:liu~d tn a -p repared childl;>i.rth :program, by hyphens .as: ,:follows; ~-;."t-'2-,5~ The iirst-~igit :
:~- <:,_>i-'-k_. :... .. . J4ni1: pdllt Dn\j . refers to tlle n,1,imb#: ofterm{JX)-~ttetm infants,. :
..PEFI!WIl ONS - - +-"'~"~n,..,toth~num,_..__ o
. f.~:..rrn p~.. r.~......
..,:.<r :~ _ . .... . -~i1~ti: .IJJI-~:pu!.(rt,~ . ~; -;w;d~~- tli;~u.m;;; o?';~;:~bi~: .
. .' . ~:prtr!upanus ~.:worp.anwho ~~ -~ deli,v~ed ": and the fourth _. to tile numbct:.of children
c :~~Ce'.O"f'a Jetus or fetuses. .. w hich_ reaebed... vi9;.bility -.~..ntly ali
c... .;;... ...~ ....."'. . .......... :,.,.<L~-trl ~. . . . . '..
. ."~d
\..,.,.~''.

" 2{)<~> week 0 f pr~gnancy.o!"


. . .
~- d th
vc:;yon

e- ........... ~
The . ~

"'""' ,!..qJ.-.' . -l:il-
..,.....,ple>7iven~.,;>di
.~
."""'
;.;:,;
~I:<,;W-1.
.
~.... ---~-.... ~. ~ ~e.
.......~. ,_.~..:
. t...:'k:
. ,. ti. 't .h. d
U;l.4. . .,.,.e :w. en . a

. ~-s~ .?!.a~rtio~~: Comp~etion .of :~Y _p~cy. _..five .:t~t~/:P.Q:$ttenn dell~e~~~~ :o.Ij.~ :-p~et:~-~=- :,._
. . -~
.~-!.~-~ -.the s+""""e
106 .
of aborhon

bestOws rn<>_ntu
- ':I
upon d C!I'.rery,
1- . . .,,..,,..-_.,_
...;.:;..... . ~ . -'d ,Q. ,:..:: -1::::-t.J_-
'-"">' :.,u~n,~.;~.OpS an '.u.V~ . uvt~g ~t:;n.: . .
-

'a~ : . .: This series of_ <P.glts .~.bvj,<n~_:sly ,.gjY~s a, niore.. .

. :~: :-~tfpara -is a '~o.tnan w1m P,as: eompteted
; :~~orm:ore-p:-egn:anci,es":'.tb-viability,_. Itis---me
'.:, n.~~o!'J>re"gn8nci-es--re:acl:r:i.O:g-viab,ility; andnot
.' ~ nUmber of fc;tuse~ delivered that determines
.'..~~ ~arlt;y i$ the
w~ethen'l. SingJ_e fet\,Js,
. iW'iiiso r quadruplets were bam alive er .st:i+lborn.
... :A :nulliravida is a woina.n wt.o;is not.now .and
. :n~er b een p regnant.
.,. . t
.:
. A gravid(l is a woman who i~. or h:as been
.P~tirre~tive of pregnancy outcome. With
-~e:~est~blish,ment of the first pregnancy , s he
-~~es a prim'igravida and \'1ith successive
~p~gnimci~s. a m:r.iltigrauida..
. f.. -nu11:ipara .is a woman who h as ne ver
... co'm.pleted a pregnancy beyond the stage of
vi:a:t:>tlity -or beyond .an abortion~
CQxnpl~t~ o~t.MI.i'c. -i.I;l.form~.t:l~n th:. the :mcere
deSignation GS:P5. ~~.;; ~ ~r~l.-' . , .--~ -
...q-eiJ~~~l: fiJJ!t\j: f tf-t;r-:-tnfi{~"-~-~MM--~ --1- _. . _.
.. _ __ _..,__ -- ...... . ...--....:-- .. __ __ _ _. .. - --...
ESTIMATlvN :OF 'i'HE ,PURATION O:F
$aiDe
PREGN~eY
Pregnancy be;gins wi th ,fe~tion .oi :i.he ..
ov:u.m. Since ihe -::x:a;ct time tb1s eten.t occut:i-:is ..; .
:usually rtot. \cnow..n, the ~~~ct .auratian .of a ::~
. p~gnancy,-cru;l.I').O.t be asc~rthln~d. S4lce duratiori .
of pregnancy is one . of the .most -importa:~t :
para+net~rs to be consid:ere<i when ~g-d..ip.iCal .
jud:gments, an accur.ate d .e t:er.miilation of
.ge$~tional length_is qne .Of the ~b'st important"
functions of pr~natal C?re. :sev:~ methods an
be used .to eStimate the .dura,tion Qf a pregnarlcy .
with reasonable a.ccuracj.
Naegele's. Rule

: . :; .. A parturient is a woman i n labor. . The -~verage duration of .pre~ancy calculated : :

. . ..
. . .from the first 'day of the la~t menstrual peribd ,
.. A puerpera .is a woman who .had just given . a~~~_ges dose.t o 280 days, 10 .,lunar m()nths ,cit
. 'birth.
. ....
' ' . 40 wee~;. Several large studies h ave found the l

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 CHAPTER 16: PRENATAL CARE OF THE HEALTHY WOMAN
----------------------~----~~----------~----~~----~~------------ ~~

average durationof pregnancy from the flrst day oflightening.4 Johnson mentioned that the fundic
of the last menstrual period to range between 279 height in ems is numerically equal to the
and 282 days. A convenient method of estimating gestational age between 18-32 wee~s. (Fig\lre
the date of confinement is Naegele's Rule: to the 16.1)
first .day :or
the last nortnal menstruation, add .
seven days, s~btract three months, and add one
year to obtain th~estimated date. of confmement
( EDC). For example, if the . first day .of the last
normal menstrual perioQ. began on July 10,.2007,
the EDC would be April17, 2.008. Obviously, this
meth.Qd is b~i~d on the prelilise that most wcmen
ovulate a~ut day 14 ofa '28-"day .cycle. From this
method of calculating EDC, it is apparent that
pregnancy "begins-on the av.e rage 2 -weeks before
owla:tion, whiCh is qwte en:oneous. Nevertheless,
clinician$ persist ln using gestational age or
menstrual age to identify events in pregnancy;
whereas, embeyologists .a nd other biologi-sts
-empl()1 Wularo.y cge or ferl:ilfMJion. age which is
2 W:eek;s.you..'lget t'h.a:n .m enstrual i).ge. '
. .. . .: -

'' 1f u.re.woman's date of the last ov.ulatic.n. is

J ..~-' . ..
.' . . :-
. . . . -~--~-~\'~:::.:...ryt~:~~,;;: ..
. khown;just add 267 .~lays to .estimate the date of Figure 16.1. Heighto'i.the fundl1s at'diffe'f.r!rit'ages
~~vY~ :.. .
~- .. '
. of .g estation.
. ~~~ ~ckemng ,.-:' ~:. :. ;\ ..
: M.a:ternal ~rception of fetal movement can Panlilio,. et al. studied mean values. of.'ut~tme
fu.rnish an est:ixnate of the dllra.tiono f.a p regnancy. _hei&,ttin p~~ ' Flll.pino W()IJlen by..IQ.et\~u.ring
Moveto,ent U$uatly perceived initially betweert the thefundic.~~~~~~~'!:!~::&~~~~~-i!i~.~ ..Th~
16111 m:rd t8do weekii m a multipaii!f a.nawo weeks lji~o<rii~~~- :!~ ')n~asut~Jundi~- heig..lit.:~. :..~,
J:atetmapdffifgraVia~ -Tliis meffiocHiuseitilmore follow~; The s:uperior bo.r der of the symphysis
as a confi.nxlation .o f the other parameterS rather pu~i~ and the top of the fundus were Identified. ,
,than as a prhnaty method of assessing gestational by palpation. A tape(:a)ibrattti iri ~timetera was
age. applied over the abdominal curvature to measure
the. distance .belwe-'-4 .:th~ ~physis p uQis and
IJetghtof the Fundus the highest le\rei of the uterine fundus measured
off'from a vertical line drawn at the level of the
The prQgressive enlar.gement of the uterus can greatest thickness <>f .t he fund~s. Results of the
be followed. during pregnancy, and the height of $tudy .are 'depiCted on the graph (Figure 16.2).3
~e fundus can be used to estimate gestationa l
age. Ultrasoun4
. .
. The fund\,ls can usually be felt above the pubic Although dirucal ..estirnates of gestational age
~ymphysis l2 weeks a.ftei the last merist~a:I at~ useful and rea~:;~nably accurate in women who
period. At .16 weeks, it rises to . approximat~ly have regularmen~t,nl~cy:cle!?. a..nd who re.meiP,ber
halfway between the . symphysis and the the first day of their 1a$t mens.t rual ~riod, the
umbilicus, a.nd it is at the level of umbilicus by 20 obstetriciari must frequently estimate gestational
we~ks. By the
36th week, the fundus is just below age onthe Pa.sis ofinadeci\iate clinical infoimation.
the ensiform cartilage, where it may remain until Fot: example, women :can .become pregn~~ while
. th~ onset. of-labor in the multipara. ln most lactating, .or .foU:owin,g discqntinuanceii.e >Loral
.primigravidas, the fundal h eight drops a t the time contraceptives . Rec(fnt advances iri ultrasou~d

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2:60 S6CTION Ill: CLINICAL APPROACH TO PREGNANCY

P c~ elz.
INI'I'IAL COMPREHErJSWE EVALUATION

The goals are the following: 1) To denne t.'le

health status .-of the mother .and the fetus, 2).To
determine the gestational .age. of the fetus, 3) .To
initiate a plan for continuing obstetric -ciu-e an<;l
4) To -defme tho.s e at risk for COlllJ>li$1tibns and to
minimize that risk whenever possible.

History
. . .

i .. . /. The history~taking follows the convel\tibnal

r.~~~4+++rr~~~HHHH~~~

1-+H-+-I~-+-+H-+~~-4.-J.-J
pattern and should indude a 0mp~tc past and
'fa,m ily history. and a . good obstetrle resume. The
. ,:~++++~~~r+~~~~~r+44~~~ latter .should. plabe emphasis on the menstrqal
. : ... ..
, ;_ history:, evidence of infertility ~da ~~ inquiry
~r++4~~~++~~~44~~+4~~~
.. .... '
~
into previous pregnancies. The time :1n :geStation
when hibor occ:Qrt:ed, its dutaUo~ . the type of
delivery. a:ny complication$. and ~e ~eight :a nd
~++~~~r+~~ -: ~
+4~ ~
. ~
~r++4~~~
. . . .. .- the sex of the bal;>y .shtm!d be :recordf;d l"9Utinely
t-t-+...r+
. -:H-HH-i+ . -t,+:r'+. +l-+'-14'++4-::1:...:.~---.~,4-i for: all previous 'pregnancies. The indications and
conditions surroundiii,g operative ~d~ m.ust
be ~efully: revie.w ed, and,ev.aluated~. An :inquiry,
should be made .t~4itig the po~.tpartUttl course
~ ~6.2;. Co~nparative.~ valu~ of\\texjne.height of.both the m:other.and theil:lfant; M.d .Ute latter's
loc:alanli!orei~u~dy. subsequent well-being. Inqu~.:y must ~catly
be made with regards to symptoins .(luri.p.g the
.presentpregnancy.6 :A no~ showdbe4\4dedabout
the woman's reaction to her :e ut:rent p~~cy.
.A dietary history is .u$eful i n..~stu.na.ting the
. imagin.g .h:avc made fetal :a~e ~nd .growth rutequa~ of her.' nutritional iJ:?.take.7
~sessrileril ..."ssiDfe. :WJ:tli ar~sonaure <regreeor
.ti~<:Y:~-~~gihiU'liftiitooun<Ftaitdefect a t>hy&lcu EiiiiiilliiHon.
pregnancy-a:t4.:5 weeks (menstriud.a.ge) gestation
c<'ittespoilding to tAe J}':..bCG conc~htratjon bf A thorough geher:al physical dalbifia:tion
:rsoo.-~'000 tniP/mt.U the ~-h'CG concenttation should be done. This includes the .~\llaJ' fundi,
is greaterthail4000 ml~fcl, the etribtyo should the e~s. nose, heart and. lungs, breast$, abdomen,
:be Visurilized
.
bY .all teehnique$. '
and extremities, weight and blood pressure. At
the time of exa.rn:ination of :the breast!!, the vall.le
~~ '~Y Trlm;est~.r$ of breastfeedin:g &hP.Uld be
impres$ed on the
patient. In t he exa'ination of t.he lower
. . lt has b~come a usual practice to divide extremities, the venous pattern ~hould becarefully
preg0ancy into three equal parts 6C trimesters, of recorded at the irtitial visit, sincevanccsitjes tend
3lightly more than 13 weeks or 3 calendar months to appear or worsen during pre~cy.
each. There are cetUIJ.n major qbstetrical problems .
that cluster in each cifthe~e tifue periods. Most At or . n ear term, the incidence of the :variou s
s:Pontaneous abortion oce~rs during the first presentations is approximately .as follows: Vertex,
trime~ter; vthereas prac.~ically all cases .of 96%; breech, 3.?%; face, 1.3%; and shoqlder,
'pr.egnancyinduced hypertension be.c ome 0.4%. Two thirds of au
vertex p~tations ~e
c.Unicaliy.evident durlng.the third ttime.ster. What in the left occiput position to .conform to the
is impera:tiveforan ideal:obstetrlcal management pyriform shapeof the uterine caVity. Although the
is to know the a ge,of the fetus .and the appropriate fetal h ead is slightly 'larger than th~ breech; the.
clinical unit of.measurement iri weeks of gestation entire .podalic pole of the breech with its
.c ompieted. extre mities is bulk1er than the cephalic pole .

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 CHAPTER 16: PRENATALCARE OFTHE HEALTHY WOMAN '261
--------''-------------------~----"------'----------, ~ ....

Although the incidence of breech presentation is
only 3.5 percent at term, it is more commonly seen
inpremature pregnancies.
Diagnosis: Lie, Presentation at".d Position.
Severalmethods can .b e used to p~!termine the
fetal lie, presentation and position. These include
abdbminal palpation, vaginal examination,
auscultation, and when in doubt, ultrasonography
or radiography is _requested.
1. Abdominal Palpation (leopold's maneuver)
-- - ? - t-~ ill1lr!th1 . -
The ftndings .on Leopold's maneuver pn>Vide
infoonation about the presentation and position
ofthe-fetus and .the extent to which the -presenting
f tP' A'-" j
part has descepded into the pelvis. The degree of
cephalopelvic disproportion can also be gauged
by evaluating the extent to which the. anterior
portion of the fetal head overrides the mother's
symphysis pubis. The ma..1euver can be perlonned
throughout the latter months of pregnancy and
during the int.erV:als between uterine contractions
of labor.
The mother on the examining table with her
abdomen bared, the four maneuvers suggested by
Leopold and Sporlin are conducted systematically.
For the ftrst thr~e maneuvers, the exammer stands
at the nght side of the bed and faces the upper .
part of the mother, but reverses the position and
faces the lower part for the fourth maneuver.
(Figures 16.3, 16A, 16.5 & 16~6)
t HcHlVCA~ te<NWt .
cw; 14 fd'-1 ~lilnM

ba~()l
H-h"~ ~~lrfr .. ;-;:-~~~~~
.... ,..,.
:2'. \-
:;~- - ~ . .

,-- :

\
. Leopold'a-lirst-maneuver; Determines-what Leopold's:sec!:>n~d.'man.ueve-r. Deten:illnes on
Jet~ part:oC.cupie;J -the fundus. which side.is the fetal .back.

-:\
.: \ .: ;
'y
-.
-

' .

.,:-
Leopo14'a third maneuver. Determines what Leopold's fourth maneuver. Determines on -~'
fetal part lies over the pelvic !Jlle_t. . which side is the cephalic prominence. In flexion ~~;
attitude,t>cephalic prominence is on tlle same-~: :
side as the small parts. :'-1:'1,
. .
Figure 16.3. Maneuver.s of Leopold in cephalic presentation left occiput anterior position,

Seanned By: ~
262 SECTION Ill: CUNICAL APPROACH TO PREGNANCY
Fl.PR 16.4. Maneuvers ofLeopold in~ prtsentation.
Figure 16.5. Man>:u vers of Leopold in transverse lie.
Seanned By:
f
..y',. flj.
Fl~ 16.6. Palpation of the head in fa.ce pre~tation .
(LM<t). .
t-. : J ,I
. b-. \
First Maneuver 1 FundatGrip .{LMl)
. . The exa.ttJ.jner .gently palpatesthe.fundus with
t he.tips. of. fhe,.fingej-:s..cf:botb,.hs:nds, in.order- to ...
define which fetal pole is prsent.: Sensation of a
latg~ nodular bod.y .r epresents the :buttocks or
lowt;r extremi't.ies .o f fu,.n du.s iri cevhalic
presentatiQp; w hile palpa$g. a har.d, - freely
movable and lJallotable -part..repre~ntS' the fetal
head at \the -fundus,in::b reech:presentation.
Second Maneuver I Utnbili~ Grip (LM2)
Palms ofthe ~er's .};land~ are placed on
either side of the mother$. .abdomen and gentle
but deep p:-es~trre is exertetl'. On pne side, a hard
resistant convex strtlctute represents the fetal
bac::k (right or left); on the otijer side, numerous
nodulalions ~present the fetal .small parts (left of
right).
Third Maneuver I Pawlic's I Pawlik's Grip (LM3)
Use of the thumb and fingers t>f one h a nd,
gras p the lower portion of the ma.temal abdomen
just above the symphysi.s pubis. If the fetal head
lS not engaged, a movable, roUnd and hard Pody
represents the fetal head in cephalic presentation.
LM3 is considered ne.g ative.if the lower pole of the
fetus is fixed in the pelyis or engaged.
In shoulder pres entatjon, the 's ide of the
mother towar~ which the .acrom,ium is directed
determines the designation of the position as right
or left acromial. In either position;
..,
the back may
C
 16_;_PR_.,~_NA~:t_AL_C_A_RE-:-
_ _ _ _ _ _ _c_H_A+P-_TE_R_.._ -o~F-TH_E_
be directed anteriorlY or posteriorly to di::?tinguish
dorSoanterior or dorsoposterior, respectively.
Fourt.l} Maneuver .I Pelvic Grip fLM4)
This step determi."les two things:
l. Engagementoccut:S il both haluis converge
from each other since the p resenting part has
entered the pelvis. With the tips oft.~ fmgers
of each hand makin_g .deep pressu'r e on t}le
~ori of the ajQ!J of the pelvi inlet, of hand
descends more deeply inw the pelVii:i wliile the
o~er band is atTeS.ted ~riet. ln LM4, if the fetal
head .is not e ngaged, the cephali~: prominence is
~ted; however, it is considered .n egative if the
:f etal head is engaged.
. .2. ~~:pt'Qm:b:l~rtce ~th.e E..~me side of
s~~ rn~ tbeheadisfiexed and the vertex
is tbe ~tin.g, ~ while cephalic ptotninence
palpateihm th~ ~e $ide as the fetal b~ck means
the ~head "ls .exten!ied apd the .PreSntin~r Pfu->t. is
the fli\ce
. .
Dui:ihi( fubOr, with:dilatation offue ~ the
diagno~is of presentation and positjon ma:y be
obtained accu:-ately. Presentation;; are identified
as loilows: :s utures and font:atl~is tc)( verte;r,
po:ffi~..orthe~"'feml"face rcft Tac:epie'Stiitation,
s~cfifiiland-Tsclllal--filoerosTITes--f'oi--t:r-eecil
presentation, and a.c romion for shoulder
presentation. _ ..rvvw
, ....hIJ ...., Jr,,........~r''J
~...t~~ .~.fir' H.I'"V"'"'
Pelvic ~~tion h~ liJ~VI : klf-hlll.:, ~
. . . . . . . - ijr,_,n ..~V4.~ Wr1c.(td . .
v:r
In the early ~ontlls, ~purpose of.the vaginal
examlnatic;)n is to .establish the di;:tgnosis. of
pregnancy and
to detennine the presence of or
aqSen~ oi uterine -~'r adnexal pathology. About.
the 7rh month of ge,Station. -one can meal?ure and
evaluatj:: theobstetric pelvis. By then, the pelvic
tissues .are more Telaxed, the uterus .has become
~abdominal organ, and the presenting pa,rt of
the fetus has noty.e.t.e ntered the pelvis. The pelvic
cavity is thus comparatively empty, making it
possible to palpat~ more easily the sacral
promontory and .'t he other pelvic landmarks with
minimal .discomfort to the patiept. Also, the
patient is more accustomed to being examined arid
is less likely to be appr.e hens ive. The vaginal
- ~rir.oJdltd - Lw.J~ C1 (lt'l pi!{I\M) I
,_ . ... ..... ~ ( t.,.,.;A ....1.1t .'1 . .
. _HEA_
_L.:_TH_Y_W_O~
MA_N_ _ _ __ _ _ :::_:. 263
~i:hation .should be performed systematiCally:
inspection followed by palpation. After inspecting
the vulva aild desctibing any local lesions, the
examiner should observe whether the perineum
is anatomically intact .o r lacerated.
Screening for cervico-vaginal infections and
cervical cancer is now considered routine in
prenatal care. The vaginal speculum is moiMened
w.ith water, free of lubricant that . tnight .
contaminate the squamo-:.columnar juriction and
interfere with ob1:ai.njng a meaningfuJ. cervical
scrape. .N ext, the cerroc is inspected for the blui.s h-
red pas~iye hyperemia clui.-acteristic ofprqrtal'lcy
(ChadwiCk's sign). and for 1~ lesions. s uch as
occlusion cyl>t ( Nabothian .cystsJ i)f the
endocervical glands. 'The character of v;:tginai
seGretions is noted. The presence of fO<UDJyellow
liquid in the vagina is associat eci w ith
trithQinOhas; cutd~like .d ischarge .with candida
ilifecti.Q.n.- and grayish d isCharge with Gan.IQe.rella
vaginalis ~tis. Ma:te"ri;al ma,y .'be swa,l~l~~
thedvaginafor microscopic examination:;. Pap~: .
an culture. .!, . c,:~'' <
-:~.~ :'-.,'t.J,>:::...;;r...
'the speculum is removed and digit.a l
examination js pe.dorm~d. with special .attention
giyen to the consistei:lcy,len,gth and di)at:a!j.o~. of ,
the cervix; the ,;:resenting~ (ifia~ P.~pjj,
the bony archltectur e of the pelvis, .an4 .any .
anomalies of the vagilla a nd J)elineUm. ____
Rectal"and~RectovaginaJEXIUJiifiatio-n:s .
.
.~ .~e~~~ -~-~~~i~~i~~~~ ~~~~~~ be .done to
ev~uate the integritY ;.of the petin~um and. the
,.,, .J
.-I.uA~ - .com,pete . nee 0 fth .._, k:-
. e rec~ sp~~cte.r; l o::ddect the
pos~ible pre5enc~ 'and emn:t of a rect~ .a nd
to nile P'!,lt any patbol~gic condition ofthe:rectuni.
A rectovaginai examination. consis~ ~f the
siinultaneous introduction of the middle firtger
into the reCtUiil and the index fmger into the
vagina , may be occasionally indicated.
Routine Antepartal Tests
The initial visit shall include the first dght of
the antepartal tests. Other examinations may be
done depending on the history and physical
examination.
Prenatal Instructionss .~
......
@ iVIJ~
,C'I ( \ ,, ,;A;AV\ f0 If
Scanned By: ~
 .1~~
...
. ~.:
.;--
264 SECTION Ill: CLINICALAPPROACH TO PREGNANCY

2. Begi.D. the antepartum educatiollal program by facto.r s. Those without any anticipated
meanG () pet:sonal interviews, reading compliCations - 80% of women screened, were '
materials and hospital classes. seen. again at 2 6, 32 ~ and 38 weeks. Compared
3. ~lain futrrre visits. with routine PNC, the new model orily regained a
4. Discuss the "economjc aspect of -pregnancy. median o.f only 5 visits . these r esults are
5. Give instructions about diet, relaxation and consistent of other.acts (1999; 2006).
sl~p. bpwel hapits, exercise, bathing, taking
recreation, sexual intercourse, .smoking, drug
and a.lcohollngestipn. Table 16.1. Routine obstetrics tests.
6 . Emphasize danger signals which must be
reported ~ediately. day .or night. These
da.D.ger .sif'-1$ .are vaginal b~. per.siste~t 1. Complete blOod count To detd:m.in~betnatologic
sta~s: to m le wt -anemia
-..oniitU:lg, dUlls and fever. sudden eseape of 2. 'Urinal,~s and urine . . To evaluate tor U'I1 and lCnal
Rl}idJroQl Va.gina;abdommal pain~ .s welllngof c:uitw:e and sensitivity funeti(in
3. 8100dgroup, Rh To determlnc bJiood type. Rb
face, blurring o f vision and continuous statlla, and riSk oClsoimmu-
headache. n.ization . .
4. ~logic test"!or T.o :detectp~$/cuUeut
Syphilis (RPR, VORL} W:ec;:t1;0ili.~~~~~c
Freq~epcy of Visits . trepontmel 'f!:att eqglRd

tra-ditionally, :'the .timlug .o:r subsequent '5 . Hq~atitis B swtace

~-titen
~lti~~==;~
. . ~~:~,pc;s;itnoe.
prenatal :examinations 13 .sclled:'Uled .at inter\rals r~ea:~ir:ldic:a~d
o f 4 :r~ki~until ;28s.:weeb, >then~'evety. 2":W~ .. 6 . . l<u~a-titer ..fq~ ~o9!11tl;785%dmothtta .
untiFa6=-w~ks.,~w..~lcly'>tb~iU't~r::~ ili.'the-~ -thn:ft t;yM\zJ ~: .

~e;'biltq~<:e.-~Dor....
ilif~!)!t;:;t;pat)tat'is
..
patient ~lo~gS-!>to~;tQ~~gh-nsk grouptt,the}Visits.~ ...~~#1-1P~~;~.t!\ .
~eptive,-ilpi!il
rQ~l)W-'1 _
. are mor.e often. .de~nd4l!f on the ri$k factor prt:CautiQJtli~:Deede.l to .

pre~nt. . : '
,.he.,.,.,._ . ~J,nm'f'll!'""' . ~void tnfectiOO. ~- can
~ biOi\ ~k;;\MI Ylll'\ .sev.etdy el!'~:dle ktus,
_ van;iX)'inio~.is~requ.ired
Tft~WHO 1'~..W.Qrlrin.t~rt>\Jp' tha,t~:met - .J!tb4 ~ - vjlll\frW' . P9~
in Geneva m: '19.9 4 recOmmended that women 7. .~ -~lozy T<t '~eenfor,~
. w.P.sm~ .d~~~~
sh9uld mwt at -least".(o\tt ~$ and'lnore~if>'they
have any prablems. The first vistt .by Ule end of Su~ent,Assessmen't:a
.. . ~ .
the V*..trimestt:s: - (l2'W~)-ro~Sct:e~- a:nd ~tteat s. ~c8! Ciilhu:e tor
.anelliia;seieen-and~:tteatsyp!iru.s-that~C'an'~ :be~t . N~'rid:?JO.ffb~~
~ ad{.jre$sed.in earlY p~cy. The seoottd -,isi.t
in the 611.-or 7fb.mo~th .(!2~28 ~l ~d the third
'iliSit or the :eight t'Potlth (32.~J. to screen for
pte-elampsia', Iriul~ple gesta:t ioq ~d anemia. 9. Hemoglobin .
The foUrth:visit on .Ui~ 9~. inrit;h (36 W~e~) lo electrophoresis

'identify fetallie/J're~tat;ion an'CJ .tO :upd~te the

inai.~i'(i\la!i:::birthplate.-. The -~MO. !~ch:nicai
working.group (2001:)added ~- eXtra Vl~1tbetween 10. HlV titer by EU$A;
the firSt and se,comi visit and:sqggest:edthatthese West;m blot ~fl:Ii'v +
recommendations may change wh.en new byEUSA .
information becomes available~ lt s:h ould . be
emphasized that thi s is on:iy a minimum
requ~rement~ and that tnor.e v:isits -may be 11. Olui::ose screenin&
nece~sacy .depending on the woinan~s coi}dition - ~l(- '};t ~~
and needs.

The WHO conducted a mwticenter .RCT wiili

a,.lmost 25,000 women comparing routine PNC with
an experimental model ~esigned to"minimize vlsits
(2001). I n the new model. women were :::;een -once
in the 1it. trimester; screened for certain risk

Scanned 8y: ~
 CHAPtER 16: PRENATAL CARE OF THE HEALTHY WOMAN
n'V1i ~1)i'\' .
~tJv ,
SUBSEQUENT PRENATAL CARE
. ...
The goal is to assess well~being Of the
expectant mother and her fetus. The routine
examination ia less detailed than the initial
evaluation but has the sa.m.e basic components.
A histozy since the last Visit should be elicited, a
litnited physical ex:amina:tion should be performed,
and certain me.a~ure~ents should be lllade at
each prenatal visit.. T.itne should ~ .allotted for
patient :edueation; and she should be given the
oppott'UJlity" to ask q-uestions and to discuss
matters or concerQ. to her.
Matemal Evaluation
1. Blood pressure, actual and exi:ent of change
2 . Weig.'lt: actual and a.thount of change
3. Sympt{)tns: he~dache, . nausea, vomiting,
b~~~g, t;ly$llrl~ fl.uid ~rom vagina, etc.
.4 . FW:t,9J.c~e.ight from $)?llpll.ysis..pubis
. 5: . Abdtiniihal examination with Leopold~s -pregnant patients i:~debatable, serlal:sonograpb,i'c
...... . : ! '
nruane~yer .
6. Va_ghlat examinaQ.o.n during th;:;: f"J.rSt visit;
s~~~ently only if indicated; 4owe:vet, .a t
:ten:n~ ,v aginal ~ipation. -s hould, be.done
:w.e~J.t~.Yi.: .to deterJl1ine the con:SiS.teney,
- .--ef!abeiJient/ and .d ilatation of the cer.tix; the
pi:e~ting part. "the .s tation ofthe p~ting
-~ and diniCa,l J)lensuration 'C?f.. the pelvi~.
It s):lQuld,notbe done ifthere is histoxy o f weight .c ontrol. Although some literature jn
.vaginat~oleeding:
FetalEv8.luatlon
1. Fetal heart rate
2. Siu -Qf fetus, actual and rate of change
3. Amount of amnioti.c fluid
4. Pres entingpart .a nd station (late in pregnancy)
5. Fetal activity
Subsequent Laboratory Tests
If the initial results we ~e normal, mos t of the
tests J:leed nc>t be repeated. CBC should be
t:epeated at about 28-32 weeks.
A 2-step screening for glucose intolerance
between 24. to 28 weeks is recommended by the
American College o.f Obs tetricians and
Gynecologists (1986). If pla sma glucose at.l hour . during pregnancy is based on her pr~~pr~ancy
exceeds 130mg/ dl with the 50 gra m ~ral glucose
challenge test {GC'l') , then a 3-hour 100-gm test
"265
is recommended. 1 This me thod has .a:. better
predictive value than does glycosylated
hemoglobin which has been extensively
investigated. Howe\l'er, the WHO andtheASGODIP
recoir..mend a routine 1-"timf! screen using FBS and
a 2..:hour post~ 100 gram glucose"load examination.
Due to the susceptibility of neonates to
hepatitis B ~s (!{BV) irUection and the high
probability that those infected wilJdevelop chronic
disease, iUs important to identify p~twomen
who arecbronicliBsAg carriers, ~g should .
be done durirtg the. last trimester. -T he
adtnin'ist:Tation of .hepatitis B immune globulin
(llBJG) and a course of hepatitis-B vaccine to
newborn infants of HBsAg-poSitive mothen:s has
beeri demonstrated to be 85% ~ 95% effective in
preventing the developtnen~ of the HBV cgtrie'
state. 1
. . ........
- Although i:outine'tiltrasound''scteening of till
. .
. eA.atninations shoUld l;>e <:onsidered m arn:ilin~:: :
of high-risk circumstances in which..fefal!g,tj)~
may be in jet>pardy, if gestational dates.-:-are
uncertain and .for con genital anomaly sca:nnihg~
:. :
NUTR.I'tiOlf DuRm~'PREGNAlfCY J<(-- "1 :-,~i-;t:-, ..
., .' . L+C1!~o~:v:;
Of the many itetn!l included in prenatal':care.
.the most impo~~ -~- prqper nqtnf:\oa - ~d
oost:efiicsccrnfiilii'~ta:te!!ien~ii~:11~~c~~-
mosf -c.nnicians - believe that pregnancy
complications are enhanced by obesity and
excessive weight gain;
A woman's nutritional status before, during, and
after pregnancy .contribu~ to a s1gnificant degree
to the well~bcing of both herself and her infant.
For the :p ast 2 decades, the American College
of Obste tricians a.d Gynecologists (1989) h as
recommended tha t pregnant women gain-around
l0-12kg (22. to 27 lb) <ll.lring pre g nancy .
Normally, pa tients can be expected to lose 2 lbs
or more two or three weeks befox:e the .o nset of
labor. This loss in body water is referred to as a
prelabor 4iure sis.6
~-
The amount ofweight~ woman need~o gain
body m ass index (OMI) which compa-res weight to
h e ight.
Stanned By: ~
 . ~w. .
-----------------S-E-CT_I_O~N-11-I:_C_U_N_tc~
: A_L_A_P_P~RO_A_C~H~T~O~P-RE-G-~---C-
- Y----------------- ~r
2"66

Recommended Dietary Allowances .(RDA) fiber, water and electrolytes, fats .and fatty
acids, and the proportion of dietary
.In. March 1989, the Food and Nutrii:icin.. carbohydrates, protein and fat. u
ResearCh Institute -of-the Pllilippines revi~d the
1976 .i-ecommended. dietaJ:y cllowa..ces (RDA) for Calories
Filipinos. The RDA Committee, in the 1989 e dition
dec-ideq_ to adopt the definition of RDA in the US An average woman needs about 2000 calories
as the RDA for .-F ilipinos. The definition is as a day and an additional 300 kcal/ day -~ allowed
folloWs: ~eeo.m:lnenaed dietary alloW:an~s~e the du ring the s~conci and th.i.rd. trimester. of
levels of :i ntakes.pfeoergy :and e.SSentia.l _n:utri:ents ptegn;:tncy. II Additional ~nergy. if) r~quited dut;ing.
considered ;11dequate to tnaintaip h~alth and pregruin.cy because of .the a\ided pi~ternal tissues
pro\ride r~asom\:ble ]evets of r.e's'erves i~ body of
and the growth the fetus and piacenta If dlloric
tissues of nearly all healthy persons in the intake is inadequate, pH>.t ein. is r.ueta'Qolired. for
population.U ener-gy rqther than being- spared for i{s vital role
in g(owth and dev elopment.
In. the 1976 r~Vi.sion :of the . Pl)ilippul:-e .RD.A,
reeommend;:ttions were ~ve~ for _energy .p.t;otein, Pro!:ein .
vit.amiris A .a nd -t;
-t hiamme, riboflavl..'"l, piacin,
Calcium and U:oil.. No specifi<::a;ID-ounto wer.e give~ More protein than u.s ual is n~eded by :the
for .salt. water, fat, ek., for lapk of data at that pregnant wo~~"l<.f~r tissue. synt!"fe"s is ir~ -th~
time.- ,ihe,.:pre~nt RQAC6I:Illrii~e.agr~~tin ma~enial a~d fe.~i. corJ?-p:ar:tments. T4e 198.9
additio.t;l to. ~nergy . -and .nl.,l.tti~bt~ .~o':'e_r;e.d ommi~tre, qn.'Dietary.Allowahc~;; under the ~pod
pi"e'vi0ualj 1.:Ale4-9j3'9"'P.:h,ili,ppin-;Rb.A~~indude... . an,d_lj.ut.r-jtion : .Rete~r.ch .. l~s.t~t\l.Je .of th~ .
the _foQOw;ing:;~ .. ,_ .;_ _: Pbilippine.s, _;rr;commends ad_(l'itionar _protein
intakes. of 2 .9 _ri.nd.T S.gnifd?-ycd.Uring the ,Jot,:.2rw~
.;~ . .. ..., . . .. .. . . . , . . .an:d 3Td trimest"r;s or . an 'a-verfi:gc of 9 gmf d
. 1. R~mmeri.da"(i<?ns. for, fola,te because. of the . .throughout-pregnaricy:.~. ?.rofu4l :O.eticiency i+l.t~e '
hign~:pt;;~y.ele}lce.,of.;~~~+it~pna.J. :_a ne.mia,.,in,, . mothep ~y: t.>e"aceompa.iiied.by :a: loweiing:.t?t tlie
pr.~a"-..::.f.jw:o~~n).n~ w:h(mi. .roiate.._d.efi,<;iei_lcY.. , _. store$ ofhel;llogib1$.ll...,p~-p.,cing:factcrsin-the'liver,
I
:a..
.. ha_s_b;en.'f6.lirl:d.-':tP oe co.ptri_butin'g":Ja~tor.; wh-lch .ma,y res\ilt . ~ hypocllromic ane:rp.ia .
.an~ -~o.~z)P.ftine, becau~e con~rol' Of iodine- Likew,j~,. it may l~d .to-a U:fl.Jqi~nt r.~uctjpn cf I
de'flde_D.cy..:(fiaord.er~ .(IDb)-..}s..now.. a .priority . ..p~as~.'p;:q:telri.s, .. ili~r.eby: .ca.U.Sing.. a..d,i.sti.ll:liahc.~
'~on.~e~---qndei:-~t;he~--P-hi}ippi:q.e Fo_qd --~~d. in-water- balance- and. :nutcitiof1aLed~... T.he I
Nutrition .P rqgiaill. . . absorption of calcium .from the:in:testin:ai traci: m ay
:2. Saf{leve~_o(ititake for_.vitamins D -_a nd E _.. . alsc be impaired by a la:ck of protein ln. :the die( 1
s.. Information on the recomm~ed izl.take of Meats, milk and eggs are the best sources of I
zinc and phosph_o rous, carbohydrates and protein.
I

'
I
Weight Gain (kg)

M~temal Classification Total Rate (4 weeks) Totai .Rate (4weeksl

I
1.7~2!'egnan~ Bll;l .
Underw~ght(<i9 :8) 12.7 -18..2 2.3 28; 40 5.0
I
. ~ormal weight (~9.8- 26.9) . 11.4 .. 15.9 1.8 25-35 4.0

.
Ovc-rwdght(26 : 1- ~ 29:0)
_
Obese [>2:9:01 '
6.8- 11.4
6.8
'1.2 15-25 2.5
2:0 . .
I
0.9 15
Twin.gestation 15.9-20.4 2.7 35-40. 6.0

Adapted ~m llutriti.on During Pregnancy, Waslilngton DC, NationalAca_d~~y.Press. 1990~

BMI bodym as~index
. Ra~c ha3 be~ adj~sted to sttoii.d trimester
> . Prcgnantwcight .(kg} :t 'Peigh~.(cm) x 100. :

Th~secategories were based oo. qody ~?Ss)~dex cBMI) defmcd as.pr~pregnant wei~t in kgs. + h eigh{in m~ter.~

Scanned 8y: ~
 CHAPTER 16: PRENATAL CAREOF THE HEALTHY WOMAN
--------------------------~--------------------------------------~--------~---
Carbohydrates
Dietary carbohydrate.s are the main source
of energy during pregnancy -and are required in
increasing amounts as gestation advances. In
the Philippines, carbohydrates acc-ount fo!" .an
average of 74 per<:cnt of total energy inta:ke . 1 ~
D~:illy iiltake of 150 gm is recornm~nderl in the
(1I'$t trimester, to b~ increa:se d the.r eafter to 225
gm a:t the end '0! pregnancy." However, according
to the FNRI of t.lte Philippines {1989), an intake
of 50-100 gm available carbohydrates per day is
~: Sl.lfficlent to p.tev.e nt ketosis and other symptoms
ofdietary carbohydrate lack. The available
fractiorts .o f carbohydrates con.s istirtg 'Of sugar,
dextrins, starch and glycogen are digestible in
the human gastr-ointestinal tract. Ample
carbOhydrates seem to lessen the nausea and
vomiting which may occur during the early
months of pregnancy:-,
. .; '
.. .
~~.
'Di~tifiYfats w-e the most c;cncentrated sources
.Qf energy, providing more 'than twice the energy
yalue 'ofanequivalent weight of carbohydrates or
ptOtein." EileigY from dietary fats constin.ttes about la.st trimester of .pregn~ncy. : A'S.~um.mgtthat
4~:~t. o_f.,tJ'le total .calories consumed in the
W~aftni .di.et1 while in the Philippines, the average
daily fat ,intake of 30 .g m accounts for 15 percent
pf energy i:1take. 11
Fatlnnittpabftabilicyandsatiety v~~~. !?.._(git~~ __... of ,Ghe.es.e. in.the diet:.e ach -day~ .
Lik~"'artl50!iydrates, . tliey .are spare-d of protein..
They also se.tve as Carriers o( fat-soluble vitamins
imd essential fatty acids, and are vital structural
components of many bo~y tissues. A minimum
daily intake of 15.:25 g of appropriate fat can meet
these needs.U
Dietary Fiber
Food fiber h as long been considered important
constituent of diets because of its role in
promoting normal bowel functions and providing
bulk or satiety valu~ to meals . . The renewed
~nteiest ofthe 1989 Philippine RDA in fiber tenters
on its pos sible relation to certain disorders such
as hyperlipideinias, appendicitis, diverticular
disease, colonic cancer, deep vein thrombosis,
hyPe(glycemia, gallbladder disease, varicose veins,
hiatushernia arid hypertension. 13 There is strong
evidence regarding the beneficial effects of'fiber-
nch diets in preventing some of these disorders,
Stanned By:
'' 267
but the evidence .for fiber itself is less dear and
remains .c ontroversial.14 Therefore, it :is 'Qot
possible at this time to make quantitative
recommendations on (:iesirable fiber intake beyond
a statement that a 1ibe.1el intake of fruits,
vegetables f'.nd whole grain -cereals is highly
recommended. 11
Minerals
Calci!lm
Calcium ser;es as the main structQ.ral element
of bones and teeth. Outing pregnancy, frQm 2S-
30 gm calchun isdepositedirt.thefetus'at the rate
of 120-150 mg/d dUring L'le 20q,"to 30\ll week and
a range of 260-300 ing/ d from the3Stb week until
terin. 15 The ass.um~ o'bligato:ry !l'laternal calciQ.m
_excretion is 100 m,gf'P.. 1fi .Therefore, the requited
ab~rption to me~t this e~Qgenpus loss and the
need of the fetus is $0.-380 Uig/d:
; ~ . ; ..., . ..\ , , .... '-!~ .l' , .;::. ;
In 19Q8; .us Food and NutritlSrt':~~tift:d
calculated the recomn'lended ~dditional ~urn
intake for pregnant w.amen on a ba.Sis of d~!y
calcium retention of 200 to ~50 mg dl.l.ri.Og . U:t~
obligator)r 'losses and-calcitim reten,.tlrirt'itfFiitp~d
pregnal\t women ~ siiniia:r to tllb~;;brw~~:tsfn
women, an addjtioJ?,8lhllowance or4oo'irtg:~fllifu!
qf900 nig/ d is re.Commend.:!1. u Ad~uatecmciu.m.
will_,~_(v.W.~hed ~by..a_quarl.of-Jnilk.arid-oneounee
Phosphorous
__Next to calcium, ~phosphorous constitutes a
major part of the mineral content cf the skeletal
system. It is essential for the calcification ofbon.e s
and t~et:h. The best sources of phosphorous are
foods that also contain good amounts of calcium
such a s milk, and milkpro.duc:ts (except its fattY
parts su~h as qeam,. butter and cheese). Beans,
carrots, cauliflower, corn, peas, potato, banana,
peanuts, liver, eggs., fish a,nd 'meat products are
a lso good sources. Because of. the Wid'e spread
occurrence of phosphorous .in food, there is no
evidence of a deficiency inhumarts, except in those
who consume large amounts of antacids which
interfere with phosphorous absorptiori/~f.mong
the deficiency., manifestations are fatigueTlo.ss of
app'etite, and demineralization of bon'e~u The
dietary requirement of phosphorous, :fi1is not
received much attentiorr because it is presumed
~
 268 Si;CTION Ill: CUNICAL APPROACH TO PREGNANCY

that most diets are likely to provide adequate Iodine

amounts; and deficiency is unlikely to oc:cur.
Iodine is an essenti~ nutrient because it is .
Jrqn an integral component of the thyroid hormones,
thyroxine and triiodothyronine, bot~ or which have-
Pregnant women require jron to replace basal importar,.t metabolic ,r oles. . The r.equiremen:t for
losses (0.77 mg/d or about 220 mg for full tenn iodine was set at 2 to 4 pgfkg l;>ody weightfd or a
pregnancy), to allow for expansion of the red cell total of 0.15 to 0~30 mg/d for adults.; Aithougb
mass, and to provjae for .t he needs of the. fetus this r:equirement i~ small, it may not be present
and placenta. Basal loss is simflar to the non- in .-a dequate amounts in some diets. A survey
pregnant. During the first three months of conducted jn the Philippines s howed t.~at iodine
pregnancy., women need -iron only-to replace bas~ dCfi<;iency 1s a problem among mariy population
ios.$ es. since m,ensttuation ha$ cMsed . md the ,p-oups. Consequently, it was decided that iodine .
.dei;oSition of iron . in.-fe1al tissues at. ~.hi$ t;i.nie is be ~levated to RDA status in the 1989 -edition.
minimal the requirenel).t per day during the first T.be RDA recommen,ds lOO pg for a reference
Qinlestr.is on,ly Q.69 ~bSOrbe4 iron whtch catt be woman (49 .kg}, and an additional all?W<itilce of2~ .
met by a daily intake ~f .S m:gha$.e d on the J!g for the .p regnant woman. to
.abso:rPti"ura.te of .s~~/1,.:Since.iron ~rurdl'lents
a..--:e .$light during tllls Pf!.tk>d. it is therefore, not IOdine deficiency di~orders . refer to aU effects
n~ to .pr.ovide .suppl~men~1ro-ri d\lrl4;:.this of iodine deficiency growth and deve.l opment.
tim~-" Withholding ifQn $Upplementation during These include .goiter, ~hich c:m be prevented by
the"'fust'trilne$~' avoids therlsk . 'o f:aigravating providing an adequate iodine intake through
:nau~altti-vQDiitfil~':>~im~d:ul~t.d-fu~iron ' 'iodmesuppletr1entation: Severa.t-1Jlethods tim'be . -
develops~du.riz).;g.,tlie.'~p.tJ.~.and-thitd:1riJnes.~' adppted,.-~ly:- 1} .the ~se of iQdized salt, 2};the
of p~ahey whent:lle :deP.Q.s ifion rif irOlitrJ 'fetal.. <mil adnllrii~tration of iodine t:ablts3). inj~tion '
~d;pli:leeta ~ssuts ~d- thtdl,'lct~ itu:ed cell ~fiodized oll~and 4)a dditiono fiodine tom\Uiicipal
roa~ ~.:~ta.t'llpt.cl.;t;a:~..~The ~te,d t.otal,' . w ater supplies,u . ..
iro:P :ine~tf.:.:;(h:idtl't,/. .thei:~eO.nd. :trime$tet 'of
p.~cy is abQut 7~(pg[j/tJ.-; .J)uring the:third Other Minerals
trimester, wom~ -with lii:pi~ 'i ron :store$ need
114 .pgf.kg/<t-or:s,.:59 ~a m$
~s: a daily It is now known t.~at many ()t~rm.itleqilinu-e
.intiilCF orolr:~~~ ~tacy"lfon. The---ave~t~ge net-essa:ry for human reproduction, growth- and
requfrtment ror tht .l\(1iore-:q.u~tioif:of1iiregnancy generar health~ lfi(;ludln-g h'ro)llium~ "in:lrirganese~
is 41 mg/ d 11 an alllount which is hl..gher tha t what ~balt, copJ)er, selenium, molybdenum~ .n ickei,tin,
cari be pr.o vicled by the diet . alone; silicon and 'sodi-~m. Limited knowledge of
supplementatiop. iS tqetefpre, r ecommended. . requiren;1en.t~ in man makes .it impo~sible -to
establish recommended daily intakes. Sodium
deficiency d~ring pregnancy is unU.kely unle.s.s
diuretica are prescribed or dietary sodiu:tn .i ntake
Zinc, second t o .fr.o.n, is the most abu.ndMt is reduced . Neonatal hyponatremia bas be~n
t:n;\ce element in .the huma:n body. It is essential observed in offspdngs of women with undu.ly
for the activity of nume~us enzyntes. It is required restricted sod ium intake before delivery. 17
for .normal growth, and SCX\lal:m~tmation , hrolri
4eveloptnent and.fup~tion, andimmur\e function.
Nutritional .zinc deficien~y is fairly preval<mt
thFoughout the 'World. In the absence of firm The physiologic a nd metaboti~ demands of
evidence Jor increased absorption efficiepcy in pregnancy incre~.se vitamin : require~ents. The.
pr-egnant women, a :d.i.etary ~inc inta~~ o.f. 15 incre.ased r~quireme nt .{or vitamins during
.rngfd pas been recomm~ded in the .u.s. The .pregnancy~ {with the exception of folie acid), Can
extra allowance of .3 mg is based o.n the calculated be supplied by any general diet thit proyides
0 ,60 rngfd reqU:~re.d Cor growth of fet:us: and adequate . am~mnts of cat.o.ries and p.rotein~
placenta..The satheaddition;ll.a llowance o3 mg/ However, pregnap:cies. :complic~ted by .vomiti..1g,:
d or a total of 12 mgfd has been adopted for hemolytic. anemia or multiple fetl:lseswill require
Filipino pregnant women. 1i - vitamin supplementation.

Scanned 8y: C
 CHAPTER 16: -PRENATAL CARE OF THE HEALTHY WOMAN
----------------------~~------~----~----------------~------~
Folate
Folate il;l a shortet word and is preferred over
the. term folic acid, which gives the wrong
impression of a corrosive subs~1'lce like nitric.
.acid. 11 A deficiency o f this vitamin lead.~ to
megaloblastic anemia du.ring pregnancy. The
prevalence of folate defic'iency varies among
different populations. In developed .countries,
meg~loblastic anemi.a ~s .r elatively unusual.
Senun .folate levels .fall with gestation, and low
V~Ue$ (i.e less than 3 jlgfml) are s~n in as many
as 20 percent of otherWise .~nnal pregnancies. 1
M~ .reported ~ . 15 ,~o percent ~valence of
. folate deficiency. .i n FUipino . pregnant women. 19
Acx:ording to h}ril, this -deficiency is not u sually of
suCh ~ degree as to pre<;ipitate .m~galoblastosis.
The lowering !>f Jcl.8.te ;rtOres is attributed to bigh
folate requirements dur'ing pregnancy. A
~um.of 350 Jl.g/ d isr~otnmended fur Filip~o
pregn.ru:itw:9men. 11 'Lotit0!4 et ai. a nalyzed the folic
. acl~' ~nt~nt of:so;n Philippine foods and found
t4fl.t .d~gr~n colo.~ leafy. vegetable$, S'.l.Ch as
tn.uf>tanl&nd Philippit;le spinach, as well as ~.al
liver~tain vecybiglpm1ounts (tOO Jlg[lQO gms
AA9 a~.Pi 'dle-:v.iUU:nin.2p . ,
Vitamin A fs reqUited for yision . gr.o:wth,
cell.ular .differentiati<m .and proliferation,
reprQduction and integrity of the im~nine
syste~lkifhe--hnpact-rp~vitamin . A-defit:ien:cw:dn
h~an-.;pr~gn:ancy :o~tcCJnre t s 'illilroow.n~out
excessive cOnsuinpti~n of this vitamin appears
to bC ..teratqgenic. At least 7 cMe reports of
adverse pregnancy outcome . have been
associated with a daily ingestion of .2 5,000 IU
or more. 17 The RDA (1989 edition} for Filipino
pregnant women is 4'/S RE (retinol equivalent)/
d . Dietary sources are liver, milk egg yolk, .fatty
fish, dark green leaves, deep yellow a nd ora nge
fr:uits. an~ vege tables.
. .
Vitamin BI or Thiamine
Vitamin a1 .or thiamine, . is also known a s
aneuria .aJlQ)he antirleUriQC factor, indicative of
its role in preventing symptoms invqlving nerves.
Most investigators have .found an incr~asing
thia,lnine:reqUirement: throughout pregnancy, as
shown by thiamine excp::ijon or. by the erythrocyte
tra~sketolase lETK] activation t est.H Among
Filipino pregt:1ant women, .t4e prevalence rate of
Scanned By:
,.. 269
thiamine deficiency was observed .to he~ 29. 9
per.c ent using the erythrocyte transket()lase
activation test. . In the absence of local data .of
thiamilte requirement in pregnancy, the 1989
Philippine RDA Committee, decided to adopt 0 .6
mg/ 1000 kcal as recommended by the US Food
and .Nutrition Board. The RDA therefore. for the
pregna..'lt Filipino is 1.~ mg/ d, based on the energy
intake c;>f 2200 kcal. recommended durin.g
pregnancy . .
Vitamin B2 orRibojl(lttiti
.. ,
Riboflavin exerts an, ,hnpor,tant controlling.
influence on.body.processes. .It is present in large .
amounts in lllilk, eggs. liver, heart, kidney, and
green leafy vegetables like malunggay. saluy(>t and .
sili 'leaves. The clinical signs .of riboflavin
defiiency ar~ angillar somatids, cheilo.s1s,
glossitis.:and 'SCoorthciC dennatitis. ~ased :!>n .t he
re~ent 'studte'$. on riboDavin .l"eq)l irement in
women, .i t is recommended that the:.:additional
atiowance .during p.regna:ncy .of cO.~Q:;.mgJJ4~be
adopted. In the non~pi;egnant state, fo~: a. wqrn~ .
weighing 49kg, the RDA is 1,o mgf d}f.H:o'V.i<sVei:~ .
this is :riot easily met .b y the usual Filipino diet ~s
shown in th~ ;l atest :survey.11 :To helP:4IP.~~- tbis
dboflavin requirement in .ptegnari.t ;,,woP;i:eii,,~
supplementation ~s necessary. :';".~'-.. .:.t. -:,- ~:.
.Vttamin .86 or Pyridoxine
Vit:amih'Bo __ _______ ,_ .._____i~,._ ...another
- ...o-r p}-fiao:.ici.ne
, ,
im: . rtant
_.... .....-- ..---.-~-- "-"- .
nutrient 'concerned with amino acid metabolism
and protein synthesis. Vitamin .i36 .deficiency
rarely occurs; Symptoms of ~eficiency include
insomni~, con,fusi!)n, nervqusness, .. depression,
initabiliey, periphe~ neuropathy and later motor.
function itllpainnent. Skin lesions incl~de
seborrhea, Cheilosi.s, glos:sitis, and stomatitis. the
bes t sources of Vitamin B6 are muscle meat, liver,
. vegetables ~nd wh.ole grain cerea l. Of the
Philippine food items that have been anhlyzed fbr
pyridoxine, bawang, m.alunggay talbos, beef, liver
. and salay:-salay ha,ve the h ighest values. 11 It has
been ge nerally accepted that Vitamin 86
requitem~nt varies .directly with the,dietary protein
b ecause {)'[ its involvement in amino add
synthesis. So far, there has been no studyon the
Vitamin 86 requirement for Filipinos. BaJ>ed on
requirements in other . couhtries,,~ it is
recommended that 0.02 mgf gm protein, ..(a: vall,le
which includes a safety matgin), be tel\tatively
adopted for Filipinos. Thus, the RDA 1989 edition,
~
 "~
,...,_.,
_ __:.__ _........__~-~-:-=.::-=:::":"":"':~-~-:-::-:=-~~==:-:-::~-::::"'~~~~ -:---___._,____...._;,_______ ~

270 .SECTION Ill: CUNICALAPPROACH TO PREGNANCY ,.:

for male and female adult are 1.2 and 1.0 .mg$, Vitamin D is the effect of ultraviolet light on the
respectively. During pregnancy and lactation skin. In tropical countries like the Philippines,
vitamin B6 intake .should be proportionately deficiency r~ely occurs since sufficirtt Vitamin
increased because protein allow@ce$ increase. D.is obtained from exP<>s~re tQ sunlight ~<d from.
the incidental -ingestion -of small amount of
pretonned Vit:aifiin Dwith food. Thus, no RDA Co~
Vitamin D ha-s been set.
. A deficiency in n'ia~in leads to -. th~ disease
pell~gia whi()h is chare.cterized by bltateral Vitamin E is Uie least toxic of the fat-soluble
~ermatitis, glossitis, dianhea, irrltabllit;:y,-mental v!tai:nins. The rlc...~e.st sources of Vitamin E are
cor.fusion and .eventually delirium .o r psychotic ~table oil, matgarin:e ~d shortening. The RDA
~~ptQms. Niacin .is pte.s enf in plant foods as or Vrt.anrln E for Filipmo$ ea.nnot be established
nicotiniC e.cit;l_an~ in rurlmal foods :611 nicotinantldt.- .a t this P9int because we do not have data on
1
M~t; lish whole wheat.and ~lll'e the tiCb~t Vitamii\ E t::on:t~t of our rOO. However, itis
$0Ulte~ or niaM. lnthe PNU_ppiries; riee which reaso~ble to assume that it m aybe lower than
compose!~ the ::ntlin bUlk t>l' 'the d.iet i~ the major the us RDA because or t}:le sigllificantly lower
co.nttibut~r or p refoinld niacin. S.tuc;iies or PUFA (.p olyunsaturated f4tty acid) intake of
OO~th. ~t al.22 ~ -Jfian h:av.c-sh.ovm . tht 1 mg Filipinos.
of lila~ t:rderlv.ed-ffpm:.6 0 tt!,g~~~ 11tus.
th~ ~Qp. 4)ntent offd Js ~~-$iS ma)rt .Breaatleedb~g .
eq;-~!n.l~ts {NJ) w,Uh bldufie both 'Jl~fottned
.~e;Pl.-~d 1bat:~ Wtb~:.: fror:tt;::.t):y.ptQphan :cby ., . ,Prenatal-w~ is:ancexcellent.titne to ~ducti.te
xne.li).~~~-c.ion,Y-tt:$i.G!i'.'.tk:;._.~ .. 'o{' . ' ..!,.-, .. '. ;. ' ..>.-.~ :~ . . . .fhe,cpatient:.,abu~~~:<fueljbet~efia;1bf:l>reast Jeedihg:o:- . :
. . ., - - wbih:ifucl'!l4e'f.ot-:lile''tleWbom~e.X.cUent;nutrition
... 11,1~ ~A!sf~r',;~~ ~;NJ~\f:d'i~:a,~e amtptOvisiono(oimJnU.."'lo1ogit-~tectionan:d :for
and..:l8'1Pr.a -~'e ~thJlS,rQ $')(~ -J:~ ~~, . the -mother.-.r apid . .uterine inv.oluqon, etononiy, ..
~~ t1/1i~'$e~~~: ~: ;~d.;i1Lbe. . . materna}.,;,c Ml<l bondin_g, . ~d. -to some extent.
~~:l,lpplietl py.1 be, 4V~ l1'illpjno :di~~' "na;tlita1 ehjl(bspacln~. .TheSe:benf!fits w-es(rgreat
During gestatio~--,;;ul(Vlac~tionj.,an , ft(lditio.n.al that wcmen, ~hould. be :enCO.utaged to 'consider .
requiretnent of 3' .an!J :5 N$ res.~tiv.ely,. wa$ breastf~g, .for _a t least the ~t feW' months -of
recoi:Pinended~ on the'~in:eri~mtakc. li~e~ .:ltowevct; brea$tieediri~ .t s -not f oreve_ry~rre,
. antt SOfifewom~-n. -SiiifplY' cannorl5reastreea aue
v~::or-tt:~ro'lt:.t)~ fo' ;m foieranl '":ei:tipioyment ,-$Ifiiiillt;tii~: a,nd. -~ltriiTaJ.
con.$trai'n:t$. ln the:so Urif9rtun_Ei;te ciFcuins~c~s.
D.urlpg pt.e~ancy. the ~tbi~ ~ct4 wl}tent the use o breast pumps
,arid l1:illk storage may
(>f tt1a~rtlalblOQ<l.'Q~s,.wbUe Ule:feta:tpla:sma allow .$'0nie degree Of breastfeeding tha:t is
valu~ ~~w~yshi,ghet.t..lta.ntho$<:o f the.tnQther. . beneficial.
'fh~. 1Ct>.ls aept;[ldS.-Q~r ma:t.CmJd .a nd placental
stQ.~s; :UVittilitn :~is deficient,. SJmptptfls Pf
sutvy.m~y 8.-PP.e at 'Jn .,u.,t~ ri).Otn~r. :The most
comt'pon sPu.rc~s of asP.rbic a1(1 .irt.the Filipino :Exercise
diet a.tt .greeri leafy v~~eta:ble$ @ tl Jre.ah fruits.
P:;;tient~ should~ ~oQhed ,that,~kin,gde~troys The type -of exer cise tha t' yQ\1 can do during
vi~ CmrawJoo<!s~ .The 1989. P..PA Co.minit~,~e pregnancy depends .on your health artd on how
reroriimends~:the reten.ti6l.l of .t he 1976 RD~Of ~75 .a ctive you a re be fore you get pregnant. Safety
a.r:1d 70 Jl1g. for ad~lt -Fplp.ino males and fetna les, con-sideration s s houtd always be a prima ry
respeqiv.ely. For. p~c;,gna!lt w-omen,. a JO tng/ d cpncern when:.prescribing exercise, particularly
increment in the Vitamin C intake Df the mother during pregnancy. The goal of eteercise during ,
ia reco'~end~d..n .. pre.~ancy '.is to maintain .the highest level q f
fitness consistent with maximum .safety. There
Vitamin Dt111d Vitamin. E . are four kinds ofex.ercls~'that~ be useful duriilg .
pregnancy: a e robics, calisthen1cs. specifically .
It.is difficult to esW:blish the .d esir-able dietary designed for pre gnancy, r elaxation: techniques arid
intake for Vitamin .D, since the main s ource vf. .toning (Kegel) exercises. H . .

Scanned 8y: ~
 CHAPTER 18: PRENATAL CARE. OFTHE HEAI..lHYWOMAN '" 211

Aerobics: Th~se are rhythmic, repetitive activities
strem,lOUS enough to deroand intreased oxygen .
to the muscles, but not so strenuous that the
demand exceeds sup,p ly (walking, jogging,
bicycling, swimming, ~ennis doubles). Aerobic
exercise. silinulates the 'heart and lungs, as well
as mu::cle and joint> activities. lt improves
circulation. increases muscle tone and strength,
and builds endurance (making one better able to
cope with a lengthy labor). It bums calories,
allowing one to ~t more of the good food ne~ded
without gaining excessive weight: thus promising
l l better postpartum figure. Furtheonor,e , it
lessens fatigue .and promotes l)etterm ght sleep:
impartS a feeling of well-being and confidence, and
in general, ~eighteris the ability of the woman to
~pe with th~ physical a,.,d emotional -challenges
of :eb:ildbearlhg~
~-t'.S.: These.are r hythmic, light gymnastic
:mqvel.Jlent~ that tone and develop muscle$ and
impro\repo.sture. Calls.thenics e~~Y designed .
for pregnant<women can be \'ery beneficfu.l in'
relie:'Jing back8.cl:ie, artd impro\74lg physical and
.mentalwembeing; Calisthenics designed for the
.gen~ .pc:tprilation, how~er, may be unsaf~.
Re1~iitionf~:Technicp.tes: Breathing end
roncentration exercises relax tnind 8.11.d body help
1
labor. Relative :corttraindications .a re .e ssential
hypertension, anemia, thyroid diseaSes, .diabetes,
breech presentation in Ule last trimester, excessive
obesity tuid extreme underweight.
Bathing
Baths and showers during pregnancy. or the
puerperium are .n ot c<5ntrairtdicated. However,
they are not totally risk free. partiC1llar~y in the
last trb:nester when.the h~vy uterus lllay upset
the balance of the .pregnant woman and increaSe
the ~lihood of slij,pin8 and fallil18 .roavoid such
m.!s:naps, bathing should be done with care. ,
Clothing
The clotbing worn during ~r~g\).allcy $hould
be ptactical, lo()Se .but attraCtive. There .sl;lou.ld
be no constricting bands abOve the waist, . and
pressure .over:the breasts andnipples. . Pendulous
breasts ~t well--fitting s-qppor.tlngib.JasSier.es.
A .maternity 'girdle tnaY. ~- worn. I t iSi"qf ~u~ilil,
p~enting soi:ne !>(the discc.clfu.rts ot~cy.
The shoes sho~ld be o! sensible designw.iith'.~a
subs~tial beet. Hi~ heels .lead .{9 ,fatigue and
backache and.<increa se the problem.~. or:.:body
b81ance in :walking. , ,, ~-l'; .:;:.,;;:;_r$ii;',,' .

conserve energy for when it is needed, assist the Bowel llab.lt.

. mind to focus on a task, and h1crease body
aWilrelle~s.
.. .. ~~~~~!i2~ ~~~ ~~- ~P.!t?~i! .~ffi~t:~g:
p~gnancy, ~sJ:Un~'!?J.1. . l>e~u~~ .Q{. the:.. stero1d:
Peivic-To:ting: -Ke:g~l ~xetcis.es- are slmpre irid.uced suppression .of b owel motility and the
techniqties for toning the .m1,1scles in the vaginal compre~siori pf the intestines. by the ~nlarging
and periQ.eal area,. str-engthening them in uterus. Woroen who had normal bowel habits
prepan.1tion for .d elivery a nd also .aiding in' their before pre.gnancy can usually maintain reasonably
retov.ery:pQstpartum. This is one ~ of exercise normal bowel functi()n,..durlng ,pregna:ney by
that ~very p1egnant womar.. can perform and drinking water lib.erally and having generous .
benefit from anytitne; .and any pia:ce. amount olfrttits, vegetabies,and salad irt ~e di~L
MUd laxatives such as milk of magnesia, bulk-
.No single exe:r cise or exercise program will be producting substances or stOQl softening agents
able to ineet the needs of a:ll p:-egnant women. It may be used:bJ maintain regular bowel habits. The
is incumbent .on the physician to assess each use of enema~ or strong cat..liarti~s should be
individual's abili.ty to engage in physical activities avoided.
and to advice on a program that maintains the
h,ighest levelrif fitness consistent .with maximum Sexual RelUons
st;tf~ty. Be{or.e presc.ribing exercise, patients
shoulq be screened for any obstetrical or medical Until recently, it Wa.s :gener:ally accepted that
complications. The contraindications for exercise sexual inlercour$e had. no .adverse ..effect on
in pregnancy may be absolute or relative. At>solute pregnancy outcome~ Many practitioners :auvised
conttaindication.s are heart diseases, IU.GR, severe ag;ainst coitus in the last month .o f pregr:1art,~, but.
hypertensive diseases; ruptured membranes, this was not based on reliable .data: r$:everal .
uterine bleeding, and those risks for premature studie~ done r ecently have .suggested thc:.t sexual

Scanned 8y: C
 27-2-

intercourse during pregnancy may be detrimental working during pregnancy is .associated with . ;.
to some patients. 'Naeye_.(1979} .~uggest that decrease ~infant birthwei~t. Other .s tudies have
intercourse during pregr.ruicy may be associated failed to document this finding. Obviousiy, the
with amniotic !luid infections lea<ling to premature range of activity .and stress varies widely fran; _
rupture of the ;ne~b.ranes with subsequent occupation to occupatipn. Re.co.mmendation
preterm. delivery, neonatal respiratory distress and. should be 'individualized and shou:lci take into
perinaU11 death. 25 Goodlin -h as su"ggested that account the type ofjot? and. the ris k factors of the
orgasm after 312 weeks .gest):l.tion ag~ may pregnant woman.
pted.i.Sp6Se tc-pretnat.We laQCir. '?6 Oth~s h~ve failed
to :Cortfum theSe findings. It h3..s also,been :p mposed Travel
that preterm 1abor:J!iay p e initi~ted by ttte
prostaglandin in the s'~:me~ . 'Gntil a well-designed 'Travel by the u~ual means does nqt directly
stu~y can a.nsw~r. the ~e$ti.on of.the effect of coitUs j eo par~ pregna_ncy. Di~dvantages associated
on p~cy 'O\cttcome, it'wi;>uld $eeD:l.pm~ent ~q witl~ travel are .indireGt. ones. involY.ing..such
counsel h.;gh ris _patients about possible adverse . drawbac}cs as cp.ang~s i.n .G..ietary and sl~ep .
effects. Pa&-....nts at riskmclud.ethose-with 'P~~ous patterns, a._nd the possibility .qf no1 having
.h:lstoly of .prema:1;ur~ rupture nf membr:a,..'les or competen~ obstetric care immediately available,
pretenn -li:ioor, ~d t.i;lbse who expenetice strong should an emergency arise. Prolonged .periOds
:utciine eontractiori'S'fo,llciW'j:ri_g :coitu.s. . . of 'sitting, wh1ch ent~il the possibility of
' inq-ea,sed venous stasis, ..should- be avoide.d .
Dont;hes Lo~g automobile trip-s :sho~ld be b:r~ken up-.rith
~-= ."-~ .. . .. ~ . . .regular stops tp . al'lo.w ..the ;pregnant wol:nan
. . r,.J~ucfil:ng.~is: not~mdita~~~g-:-pr~ancyt~"- :per~d.~~ o'f,"waiki~g1'-l ,Rt.O:l,Q-~ed-.SitJin:g'.'!in, ..at. .,
_ '. .. . ; : -.. ..... : ~ . . . ,. . . :ai~aft.should,:be :.i.nterruptediby.:oc:ca;sional ~
-bare ot~e:Te~~tJi,. , . wa.l-kiirg .in th~ - ;dsle. : Ttav:el- j:n _pr~ssu:rized.
..J; ..;. . ID..rcta.f~,h9we.v.er-, .~oes nl)t;.se'Qn.addltiona1 risk:
: ;~~ination,:,c>Hhe't~Jl:,.f'Sh9W.~;;partofia:,,. .to pregnan,twoman. ~
complete~tpi:enatal~,:phy:Sical: ~ation~ ,_. ':Any.;-. . .: .. . .. . : .: .. .. . .. .... ., . . . . . .... ..
. .
lien talwo r;kntlra't?.is:.:necess.~~;-sh:ould~.::b e.~.- . .Sm.oki~g- .... . .: .
perlor:m:ed: Pregnan-cy i's .,. rarely; . ':a
'COP:~iqgiql'ti~Jl t~ a nee@e~ d~ntal tre.a tm..ent. Sm:oki.ng d ur:ing .p r.-egnancy .- ha s .bee n
:H-ow~V:et.;:1fp-cial-precautions-m.ust- be-taken -.issociated witl;l a numbe'Fof .. ~mplicatio"n~,~P,ke.
Wlien_. a:-~w'6tk:-m-d"''tre"'~uring-_pregtrancyto 1owbirthweighHn:f~ts;- p~mature-1abo.r;abruptio
etisurt. that th~.supply cfoxygen t9 .the fetu$.. is -placenta, bleed.Q:lg. and-.pr.~~ rupture.of the.,
no~ cb,mpromised: thr-oJ,lgh the u~e of. :genetal m~mbr"a.pes. - To eXp,lain these .adyerse dfect~ of.
. anesthetics. smoking; wuious mvestig-?-tors -impliGated the
.followin-g:. 1} :c arbon monqriqe a nd its~{unctional .
:PRENI!.T~ . COUNSELLING inacllyatio.n of fetal an.,d .Inatet;nal h emoglobin,
2 ) vasbd:msttict~r effe(,:t o f tricotine, -thet:eby:
,D~ga;_ :Med!cations an~ lm.muniza:tlon.s d a#n.g indud~g.placental-~bru]:>tiqn, ,3) redu~d :appetite,
Pregnancy . thereby r educing caloric intake, 4) d.e creased
matemal plasma volume, an:~ S) an u,ne~laLrted
This subject needs.. special-counseling and -is predisposition in : certain Women t() the ill-effects
cons~dered s~paxately in another chapter. of nicp tine th?:t p .e r.slsts. ev:en: after quitting
snioking.
Employm-ent
. In v.ie,wof the ;de1eterious effects to mother and
As p:10r:ewomen enter the workforce, ques tions fetus, cigarette sm..ok;ing s hould be avoided
.about ~e inf+uence .of. work:on pre~ancy and the completely during pregnancy.
'i;nflu~nce:afpregnancy on wor.kbecomeimpQrt.a,.nt.
C ?,tegoricaJ. statements about .t he. wi~d~m :o f Alcohol.
continued W<lrk.during pregmi.ncy carurot~~a4e.
b ased o n -currentl y .av.a:ilabl e infor:t;na.tion: . . HeaVy' cir1nking {5 or 6 drlp.ks of wirle, beer; or
H owever, there is some evidence to suggest that distilled
. 'spirits a day) throughout pregnancy tan.

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 CHAPTER 16: PRENATAL CARE OF THE HEALTHY WOMAN ., .273
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - -------.,... '~

result in serious obstetrical complications, notably . COMMON COMPLAINTS D'URING PREG5ANCY

the fetal alcohol syndrome (FAS) which is
associated With a high neonatal mortality rate.24
Described_as the lumgcver that lasts a lifetime,
this condition produces infants who are born
undersized, usually mentally defici~nt, with
multipledefonnities.affecting tpe head, face, limbs,
heart and CNS. The risks of CQntinued drinking
are cert:aUUy dose related: the more the pregnant The etiology is still not clear up to the pr-esent
woman drinks, the greater the p<>tential danger
to the fetus. Even moder~te consumption (3 or 4.
drinks d:aity) througho-qt pregnanty is related to
variety o(problems,' including the increa8ed iisk
cf abortion, prematurity, low birthweight and levels of hCG such. as multiple gestatioo and
complicatiOns during ~bor and deliv~. The ~e
dally alcohG,l dose.in.pregriancy is still unknown.
The best advice to .a pregnant wolnan is npt to
dnr.k any .alcQholic beverage.
Caffeine
Accordin:gto the most.recent.scientific studies.
caffeine (f~Urid in roff.ee, tea, 'colas and o~er soft
'drinksl itiid 'its cousiti theobromine {found in
chocohite)do;c ross the pl~nta and enter the fetal
circUlation;...AltboUgh this drug has been generally
reco~as .sM~ th~re has been s<>mecancem
eentered j>'.riinmil}".on caffeine as -a m1,1tagen-and . bing of the pregnant woman~ the .coriditiott .is
a tera~ogenttts well as its effect on cathecolamine
metabolism. Most of the incriminating evidence
is basedol) iminial studies. H uman studies to .to. correct fluid. and electrolyte
date have sho\Vn no harm from moderate use (up
to 3 cups,-of-coffee or the equivalent in other
..ca.ffein'a:ted .beve-ra-g~s in a 2't-ho'u'i period
throughout pregnancy).
The following ate valid reasons for giVing up
caffelnated coffee, tea:, and cola,s during
pregrianty, -or .least cutting down consutnption:
f) Carreitle }:l~s-13: diuretic effect, 'drawL11g tlt.tid and
calcium from the body, both vital to maternal and
fetal hetl.lth, 2 ) coffee and tea, especially when
t aken with cream and sugar, are filling and
sa-t isfying-without being nutritious, and can spoil
appetite for the nutritious food needed, 3) caffeine
can cauSe mood swings, and can interfere with
~dequnte rest, 4) caffeine may interfere with the
absorption of iron, 5) resea r chers recently
suggested that a mother's con suming .caffeine
during pregnancy might res ult in her baby
eve11tually developing diabetes. Tlley theoriZe that
ca,ffeine crosses the placenta, builds up in the fetal
pancreas and eventunlly damages the tells 'that
later produce insulin. 'l~
Nausea and Vomiting
Typically, the symptoms of ilausea and
vomiti ng be:gin a~ . early as the . 4th week of
pregna11cy and continue until about the l~week.
time, although some have pqstulated that it is
honnonai. H$gh levels ofhCG might be re:sponsible
beci,use it seems to be more 'cotnnion and more
severe in patients with condit:lori.s t).aat leruUohigh
hydatidiform mole. . Emotional factors appear to
play a role in this condition, There tnight.also be
an allergic reaction 'to the possible en~ mto
the. matern~J circulation of fragments. ()! the
chorionic villi {deportation theo.ry .of Viet). Eating
small frequent mea~~ usually a lleviates the
symptoms; Anti-nausea . medicatio~s an~
occasionally required, but should be:{}iscouraged
because 9fthe possib~e eff~ts of th~se'~?on
the fetus. Assurance .tha:t, this ccindi:tiOQt-will
eventu~y disappear as pregnancy ptd~; - is
very importapt. .If _qa"Qsea and v.omiting hect>me
so seve~ 'tbatth.ese interl~reWith' the.gen~.weu-
referred to as "'hypereme~is gi'avidarituD? t~ould
this occur, .hospitalizationis mandatory m'otder
, . .
imbalance..
. .;
-
Pregnant pa.tients may develo.p backache :a nd
pain which are often referred to the .region of
buttocks and down to the thighs; Pain associated
with muscle spasm, frequently present in the
lower extremities,. responds weU to an~.sics,
heat and rest. In soine women, motion-of the
symphysis pubis a nd lumbosacral joints and
general relaxation of pelvic ligaments may be
demonstrated. Severe back pa in should .n ot be
attributed simply to pregnancy _u ntil an orth9pedic
exain:inalion bas been conducted.
Varicosities
The increased venous pressure in the"lower
extremities that accompan ies adv~ cing
pregnancy may aggravate varicosities of ~lower
extremities and the vulva. The treatffievl~f this
condition consists of rest with eleva tion of'tbe fee t
and the u se of elastic support stockings. V~lvar

Scanned 8y: ~
27.4 SECTION Ill: CUN.ICALAPPROACH TO PREGNANCY

varicOsities usually respond to support provided Fatigue

by the wearing of several perineal pads.
Hemorrhoids
The deve.lop;ment or aggravatio.n of
hem.orrho'ids .i=s -related to the tet.ldenc.y to
constiPa,tion during pregu~cy and :to . increased
pr~sSure .in the rectal vein caU:~d l{y o1:>~tiuti9n
.:of venous return by the large "~Jter:us. Uswilly .the
piUn and ~lllilJrare r<$eved. by :t~pkal_ly a,.pplie-4.
anesthetics, warm s:Oaks .e.ndagents that.:s<ift~n
the stooL ;dn 6ct:i".em~ .cases, "it :iq.ay !:>e necessaiy
fo-.: .tb.e.pati.ent to ~S:su,me alos.tC()mplet;e be4- ~t
in order for rue .he'morthoids to subside. The
d~ger of pelvic .inlt;cticrn c(,~traip.djcate3 surgicai
removal durln.g .pr~gnany.: i~ .fact,,
:he~ofrlloide<;tO.:iiy is .:be~g. ppstpout4 .u;ntil.aft6,r
tlie ,child bearing periOd, bcause. a subsequent.
~.r'egnancy. may
.
Pr.~uce furth~~
. hero.orr.hoids.
.
Most of pregnant women complain 'cf fatigue
and a desiTe for exccssiye periods. of -sleep during
early pregnan.cy. This usually disappears
spontaneously by the fourth mont.!l of'~an.cy
and has no special signifi~..nce,..
Headac;:be
..
Headache is ~a freqlJ,ent COID:plaint early. in
pregnancy. The cause should be identiE.ed and
tr~tm~t instituted. Few cases .m.ay be caused
by sinusitis or. ocular s.train due to trror of
refr~Ction. If :q.o cause 9an !?e .d~on.strn.ted,
treatmentis !;>)'l!lptO.matic.. .By izljd-pregtlancy, t:1ifu
shoul-d disappear; otherwise. _ ~regnancy
complications 'li:\:ce. =p reg:pancy-induced
hyprt:ensi~n .'have :to be consideicii..

Jleartb~-n
... , . :. ..
~ ... . ..
~
'# ' ' .. Sh.a;~-gro.i;n.:pa.in~. J.~$pe~iilly.- as:.pr~gna:r\cy:.
A burpi.r;tg:sensation.-ii1...Jh~ epigastri\!.lll' :. ady~ee~,. isvecy..c.oll1.ID.on,-.o ften:unComfoita.ble,
accom.paru.d .:by..J~~grof r4ln~.s}~ :a-comhion and d.isturbing tq :pa..tients~wb.o f~ it.r epr:esents
<;?C!;q.pWUt.: .I t .is u~~~Y: ~:a~d :bY .tl;t~-tdl~ o'f pret~ ){'t~r..~~ror;.. ~-~ometl:.U,ilg h :w.r;-orig....
;a;9&~,g~~Ic.c6nteAta . J.p.t~. :.th.e:il9wr\~P.ba'g>.ls ... Th~ pain.}s..ofte:n::ino!:e._p,r-~.mou'riccd-~on)he rigl;lt
T.h~ ,-:uP.Yt~ ~spl:S.q;?.ment>:of,'they:sto.rila,cli: by.:.th~ .,, ..side-dut:: tb ti;e;us~al. ct~io.tatio~{,i~~e.-gni.vid.
uterus . a;a.t:l:i;e~.p~eS:~ri~~eew.tcil::?:.~ilt:ion,. uteru~~ . .'.fh.is :t:epre~nt~ ;,st:r6tchliig, e.DG. spasm
oJ the .esQphS:g~.':sphin'eter b9tb' prphably o.fthe roUn.d ligaments:, M~cation .of:activicy
cont.nbut~ .tp .thi~ :s.rP'tPto~. ~.e.liei js "Qsua}!y i~ often very 1\:elpful: _f.n~1g~s}cs :a,r~ Tp._.r;.ely .
j)r.:?,~~~PY~!h~::!ff~uq~- ~?t.JJg~~~cid:!L.~~~ indict~Jed. . .... ': - -:: '" :.

:~aluminum h.y&:!?~.-Ql;~&Q;esium trisili~.t~. Qf
l;O.S:gnesium ]:lydr.oxide, and the :avoidance' of
'exce=ssrv~IY large meals~ Leukorrhea

.P..lca During pregnancy so;me :w-om~n develop

.T-h~>oiza'r.re :crav.i.r~_g .fo~ str.~ge fo.pds ?iJ.d
_xp.at~Ji.a,ls:<thl3.t.are !h~dly <:op.siderecr.ediple :s~c:>h
:a.s: la\tndcy.starch;, day.or even: d.if.t' ~s 9<illeci pita:
and deVelops .oceaslorl.aliy during p regna_ncy:. The.
inge'st1ori of starth isa3J.led aq1ylopha.gja aad the
inge~.tlon of clfl.Y is called geo.ph;igia. The.s e.
co.nditlons are practiceci nior:e. oft:en by p.regriant
women helonging to the lower socioeconomic
gr.oup.
Ptyalism
increa~<;d v~i?;inal qi~harge :(leu.lcorrhea) -which -~
many i.p_stanes . ha~ no ,path9lqgic .cause. :rb.is
ir~c::-ea~e ill v.~~al c,iisc:h~geis due to i ncreased
muais fonnatio.:n by cervitril'giands in rc.stxm~e
tv hyperestroge~~:mia . If. the .secre~ion is
trolibl~some ~d :~.c::colnpanied by pruritus and
b~rn~ng sensation, in:fections cause'd by
trichomor:.as .~aginalis, -ca-n d.i da albicans or
gardnerella vaginalis.have to be ~o~etcd.' To
d,etermine the ca:p.sative org~sm, ,a fr~h smear
has to be taken and exarn.ined under the
microscope.

.Pro'fuse salivation or ptyalism occurs Trichomonas r,Jagin.dlis

.Qecasionally durin,g_preg:napcy . The cause of this
condition appeai::s to. be stimulationof-the .salivacy Tpe YC:J.gina1 disc~a]:ge inhls condition is fqaniy
gianctsby 't~e ingestion-.of starch. . and' the vaginal epithelium, jncludi~g: th~ cervix

Scanned By: C
 CHAPTER 16: PRENATAL CARE OF THE HEAlTHY WOMAN 275
~----------------------~--~----------~~--~----------------~-------

(strawberry cervix) contains small punctuate, treatment of candidiasis during pregnancy~either

reddened areas. The ameboid organism may be mti"tlvaginitlly or topically.
readily identified by a fresh hanging drop
preparation of the vaginal secretion mixed with Gardnerella vagina!is
NSS. Metronidazole is apparently an effective
method of treatment which c:m be giyen. .after the . For many years, non-specific vaginalis has
1 trimester. been attributed to gardnerella v:aginalis. It has
also been implicated recently by some researchers
Candidiasis or Moniliasis together with triclrottlonas and candida infections
in the etiology -of preterm labor. There is a rule of
In this typ:! of infecth>n, .the.di~~haTge :is thumb :r~~ L"ltemation~y which .requires
"cheesy.white" and tends to .adher~ to the vagillal that three of the following criteria must bC satisfied
mucosa. Usually this di~clW-ge is aceompa.nied before a dbignosis of gardnerena infection cah be
by ~ere pruritus, burning 5ensation,. rednes~ justified .naJDely: l j p.resenee of hom~genous
and excoriation of the skin of the vulva and grayish white discharge, 2) pH more than 4.5 1
perineum~ Fresh hanging drop prePara.P.on .o f the 3) .r otten fish Pdor after addition of 1\Wc.- KOH
vaginal di~<:harge with 20% l{OH will deinonsw.\te .(positive amine test); and 4) clue cells in the direct
oval budding cells ot pseudohyph..a.e. The microscQpic preparation. the treatment is the
discharge eail also be cultured. Miconazote, administration oi metroili~le, otally or as
-., clctrimazo1e, and nystatin are effective in the suppositories intravagina11y.

... ,. ..
~ ~.":.:~ .
. POiNTS TO REMEM6ER

- ... P~,m~tal care .i s a planned pr()gram (If medical evai\Jation .and maoagem.ent, observation c;~nd
edllcation of the pregnant woman directed toward making pregnancy, labOr, delivean~ the.. :_:::
pe~tparturtl recavery; a Safe and satisfying experience. . . .. -;.;'-'-;.~~: . -~~~~: ..
:.. ; .~:\"h' . . - . . . :~~p ... - - . :\:::~.~-~;-.-
Primipara is a woman Who has been delivered once of a fetus or fetuses yffii.cn .r.eached v.iability. .r;-;1!. ~ .
V1a~ility is beyond the 20" week of pregnancy or beyond the stage of abortion
Completion-of any "pregnancy-beytmd' 1fre'Sfa1J~n'jfab6rti6n bestowspantyuJ)on.a. woman.
0 0 0 0 0 0 oO ~ ' ', ' ~ ~- 0 0 ' Oo 00 ' , o ~ ' 0 ' 0 ' , . ~ o, . M 00 M 0 0 0 ' , ~ ..

Multipara is a woman Who- -has completed

. . .
two or more pregnancies to viability.
.
Parity is determined by the number of pregnancies reaching viability and not the m.imber of fe4Js
delivered.
Nulligrcv!da ls a woman who is riot now and never beer. pr:egn~nl
Gravida .is .~ woman who !s or has been pregnant irrespective .of pregnancy outcome.
Nuilipara is ~ woman Who has n ever completed a pregnancy beyond the stage of viability.
Parturient is a woman in labor.
Puerpera is a woman who had justgiven birth.
Preterm pregnancy lasts >20 weeks to <37 weeks (141- <259 days).
Term pragnaocy lasts from 37 weeks to 42 \N~eks (259-294 dsys).
Posterm pregnancy last ->42 weeks (294 days).
Obstetrical score is a 4-dlgit number
1 digit- refers to the number of term/post term pregnancies
2tld digit - refers to the number of preterm pregnancies

Scanned By: ~
 .276

of
3'!1 digit - the number non-viable pregnancies
4" digit- refers to the number of children currently aliVe

Pregnancy begins with fertilization of the ovum.

An accurote determination of gestatlona! length is one or the most important ,functions of prenatal
care.
Methods.to .estimate .the duration of a.pregnancy with reasonable accuracy are: Na~gele's rule, timing
bfovulati9n. tlm1ng fr()m quickening. height of the fundus uteri in_centimeters, and ultrasound.
. Naegele's -Rule in estimatin,g the dates Of eonfinement -.is calculate~ trom the first day of the last
..
r.orinal menstrual petiod, add seven ~tlys, subtract three months
.
. and add oneyear.
.
. .
Ovulatory-age orfertiilzatiOn ~ge Is 2 -weeks younger tbc.m.memenstrual age.
Toest!matethe date Of ~eliveryln .a WOI$l whose last ovulation date.is len~. Just add 2$7 days.
QuiCkening is the .maternal
.
perceptlonortetal
. . ,.
movement
Qu~ening is perceived usually, between :the.16111 and 18" weeks in o:muitipai'a ~nd 2 weaks later in a
. primigraVio~'\
At 12 weeks, after the.Jast menstrual period, the -fundus is felt -above the symphysis pubis.
. : _.. 'At2oweeks,the ft:indus.is'f1t-3Uhflevel'oftheumbllicus.- .- -
. Tha .fundie<heightJn.em~. :is numerically equa! to .the gestational age ~tween 1-S-32. weeks~
- :.'i'ii\ms~lo~luftra~i.m<;t:~ :a~'a preghaney~at~'wee~{metl.stri;l_alage}:gestation eorres~ng
. to the a..:hCG c6nceh~ti0tt:ol'lsp0..2oo<rmlutmf . . . . . . : . . .
- Atpf-near:tean.-<tt1e.iJnCider)Ce.'of:va.no.u_s.'pre~entations,is ~.follm:.y,er.tex,. :,96%: .br-e.eeh,..3:5%:fuca,.
1.3%, iind Sll!>.Uider, OA%.
213 (?hllverte>C'presen~tioo$-are in 'the-left occiput- pesffion to confotm-.t o -the.,pytiform_.shape bi the
utenne ~vity,
Methods .used to determine fatal t:e, presentation an~ position .are: abdonilna.l p~lp::ation (l,.e6pold's
maneuver), vaginal examination, auscultation, ultrasonOg,rc3phy and radiOg~phy:
First maneuver of L;eopold's is also called the Fundal grip.
The.second maneuver of leopOld~ !s also caliEXJ 'th? Uml>iil~l gtip
The-third .manew.er -of l.epold'sls c;llso called th~ :Pawtic's-g:ip.
The fourth.maneuverof Leo_pold's..is. also called the Pelvi.c:grip. This mane1,1ver determines 2 things:
whether .eng?gement -has .oecurred and where the cephalic prominence.is located to determine the
attitude of thedetus{flexed or extenped).
The best time to evalua~ the <>bstetric pelvis is about the 7" month of gestatien, when ihe pelvic
tissues are. more relaxed, utef\J$ is still an abdominal organ and the presenting part of the fetus has not
yet entered the pelvis.
Screening for cervlco-vagi~al infeetions and cetviciil cancer is now considered routine in prenatal care.
The frequency of prenatal-visits is scheduled as follows if patient is not a high risk
'Every_-4 weeks until 28 weeks
Every 2 weeks until 36 weeks
Weekly, ,thereafter

Saanned IJy: C
 CHAP~ 16:- ~RENAiAL CARE OF THE HEAttHY WOMAN .211
----~~--~------~-~~~
- ~~~-~---~ ----~-----------------------------~~

:: ..
. The goal of subsequent prenatal care isto assess well being:of the expectant mother and her retus.

A 2-step screening for glucose intoleranre is done between 24-28 weeks of pregnancy, using tbe .so
gl"'dfris oml g!uoose challenge test {GCT) and If the value exceeds 130 mg/dl, ih.en a 3 hour 100 gms
test is recommended.

The amount of weight a woman needs to gain during pregnancy is based em her pre pregnancy body
":lass index (BMI).whl~ compares weight to height

Recommende<t d~parya_l~.and.the .Jevels Of makes of energy and essential nutrientsronsidered

adequate to maintain health and provide reasonable levels of reserves in body tissues of neatly all
healthy-~rsons in the population.
. . ..... ..

RDA protein thr:Pughcut .pregnancy is 9 grams per day.

RDA for calCium during pregnancy is 900 milligrams p~r day.

The average requlrem~nt.ofiron, the WhOle duration-of pr~nanq is.41inWdC!y. I

. The RDA.ofiodine for pregnant woman is 1251Jg.

. A minimum of 350pg/Cf offolate IS recommended for Filipino pregnant woman. . ::' ...: -: :_:.::.;.
. . . =~'"\

. Prenata~care is an .excel:ent time to educate the patient .about the ;be~efits Qf breastfeedl'ng Wh~~....
..,,,;;;,~ - .includes immunologic protection, raptd uterine involution, matemqkhiid bonding, and.natural child .. _
.. spacing pn family planning. ..~<" ...
' ~ r,_, \ : ~;t : ~;~~- .

~"'-~ ;' The goal of ~xeJ'tis:e during pregr.ar:cy is to maintain the highest level of fetuses .con5i$tent'Witftfl..
minimum safety. . . .. .

~ .The!Jl.are :fooJr kinds.o f exerciSe that can be useful_duf.~~~~~~-~~-~-~- aerpbi~.~aljgh~m~ s;~~i9oed

for~pregnancy; te~-atiol'lleCJfr'iiques'an<floning exercis~s {fS~_g~l). . .. ... .
. .... ... - --""----~ - ---~------ - .. .

smoking during pieQnancy nas been associated Y!ith complications like tow birthweight. premature
labor, abruptio placenta, pr~matute rupture .o f the membranes.

in view of the deleterious effects to mothe.r and fetus, cigarette smoking should be avoided completeiy
during pregnancy.

If nausea and vomiting beeame so Severe that these interfere with the general well-being of the
pregnant woman, 1he condition is referred to - hyperemesis gravidarium.

Pica is the bizarre cravings for strange foods and materials that ate hardiy edible such as clay.

Ptyalism is profuse salivatiOn.

Round Ligament Pain -is a sharp groin pain as pregnancy advances due to stretching and spasm of
the round ligaments.
.,.
Leukorrhea during pregnancy maybe physiologic or pathologic (trichomoniasis, candidiasis or baderial
vaginosis). -~:
;..~

Scanned 8y: ~
27.8 SECT{ON Ill: CUNICALAPPROACH JO PREGNANCY 1 Ylttf:. .

~
:
!"'
.

14. Cummings JH. Dietary. Am:J Clin Nutr 1987; 45: 10 4\l-
.104~- .
1. KO<;henour NK. Normal pregnancy and prenatal care.
.ill:ScottJr, Disaia.PJ, Jiam,mou.:iOB. SpellacyWN{ed.s):. I:S. Pi~ RM. Calcium metabolism in pregnancr.A review
Da.nforth'a Obste-trics :a nd -G ynecology, 6th ed. AmJ Obs tet Gyneccl1971; 121: 724~737.
Philadelphia, USA: Lippincot Co . .
16. Duggin GG, et a1. Calcium b alance in p regnancy.
;2. Elli:~ JW. Prenatal .care. In: Ellis JW, Becio;J.a.< CR L<mcet.
(eds): /<. CUnical Manual of. :Obstetrics: 4"' edition,
Norwalk, COnn~t: Appleton-century-Crofts. 1983. 17. Ro~r:ts BW. Nutriti9n~d pregruincy.ln:
. . ~ .
C}Jeny SN . j

MarkatzJR. (.:dst:CompUeations ofPreg:o.anCy: Medical

s. Panlili9 :!"fe, v~ TR, Sa1uc:i J,E. Mean 'V8l.UeS of uterine . &lrgca, Gfne::dcgc, P5ychoo:da and Poinatal. 4U: .
hi!-iht in jn'egi;l.ant Filipino' woine.n . Phil J Ob~tet ed. Baltini()'r:e; MD;:w~a &.'w).nciri.s .
~~ecol"l982; ~:95.
i8. Truswell AS, Fo14te~ .J Food Nutr 1984; 41: 143.
4. taylor.ES. Diagno~sofj,regnancy. Beck's Obstetrical
PractiCe. 9"' ed. Bal tinior e: The Wiillams .& Wilkins 19. Marzan f.l\L An oyejView o{ the ~ut;ritional anemia
Co. f97L . . . problem 'i n the Philippines. Phil .J Nutr 1976; 39: 14-
2L
. 5. Wil:.:on &i, .:Beec4am. CF, .Canin,gtpn ER. Diagriosis
and durati o-n of pre~~ncy:-and prcn~tal -eare. 20 . .J,.Ontoc AV, et a1. Folic acidcontent of SQm:e PhiliP.pine
Obst~trit3 and <h:-neco!ogy; 5ihediti!ln. St !..;(>tiis: The fQCds. phil J Sci~nce 1968; 95: 3.10;,'320 .
,_ . .
.c.v.Mo$bycO. I97.s.
21. Chong YR. ~cythrocyte transketolsse :activity. Am J
f?, Rdd.{?,~:j(J.,~~e'K.Ccri.du~:of:pr~gnancy.. Clin Nutr 1970; 2-3:261-266 .
. ~ J~tinqple$!~~RPAg~til,~f;;'Of,~)~'!a~ii.?'t;p~uctiol,l.:,., , ., .... . , ... ..., ,. . . ,,, .... .. . .
?~elphia:.W8:sa~~6t~ 0. 197'2. . . 2~. :Goldimith.GH;, et!ll. StUdies ohiliinrclp.tire:nentsin ,
man: I tequir~ment on wheat aD:d' corn diets low in
'7,. ~r:w.~vm~cA;vAiee:bB: ffio:cii>tesot~t~ tryptophan: J Nutrlo:as; ~:371-386.
~e. }Itiman .Reprogution..,: Tlie: eor e.'Coiltent of
Op~driea;:~~l<igy.1c,t~Med.iciile; ~-ed. 23 - Artai R. Exerq~.:in:pre~cy.';in;Cherry.SW, .Mil.r.ka,tz :
~Clj)bia:<'WB: Saurtders:eo-:~ i97p. . : .. . . IR,C~s): 'Complita,tions of~cY: Medical, Surgical, :
0yl;lecp~o@.?~".P.!1Y.c~o'sJ?cial .'a,nd .Perina~. 4r,h ed.
a. ~uiiis~&rr~rqt;;etenata.tCru:e (Acoostilleun. Baltimote~' MD : 'Williair.t$ :& Wilki.o;s. .
.'1988). .
24 .. Eise~rgA, etal.. Exer-dse d urlng p~gnancy.-What
9_ N'!eby,r.:m:-th:e-XFrsJQcy:: Xn .ppa,ate, AcCJG Post- ro:e~ wllefi ycni'r'e-"Cxpec~'f""T9:n: . &e:w York
. -gr:aq\Fite ~COUije~' Tg87: . . .. "~;P:U
~:iliiij.g_-- . . . .;.: ',

10 .Culmklffiam GF,, et.~.\ntep~: 'Ma.!).ll.gem ent qf
Norixuil:~. Williiiin..0bstep-ies; .19 ih ed. ~ndon':
.Prentice Hau;rntdrnation~In.:;. 1993.
1;1.. F90(1 and:t{utdti()ti Rese'atetllns~~te Departl;rient of
S cience 'll:l~ Tech,n9lo,g y .R~or.p.me.nded D(e tary
Allowan~s for .F.jlipino~. 19S9 :ed'ition.
12 . viliav~ja lfM,. tit a l. Third National Nutrition ~urvey,
Philippine~. 1987. P<trtA . Food Con sum ption Su rvey
FNRI Publication, 1989..
.2:5. !'la eye RL. C.oitus ~d ass ociated am.ciotidnfections.
. N~.;;.; E:n gi J Me~ t 979; 3 i.o: i 19 a. . .
26. Goodlin RC, et al. Orgasm during la te pn g'nancy.
. Obstet. y}rnei;ol- l~7l; .3.8: 916.
27. Bec~aim G, et ~ .Antcpa,rtum ~e. Obstet Gyrtecol
199.8; S:: o 8-8;4. 3' 4 ed. J.:ip p incott, William;~ .& W~s . .
28 .. ACOG ~ucation P<)..mphlet ABOOS, You and Your Baby
.Prenatal. htr.
. Jo . ...:_,...... .,,, <>J.;. . .. ... .. . ..

29. Beckmann:C.R, et al.. ObstemC:.S & Gynecology, 4th ed .

13. Men deleoff AI. Diet a ry fiber. and gastroint estinal Lipp incott, Williams S. Wilkins , pp. 78-97 .
disease. Am J ClinNutr 1987; 45: 1267-1'27 0.

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 17

IDENTIFICATION OF HIGH
RISK PllEGNANCY

.1. (t%1 06 hiJffij .

Risk Factors
t (Q~r~ldif\.~ ( ~ bdi.~) .
- ~A-i 1f.,.l!V\JJ M\l_IWrtid 1 !'JY1,t~
Maternal Age
) 1/Wn'i)til\ ~ J'>t'\11 OVI.N'
.Height
~~:
- .x ' ~

Weight .
. ./ tMJy; >l\N
I' - ~,..w .
Soda! Factors (Smoking, Drugs, Alcohol)
-lA~}) 1~1\1 1 "" J/\lMV.rv
Obstatrical History {Parity)
1-.T1\"'ft'Aiv.A .;.-. -. '
Premature Rupture of Membranes
-'<l~/ I AAV.V-1 . . '
Intrauterine Fetal Growth Restriction
. n~ttM~ -f lt"J .(, 1tJ 1~1~ t. -;n~~t
Postlerm Pregnancy
i~~''Yj . m "'-llJ.
.
Preterm Pregnancy
.Fetal-tv1acrosomia , fut:A-lt= -l;;m11tiii.J - ~m ..(Aw'vlV::J
'

4 'Wl) }.L-j IMj i I,JT{) t~

Multiple Pregnancy
-(.11 fY'tWJIY lA( /1. 11-~11kJ
Hydramnios and Oligohydramnios
lr'iv'l - 1Nh'lt-ltri~m~
Urinary Tract Infection
l..f ~ 1'\...WII'I J. \!Vml~lh;
Diabetes Me!litus
~ 1rt- -JIV1r1MitU
Thyroid Disorders (~-\~~W1HI.l~ l{ 1- 1" li
-i-t 1"'11 tq - }y -;- 1.
-('JMU lujf'
Indications for Ant~partum Fetai Monitoring -rur % ..., Ulv"1 1,-\.U.~
-~r
Obstetric Management that Might be Influenced by Antepartum Testing

Aspects of Fetal Condition that Might be Predicted by Antepartum Testing

Scanned By: ~
 -.!....------""'---::.s=e=-=c=TJ:::-:0::-:-N-:-:-:111-:-:-Cl:"":I-N-:IC:-AL-.-A-::P-P='R.._O.._
A_..C-: ;'~-:.
H-::T~O-P_R_E_G_N_A_N_C-.Y---'-------.-~-:'~~::,
------------~--....,.,--------,----_,._--~.,.._.. ___ ,

Perinatal events have :s ignificant :role in mfant of pregnancy complications such as hype~~e.' :~;: ..
morta.Uty. Fetal death~ .may occur either during disor.ders, gestational .diabetes and an increa.a(;d:. ;: ,
~tepartum or intrapartum: Thirty percent of need of operative delivery. In a study ma:l;;J.: . ..:
. .. th~se fetal deaths' can be attri,buted to asphyxia Kristensen, et al. s.matemai 0 besit:y was assoaated :.:: '
. .J(lOQ:R, ptolo.nged. gestation), . 30 percent ~o with :a more th~i -doubled risk of stillbirth{vdds .. ~:
.. .. : m~ternal c;omplications (place ntal abnipticm, ratio= 2.8, 95/o CI: 1.5-5-3) and .neonatal d~tli .
.h.Y:Iiertension, preeclampsia, ar.d diab.e.tes (odds ratio"' 2.6, 95% CI: 1.2..:5.8) compared.:wilh .
:. . , .tfi.ellitu-s), 15 pe0eU.t to cOngenital malfon:1a:tions women of normal weight. '
~ and-chromoSonial abnormalities, -5 per-cent to . . . I '": ... .
.:Jtific~<?n and 20 per.ceqt wi~l have rio o.bvious InthestudyofRaatika.inen,etal.6 13.2W,it':, ..
.... :- . -e?'61~~ti W'i.th :: t,h~ adv.aiLc~ ' .iil.~ino<ki:Jl-' a~y ' . :: {>f :.~}):~ir p~~ltl~tio~ ~ere ~verweigh~ l.pr~~ . ' .
. . 9'9~tetri,e;s~ s~tA' f~tal a~~s. ~- !>?! :.p~even~d. : Pf~~~ B~ = 29-'~9 k.~m?} .and -7 -~ ~t.
.: ::, 'i3;~ti6tt:o.r:liigh rls~:~tients:,uting.p~t.hl w:ere: dbese _(BMJ,:~ 30 kg(~2_}. ::.. T,hey..f~~4 .H~f. : .
<:, ~~1lp:# tli~ToFe :iuld4~: . .. .:. >. . :th~:t p~efp:~P:~Y: .o.ut.coiti~s W:ete .iilip'a,h:e~'.i~ .:
. . : ..o.verir'~ight . an,d obese.. pr~gp.ap.~ :-w.pmen, With '>:
: : R(sg FA.CTORS . r~~tive odds ratios (95% confidence ind,.ex.:} as :: :
follows; 1ow Apgar sc.ore at 5 roinu,tes, I.S4(1.'2Q . .
. ~.... ~~~riua Age (Age <1$ years o~ Nullipaia:::. 30 to 1.98.) and i.64 tL2:i to 2 .2'8); new.l:>.o~n
. ;, . ::ytaiS.of,a.ge; Multipara>3.5 years vf age} . .admi~iGn to a neonat91 unit, 1-?.0 (l.o6 to "1~~7): .
..:., . <<'. and l.3:8 {i.l7 to 1.61); cesarean d~vtzY. :. L~2 ..:
.~ . :.Adva,nced :m:atem:<?J..ageis inimi6u ~t6 the 'fetus '(L~D .t?. 1,35.) ~a L<Q8:{1.48 to L9 .i); fetal d.eatli~. :.
: . : : 'inirt~any":ways.,j~he incr:easect:.:.pm~at8Lmoi1:ality . L54 . (0:88 to 2.6R) and .2 .;l~ ..~L2B.to 4 ~_3.2); . ': .
.:; c ,., ;~dmroibidity;"as; a:resu1t of 'f etal"S:bnoima:lity..,. ~tal. death.,l.5!+(0"93=to. 2.:.-4-2},and..2 .L9~(1:33I~: :; . . .
':. ,' sr:~ ~stxjc~~~.~.~t~~~- d~g~~e~tiv.e: ~i~s; . . t~;3~62)~ "A1~ noted was the mcr~a~e b obSt~t!i~ .< .' .'
j>~culady ~ardiO'r.enal -.and:.' diabetes . are ris}a; -~:a :BMI-d.ependeilt rmmncf. Tlii~r Sb.;I'd~ :..
..
.: : . ., ' . ~on. .ki:rvwJedge. ' sugges~ea that rood_est ;w:eigh.t 'loss could _1?~!(: .
. ---:. . .substantial.advantages'to obstetric outcome:. .- .
.....' : .~ ... :,~i:n: th-e:8tudy: conducted:by: mtti :~~ a:Ld aftep .... --~ . : . .. . . ,..: :--:.. .':) .:
. ... -~~~l'i.,;g~ifor.:::risk..!act0~s..;.such.::~s:.~tiple,:..~. ~-~ Factors ' ' ..,_. . }. -~ . .
: . ..~,~~jion; :b:!.perte~s.i?~!. tli~be~es mC?lllt~s, Smoking :- :
. p~tii.. p.teVla and .a bruptio, prev1o~s abortion. ... -~
. -. .-:.ijiia pii9r:tefiini~lli;~atir'en $'y~: or~e or .. < ~ ''
.... 01&t ----- - - - - --- J~~t~m?.A ggg~tt~_gnokh.!K_4~g.P.r.~m!jti:_ . :.
. : ......; .. . ,l;lad~n~.tw.?fold:~terri~kfor"fetaldeath leads to manY cotuplicat;i.ons; the most co~~m ;.
' n .W9men . U.n
. de.t" .30~ Data from Qenrn<>-+-1{
. ' t.h a
u.~....,_
...have """'llig res trictio~ of...m tra
h;, u tenne wth .res .1-0:~g, .
.... .gro u
' l..;.:..,.. .. . . :

.:- '.. .ti>:i)finned the J-shapdl curve re"\ationship between
..: .. ~~.~a;&ean!i:fetru:deathswitht}lehig4es~JO.tes
:. .. {$;teenagers :and women over. age 35.~~
. ... . ::-.. .-.;~~~.;w,.Relglit (6G inches I i53cm. or less)
.. . ... . }
in a reduced fetal we~ght and size. In a study iira(:l.e
by Steyn, et aL7 , $.e 'tpean oJ.ttliweight of-..rton..: ..:
to~c~o uset!? was'3J.'48 .~s 'arid that of th'e ,.
smokers 29s2,gfa.ins; ~esUitirig . jp, a.. sigrufiean4j ..
lowGr 1;1~ birthweight of 165. irams for ~b.l~~ ;_..

of smoking mother-S.
:. Ther.e is an increased :perinatal morbidity and
:m_9~lity rate associated with birth trauma ,
~- . .e~rean section, congehitaJ ~no:ma:lies and
: .~ .:p1einaturlty in small woril.e.n <'\s compared with tall llHcit drug use produces jp_\r~ute.rj.ne ws'tr_$..~.~~-.....
. wotteil. In-a study made by Ma:na,h?Jl..~ii Torn.o. : Low birth weight and. serioua cbmpromls~ ~er . .
. . . .: . of. 1$7 Filipino women less .than 5 feet tall. it was birth are i~creasing particulaiiy. with the u~. :or~
.!ound that 4;2 per:c.e nt o.! sh<;>.r.t won1ei}. h.ftd hard dx:ugs like op~um and its derivatiyes,~
' ,, c6J:}tr:ac.ted .pelvis ahd 64 percent required ' a . barbiturate's and amphetamiiies, and mcth2;d:op~~. ' '
eesirean section as the mode of delivery. . : , . ~...~ : ...

The rpaturity o( maternal tissues is krioVtn'.a:hd :.

:W~lght -.(Obesity f .AbnoooalBMI) .
. ln'pregnancy, maternal obesity .is associated
. ,;. With.'increased fetal growt.~ and a higher frequency
the dfeet~ 6t a dhtg are predktable whereast.b;e
effects of drugs on fetal tissues at the ~ereri(
stages of maturationof the en.zyme _systems.have. .
not yet been determined. An!:ibictics, lit. general,'
' . ..

Scanned 8y: C
 I .
CHAPTER 17: IDENTIFICATION OF HIGH RISK PREGNANCY
have little harmful effects. It is well known
however that tetrac:ycline causes brownish
~tainlng of deeiduous teeth and may affect . the
bone structure,. even ,perhaps premature cessation
cf growth of the l~ng bcnes. Ch!otat'llpberjcol,
given la:te in pregnancy, can cause cardiac failure
in the neonate (Gray's syndrome) and
Stt'eptomycln may .a ffect the auditory nerve
ca.usin,g congenital .deafncss.
AlcohOl
AlrobDl i'eadi.'Y crosses the ~nta. Moderate
use has not been sh~ . to. produce patholbgic
changes to s!fect the :c ourse of pregnancy.
Delirium tretnen.s bas been described in
newborns. The affected newborn is depressed at
birth but soon becomes extremely hyprac:::tive
with .swea.t;fu,g tremors and ,epi~e$ of twitching
of the face -~d e:xtr~ties. Chronic alooholi~~
is alSQ ~te~hvith f.etAl rtmiofacial. limb and
. canfi(;~ :defe$; prenatal aild postnatal
growth res~ction.
.. :
ObstetrJ.cat~f)ry (MUltip.lmty)
'The" ~-il:Cidence o( .certain o.b stetrlca:l
comp:li~Jio~. na$ely abmptioj)l,aeerita, placenta
previa; p()SfPartmn hemorri'.age~ uterine ttipture,
twinning dysfunctional labor and congenjtal
ancmalies, is definitely known to i11crease 'With
parity. -
Premature rupture -of m~mbranes is defmed
as rupture of the fetal mmbranes prior to the
o nset o{ labOr: It has lmee clinical significai1;ces.
First, if the presenting -~ is not fixed .i ii the
pelvis; the possibility of <;:ord prolapse and
supsequent compression is increased. Second,
labor is quite J,ikdy to occur. And third, there is
the possibility of intra:utel'ine.infection if
membrartes are ru'Ptured. '
- - . .. ,..._. . .. -
.~
The management i:i1 still controversial.
_Immediate delivery i s indicated if there is evidence
of chorioamnionitis, vaginal bleeding or fetal
distress~
In .r ome studies, expectant management can
be done the absence of o9stetric complica tions .
and it was asse<;iated with a lower r.ate of.cesarean
d elivery as compared with active management. in the first or second trime.s ter or combined with
Scanned By:
~~:
However, larger studies conClude thatimineruate
induction of labor with intravenous oJ.t)'tocin, or
prostaglandin and expectant management are
all reasonable options for wo.m en if ..nembranes
rupture before the .s tart of labor, sinee similar
rates of neQ!latal infection and cesarean delivery
were noted. It must be remembered that with
expectant management, chances of maternal
chorioamnionitjs an(} endometritis ~re
increa.s ed.
Intrauterine Fetal Growth Rt!strlc:Uon (IOGR)
IUGR is commonly"defined as. a fetus that is
less th:t.n the 10th percentile of a weight for
gestational age cuxve.l0 The diagnosis of IUGR
begins with identification of risk factors associated
with it:
Matemal Risk Facto~ for JUGR
Social ~tory (Poor 'Weight .gainJ.U:..;pre~cy..
smoking, poor-.socioeco~omi:c histOry) ,.,,. ,:~:;.i:~,.
Obstetiical history (Previ..o us IUGRii;~b~ied
abortions, stillbirths an<l neoQ.atal deathsr
Medi~ history ;{Hypertensive diseaae, .p~cy
induced hyperien~ion, ~ntial, h~n'; _ :,.
renaf di~. chronic reual disea~.~. ;.:mu~t,iple
urinary tract Jnr~ti9ns, chropie liver.di~se.,
significant ~c <Usease, hemoglc;>bino~thies,
and ~~~l)<>pp,i~ia_~).
~ . . .. . -
' - .. . . ,-,..._ .. -.. - . . ~. : . . :~ - ..
. '
screeil4igmetb0d~ in identi.fyinglUGR are
abdominal palpation, $Ylllphy~is~fun~ . height
and amniotic fluid estima~. 'l'hediagno&s 0 fiUGR
is verified by ultrasonography. P~atneters
commonly used ate 'l3PD, femur length, head
circumference, mean abdominal diameter an:d
abdQmir..al .circumferen~. A reduCed -::.bdominal
circumferenc;.e is reported to be the mostsensitive
biometric measurement in ~()Sing lUGR with
fft:lse-r.egative rate of)ess than 100/o. Together with
Doppler veloeity wave fot'm analysis of fetal
ves.s els, these 2 appear to be the best methods in
identifying and :evah.,tating IUGRpatients..
Onc.e IUGR is diagnosed, serial evaluation. of
the fetus every two weeks or weekly together y4th
Doppler velo.city wave for.m studil!s . and
biophysical testing must be done. : ... ,..
. . . . . -~~ .
-~ ~
Prophylaxis with acetylsalicylic acfd~started
~
. .. .

282 SECTION ill: CUNlcAL APPROACH T0 PREGNANCY

heparln before conception, may reduce the Multiple Pregnancies

incidence of !UGR.
Twinning occ1lrs in .nearly 2 percent of
ge~tions..
It contributes to O"'~er 15 percent ofall
infants wdghlng 'less !han 2500 grams, half of
At least .3 percent of infants are born ~r 42 . which are preter.m. Thus multiple pregnancies
CQ.n1pieted we~s .o f .ge~tatica.. The P.lltjority of account for more undergrowth neonates than ~Y
these fetuses will show theeffects ofimpaimi:ent other.known cause. The perir..etal mortality and .
of nutritional suppl;y. Man:Y 1 those infants will morbidity .of multiple gestations al59 fat ~
have sUffered &n a ctual loss ofvi.elgb.tin titerowith that of s;i.ngletons of s imila r gestation~ age.
.'..
> . .e-h:!ence of reduced sul:lcu~eotis ~6 scialing, Hencej its ear:Jy diagnosis, early elim.i.nation of
j. . .and paichment-4ike sKin."tr.i$ ci>nditip:n is ustta:ny. obstetric oom:plic;atio~s. eXtension of gestation;
J#'~ed 'tb a e-dysm:atqrity.. avoidance .:of deliVery probiems, and optioiJ.al
~'
neonaful a,u-e are essentialin the care of.motb.ern
r--
.....,mpticiition:s
. with m:ultiple pregnancies.

1} .A sharp 'rise .in both fe:~l and neonatal QJ$1ications dn.d Prqgn.osi.s . .
.. . : mortality aiter 42 ~eeks gestation.
~atetn:al complica.:ti9n'~. in~;;1u~e p.re-
2) . ~~tBI.fujury from 'fetopemc di~~po:ttibn:~ eclain.psii..ed~~~ul. "N1lich are three ~.es ~re
. ~:-:. . . . . . . . frG.~entlli womep:'With' ~ '~1lanin women with
.3)~~~lij)iiJXialdam~e:frorp.:fet;aJY~st.tess,,'-Witll;; . singltons; .pre:m:a.tUre la.:Q<>r, often;pr:~ed by
.. ~fr~'.clianci>~f;fu~istibin;\.ali~'ai?-d~- spon.tane~:n:isl=l..ip~,oh~lem~~fise:\re:a.:tlln.~~-..
... :.neurolegic .deficit. . :m or,e :ijkely ip. m\Upp~c pr:e.g nancy; premattire
se~tion .o f'the-plaee,nta.c~.u:pJ;nQt'l~~,after
th.e d~).iv~r:y. :c;Jf the fm>t of the ~s. Maternal
complioatiPns .::ol.a.c h~~ hem9trhage: :~d traun:ia
Pi~tel'$1b'irt.h.i3 :defin~<:Fa~ :dcliv.~ty :ofa;-fetus . :acc.Ount.f9r,_ el.gl:Jt'-f~kl:-inet:~~'S~. ~; .o:Later.neJ...
'before: ai.:co'mpleted: wee-ks;: :ttaccoiin:ts :..ft!r . moi;"l;lidity:,: J>o~m:.h~rnorrh.age.'O(:Clu:S often .
app;iQ~r.n~-~~/:3:~finfant(lettfuS. after delivery.
. - :~:;:, . _ :. ,. . . .
The iidilUilistra;fi'Onof ~lii<i>~to ffi.Olliei-S an theother::r.an.~; fetal'ctfthJ!licationsinclu"de:.
in -iiret~Jal>or-betWeen::2+.34wea.~-cif-.gesta:B0I'! fet:a.rdealli
. ..whicn:occlli'S::
. . .. weel:lmes-asofteh-vti.th.
' ..
{
.reo.\l~n~iru-:rnortaUty bjte(lnclog teSp~tory twine be~~se v f a bnon::Oa l f~W, orplacenta1
dishetJ~ .s yndrome -u~t>S), inttavent.r.icu1ar developmen t . circu1a tory co$p etit1oti and
hei:i:i6rrna:i~ (Mt) ::and nettotizin:g eptet~litis umbilical cqrd ~ents., ,CNSinj.wy .~'4-tra~a.
(NE'C). . . seq:>I;J:druY to asptt~:as ~..r:es.t dt of cord'prQlapse
or -abruptio pla~ta ~ c9,nui:lon and (l~q:>unts
for .t he incre~d incid~nce of ~~l;;r:al_pal.sy and
met<!]. l"et.aidaUon; tWiri~to--tWin .i:..-unsfu;sion which
. t,

Theyasfmajprity cif excP....s:;;iv;:---slzed l>abieti 'are may produce,anet+tia in one and pleth.ora.in the
boi:ii ..to mul~paras: A number uf.tP.ese n1ot1_lers 9ther. The .smaller the :fetuses, th~ ;prer the
haV.e gesta:fi9ilal diab~tes, .ov:ert 'd.iabetes : or prognosis for th.e se.co:q:d .of twins. Doubl::: ()yU!Il..
obesity~ twiris FARE better than .singl~ .o"YU,m. twins.

The complications that may b .anticipa ted . Hydra.mnios and 0Ugohydramn1os

with vaginal d elivery. are fetal asph)?da, mental
subrionn~ity which may be r~flive of fetal .E stima,tion of ~nlotlc fluid :vc1ume {AFt} by
.stres$, .and trautn~: whicll may incl.'i.,lde clavicular ultrasound is a criti~~ component .o f anten.atai
fractuioandfqr btachi.al'_pl~s injury in the fetl,ls survei114nce. In a .study made by ot~;~u AFI is a.
or vaginal lacerafiotis.:fhematoma .an'd pe.lvic weaker predictor of peruiatal . oJ.lt~ome than has
rel~tiori op. the pa rt b'f the mo~et:. bee.n classically sugges ted .. . AltP,oug~ th.e AFI
'I

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 CHAPI'ER 17: IOI:NllFJCATION Of HIGH RISK PREGNANCY .,283

identification of polyhydramnios (defined as AFI INDICATIONS FOR ANTEltARTUM FETAL

of more than 25 em) was helpfulln identifying.LGA MONITORING
fetuses and fetuses at rlsk for congenital
abnormalities, oligohydrcimnios (AFI less than 5 1. For patients at high risk for uteroplacental
ctn) was a rather weak predictcr of poor perinatal insufficienc;y
outcome. Prolonged pregnancy
Diabetes mellitus
Urlnar7 Tract Infection Hypertension
.P revious stillb4'th
Urinary tratt infe~tion during pregnancy is Suspected IUGR
a majcr cause Of premature delivery I fetal death Advaneed ~maternal age
and matertial PlOrbidit:}r.. Ab.out IS percent of Multiple :gestations with diScordant growth
o bstetrlc patients suffer from :ilymptomatic Antiphospholipid syndrome
urinary trac;t irifecti<ln. Multip~as outnumber
pri.migraVidaswith thill :c omplication. About 5- 2. When other: ~:.ts su~est fetal compromise
10 percent . of all pregnant women develop . :suspected. IUGR .
asymptomatic bateriurla. ApprQximately l/3 Decr~sed fetal movement
.o f obstetlic. patient;>. with . bacter.uria develop Ol!gohydralpnios
acute . pyeloni!phritis duti~-g preg-nan-cy or
immediately thereafter Jf .it persist$. The 3 . . Routine antepartum s-<1rv~illance
outlovk-is ::go.o d if the antibiotic compl~tely
e).iminat~<;the infective or:ganisi:n and contr{)l oBSTEnUC ,CQNDlTION$ ~- -~AG~.~NT
persists.:postpartUtn. -~~P~;,~B~T~~CED ~.:'/- . i ~f:::< '

Pre tenn deliv~ry

Diabetes me.l litus eomplicates at least one in .. ...
~

- every 37~regn~cies.. . ~tent or gestational . .Route o( ..deliv~ry; .. .f:.~

. .t~::~~ ._
diabetes4ma::Y also have the same incidence; . Bed rest :-:xt~.~~ . .
Maternal mortality is only slightly increased but Observation
1.

morbidity is consider:~bly worsened by thi-s

ttbnormali:ty. Perinatal mo$1icy remttQls at 10 Dntg therapy
percenllc ~lO ."pe-rcent ~m :~l a~~!rii;J!~~:~;'{-5 O~rnt:iY.~ ..in.te&.e.ntion .in labor
iliiies lliat o( fue nonn~populatiOz.l. fTematl,Uity Neonatal intensive care
is a problem not . only because of" sponqu~eOUil
premature labor but also due to the tend~ncy to Termination of pregnancy for a congenital
deliverpoorty controlled 'diabetic gravidas prior anomai-
.. . -~
to term to avoid fetal death in utero~ '
ASPECTS OF FE'l'..&..L CONDITION THAT MIGHT
Thyr.o id Dlsorders BE PREDIC1'ED BY ANTEPARTUM TESTING

. Thyroid disea,se seems to have . an advet:se

Perinatal death
effec t on the outcome of pregnancy.
Hypothyroid,ism Priril.aril.Y L'lcrea:ses .Ule ~tillbirth Intrauterine growth restriction (IUGR)
rate while hyperthyroidism is-more .a ssociated with Non-reassuring fetal status (intrapartum)
an increase of infants with low bi.rthweight upon
Neonatal a sphyxia
.delivery. The latter only incr.eases the neonatal
mortality rate slightly. Due to the presence of the Postnatal motor and intellectual impairment
fetus in administering medicatiop, one must be Premature delivery
able to balance the beneficial effect to the mother
agairist the possible hamiful .e ffects if may have Congenital abnormalities
on the fetus. Need for specific _therapy
-.

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 ~'~
----------------~~------~--~~~~~----~~~--~------~------------- -~
SEcTioN Ill: CUNlCALAPPROACH TO PR.EGNANCY . '.
~

POINTS TO REMEMBER

IdentifiCation of high risk patients during prenatal check up is imperative to prevent maternal
and fetal -complicatlens.

42% of Filiplno.wom.en less ti13h 5 feet tall had contracted pelvis and 64% required a cesarean
section.as the mode of c;l-elivery.

~ Clinical si9nl~.;f;ince of pr~iqator~ ruptu,re of membrane.s i.n cludes cord prolapse and
fntraamnlonlc infeciion.. lit\frie.,dlate induction .Q f labor and eJq>ectant.manag~ment are ar.
reasonable optiC~ :fbr ~en . if membranes rupture before t1e s tart of labOr, sJnce simaar
rate.s of.neor.al;alinfectiOn and cesareal'l deUvery were note~. . ..
. .
. Matern~I obesity Jn pr~oaney Js.~a\:ed wi.th .in:;r~ased fetal growth a,nd.a ~rgher.irequency
of pregnancy com!1ati9fli su1 as hypertensive disorders, gestational diabetes an<r'an
incr~ased rieed of :ope~live qelivefy.

Diagnosi~.<>f 1U$R:is_.wrm~<r.~ ultrasoiW9raphy.Parameters:comnionly.used .are~ PO, femur

le.tl,gthi
. h.ead CirCt:l.m~erEmce;
. . -.
tnean :abdomtna1
. diameter t:lhd abdqhiii'lat clrdlmfere~;
.

Areduced,abdomit:i<!lldrcumfer~is reported IP:be:'the mo~sensitive .biometic:rneasuremeht

. . ......... ..l(l dtagl)OSlJl9iiou~wi,UdJa~
. 1.~c~...:J::u... :~- -ko.!.no n - - t
..,.,~~e:.ra e.of .:~t<S.
~~ th .... .o1
S ... an 0 to..
.J. . .
-
.

. ..

. ... , ... . .

Clin1cat featwes :<i titf;mts wtlh

-~in~turity :inClude thos.e infants wit.h actuai1Q5s of...w~ht in
utero with eVidenre,-.oh'educed subcutan~IJS 'tissue .scaling, .and parch~nt-like sin.

Adniini~tratio!'l of~kt.:in: pretEmn :labor,.:be.tween -~4-~. weeks of :9~.fitie,n ~Q<:eS .

neonatal mprtaiity:by;r:educlOg(~tory. distres.S.syni:1f9rrie.(RD~)',' i11tra.vsn~l~rJi.err.6rrhage
{r/H) a nd necrotiiii:lg :en~iti$ (NEC).

. Urin~ry..tract..iflfeciioo.:durlh9 ;pj"~na ncy..is . a inajor..cause,:of ..pter.:}ature . .deliver.f,..tetal .death .

and:matem<lhr~tbiOitY: .. - - .. .

. oth~r .knoWn cause.

Multiple pregr:-ancie:S acct>uhUof'more undergrp\Y"...h .neonates th.an ariy

Hypothyrcijdisrn primari!y'itic:feases the still'blrth rat~ white hyperthyroidi~m is rnor:e assoeated.

with Gin increase of infafit$~ Jow .birth weigt::t tlpon deJivery.

4. Stein.Z, Susser M. The risks of having children in later

life. B)';{J 2000; 320: 16.81 .
1. GabbCSG;Ni~byiJRa,nd SimpsbriJL.(:Xts): Ob:sterrics: S. K.fiste~sen, J et.al. Pre-pregnancy.w!!~ibt. and the risk
'Noroial e.nd Problem.Pregnat;l.cies.. 4,;,.ed. .Phi.la,de:lphia: . of stillbirth and neonatal d eath. Br J 'Obstet Gynecol
ChurChill Uvingstone, 2002. 200,5; 11~: .403-408.

2. Morbkiityand:Mortiility Weekly,R~rt: Trends in infant 9. Raatikainen K, rt'ei~ka~en 'N and Heinonen s.

mortallty attributable to birth d,e.fi;cts- United States,
1980-1995. Boston, Mas.sacllusetu Medical 'Society,
'2000.
a. Andersen AMN, Wohlfahrt,J;. Chri~tens P, et al:
M<1temal age arid fetal loss: popUJation.:b a sed register
linkage 4tudy. BMJ 2000; 320: 1708.
Tran-s'ition'from o verweight to o besity worsens
pregnancy outcome in a BMl-.d ependent zp.anncr.
Obesi~ f2006~ 14{1.): 16'5-171. .
7. stein ic, et al. The influence of maternal cigarett~
..s;noking, SnUff: USC and passive Smo~g O_;t'pn:gnancy.
outcomes: the Birthto Ten Study. Pacdiatr Perinat .
Epidemiol2006; '20: 90-99.

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 CHAPTER 17: IDENTIFICATION OF HIGH RISK PREGNANCY 285
--------------------------------------------------------~-------------------- .,.
-''
. 'j~
8. Ott WJ. Intrauterine growth retardation and preterm 11. Haram K, Softeland E and Bukowski R. Intriuterlne
delivery. AmJObstetGynecol 1993; 168:1710-1717. groWth restriction. lnt J Gynecol Obstet 2006; 93: 5-
l2.
9. OUnsted M, Moar VA, Scott A. Risk factors associated
with amallfor-datc!! and lro-ge-for-dates infants. Br J 12. Cunningham FG, et al. Williams Obstet:ric3, 22"" ed.
Obstet Gy;-.aeccl 1985; g2: 226-232. NY: Me Graw-Hill Coinpanies, Inc., 2005.

10. Ott WJ. Sonographic diagnosis of fetal growth 13. Ott WJ. Reevaluation of the ~elationship between
restriction. Olin Obstet Gynecol2006; 49 (2): 295307. amniotic fluid volume and perinatal outcome. Am J
.Qbstet Gynecol '2005; 192: 1803-1809.

."'""-.-"'!~'.-:: ; /" . "' .

~ ~>;-. ::~-:~ ;

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 .. .

. . '

... : .-r:
.

J.

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 -tB .
NON-INVASIVE ANTEPARTUM
ASSESSMENT OF FETAL WELL-BEING

Antenatal Evaluation of Fetal Health

o Fetal Movement Counting

o Electronic Fetal" Monitoring

Fetai Heart Rate

Control (Sympathetic and -Parasympathetic)

Baseline Rate . .
- T~chycardia
~ Brattycardia

Variability
- JiliSent
-Minimal
- Moderate
- Marked (Saltatory)
- Sinusoidal
- Causes of Decreased FHR Variability

Accelerations

Decelerations
- Early
- Late
- Variable
- Prolonged

Non-Sttess Test (NST)

Reactive
Non-Reactive

Scanned By: ~
 Fetal Acoustic Stimutalion Test (FAST)
- Causes ofF alse Positive NST
.; <::au.ses of Fa~ Negative NST

Contraction Stress Test {CST)

Ne.gative

. . .. p~;. ..;. . .,
V"??U.V-

Hyperstimulation .-
Unsatisfactory

Contraindication to periorm CST

o Computeriz-ed Interpretation of FHR Monitoring
o BiophysiCQI,iP.rofi.l e:.{BEP) .
o M~med BlophysicarProfile
o.. I;Jmbilical Corti Artery Q.qppler Veloci m~try
o Middie Cerebrai.Artery Doppler.Velo cimetry

. Othe~~Non-1 r.vasiVe...~cda_iities. .
o Magnetocardiogr.;iphy.
o Ver:ous Ooppler.,.Uitrasound Waveform

' J

SBanned 8y: ~
 CHAPTER 18: NON-INVASIVE ANTEPARTUM ASSESSMENT OF FETAL WELL BEING
INTRODUCTION
Through .the years; the knowledge of the
complexities of fetal life continues to undergo
dramatic changes. Wjth.the better U."lderstanding
of materilal apd fetal physiology artd.the-a.dvances
in ultra:sou.nd teclmology, it is now realized that
there is a lot more to learn from intrauterine fetal
existence. IdeallJ:, the ultimate goal of fetal
as.sessment- is to deteCt chronic and intermittent
(etal compromise. tc> prevent stillbirth. d~ase
neonatal mortality and morbidity, arid minhnize
long ten. $eqllelae.
thls chapter will enumerate, describe and
interpret 'Vitrious non~invaaivc e.t)1ods of
ev&luating {etal status inthe ~antepa.rtubl period.
: It must be understood that fetU$ .b ehaves a Fetal a.cti\rity can.be appreciated as ~.arly a$ 7
daf~mtt\y at: various:::$~_ge~t:~ i:>~--~~'V~l~p~~~t.
m ..,.::... .... .-M...,.,,.... . s.........o.:.;..a "'t 32-34" ~1;....:.;: ~en
J'f/i,~.lo'8 - - - ~~~' -~-~J -.;: U:U~.P_., , ...._ ... .. , ,'~~~. '~H.
the .fetid .aut~nontic nel'Vou:a -.sy~t~~ c.@ b e
cOli~~~;, .Jt is d(irie f)t). .a w~l:dy ba$is
Qr..~ and-mort .freq'"ently depen~ pn the
~- situation. ,~ ~cit.Y or~ n~ in
:-tiddnt~~ of -a preteon (etU~ shout~ a1S9 be
- . nsidemt .l:)eClsi.t>n .maldn ,.asto tet1tiinate the
-~~bealu~'~t:an~,;~fetaistatus.
be~es~~ -~bhllerig.e' if 'fetal maturity' .is still
ra.,.%-tt:hed. MatemaJuanspurtto awtia,ry facility
i~l;>est$fu~ the mother's ~~rusi~J stillth best
-intubato( rath-er t}wl . ~l>tel;rlng .i t preterm
J:l,~Q.Jl~-. ' . n .m~~t be .~mt~jl: ~:utth.~'f:ticute
o:.-tirplomise..Wch"'U'.abn,:tj1tiO~t~t"eo~~aetit~
~ot~detectoo-bY"ttie'-:-meth<:xt~tliat-Will-oe
descil'be(J.
Genetally, all antepartum fetal testing has
negative predictiv~ value '('J)ue ~egaijve) of9'9 ;8%,
'White positive predic"'Jve value only 10-40%.
.Most of these surveillance techniques are based
on circumstantial -evidence.
Assessment of fetal well being starts with the
general profile of r;naternal h~lth as early as the
. preconceptional stage, Q.uring the time of
conception, and 8'S the pr~gnancy progresses.
Data from the history, physical examination and
laboratory examinations will identify a
pregnancy that is at risk. Pre-existing maternal
Gbn~itions such as diabetes. I and II, cardiac
problems, c hro.nic h.ing disease, asthma,
hyperten-sion, thyroid _problems, chrortic r.ena't
289
. """"""'""-
diseas~, SLE, throtnbosi~ (Anti Phospholipid
Antibody Syndrome)., malnutrition, anemia and
obesity complicate . pregnancy outco me.
Pregnancy-related conditions such as
gestational hypertension~ prco:-eclampsia,
oligohydramnios, p<)lyhydran'inias,: intrauterine
growth restriction, pos-t-term .p regnancy,
multiple gestation and perin.atal infections add
to the .p erinatal mortality rutd :morbidity.
Risk evaluation is done every visit; -its status
may change as the pregnancy advances.
. Fetal .Movement Counting (Fetal .l Qck Count)
weeks, and becomes sophisticatea:an~ coortlina:ted
as . p~~.adVances. At' 36w~s,'tbe feW
. helul.Vior: status is established as
observ:ed . in
ultrasoUiid: .. . .- . .
. : . .. . . . <~~t: ~-
State lF: quiescent state, with a ~ ..
. oscillato~- ~width-of the.Jekl
hear:t rate (q\liet sleep)
:State.2F: frequ~t gross body.mo\i'elne(l~
continu~us . eye IIiovem<;_nts.-'m deT
.. ~- offetalhea.rtn.te:~~Ctive
. sleep) . . . --.
State 3 F:,COJltinuous eye movements,;_~~t
. _;~!~~~~~~~~~?ns
stat~ 4F: .ngorous DQ(lyiiioveiiiert~ ~
e:Oi:lti,nuous eye mov~me.nt, fetal
. heart rate accelerations (awake
state) ' . .
Fctus:spendtiJp.ost of the time in States lF
is and 2F;
Fetal activity has-.sleep-wake cycles that are
independent of maternal sleep-w:ake cycles. It
may last longer than 20-80 minutes. It is also
dependent on the atnni<>tic fluid volume. When
there is diminished amniQtic fluid., felal activity
may be restricted.. Various techniques of fetal
movement counting are proposed.- It is .difficult
to say one is better than the other because as
yet, there is no .prospective evaluation by
standardi2;ed protocols to vali4.~te the
techniques~ ~ f
l
. - ~
1. Maternal perception of 10 fetal ~~~~ents ill
'
.I
2 houx:s is reassuring. A decrease in mo.vement
:j
I
.,
Stanned ey: c i
2SO . SECTION Ill: CLINICAL APPROACH TO PREGNANCY

from the ~atern9.1 norm ,should be evaluated
with th.e non-str-e= s s . test (NST) and the
biophysical profile (BPS).
2. fetal movement maY a tso be observed 1 hour
after meals by the mother. ljin,g down on the
left laterru position. Four fetal movements
should be felt in 1 hour. U:movements arc less
than :4., continue observation for !Ulother hour.
If there is still no imptovetne.nt~ do further
teSting .by NST or by BPS.
3. Fetal movement counting nw.y be done 3 ~s
. per week fot 1 hour. The ccunt is reass\Uing if
it equals or exceeds the ~iously established
ba~line~
The uterine contractions are indirectly
assessed by a taco-transducer placed at the uterine
fundus . where atrongest uterine contractions are
felt. Like the FHR ultrasound transducer, it is held-
in place by an =e lastic strap;. The t:raru!du~r has a
button or "plunger" that is sensitive to the changes
ih abdomihal contour brought about by theuterine
cont.""actians. The button or plunger moves in
.proportion.to the strength oftP,e contraction. .This
is converted in to an electronic. signal giving a
relative intensity of the ex>ntraction. A-print-out is
made available and changes. in t he 'fetal heart rate
with or without contractions are recorded.

EI~ni!; !euu monitc)~g .was pioJ:'~red by

. Edward Hon.{IJSA) in .1958. 'the phon~ogram
w.u the ttrtt huitruinent. q.~to :l'eCPnUetal heart . .
. s6W.ld$..~ . llowever,,. .:tb.i~;:!l)le~. was::ah~doned~...:-::
:since it; Bt:s ct rec.arded..::extt~eous- . soun~ s~,
prod\lCiJliin.f(;riQr q!.iel,ity.~ Through the
years, .bn~ent :fu- tbe :~~ology produced
. be~.:tr:ad.n~ . " . . . .' . .
.E\~~o?.~;fet~.i::.morutt>ring;~rl - be.,extern.at ..
(n.on.:.m'V8.lriVe)' or futemal' (uiva~~).' 'rhe word
~a1 ~npotes ~ . (lp).l"hl'Y.#,ive me:tlPe.r of
ev-alua~fe~:h~:r,ate:~ttem~rin: resPQns:e :to
. uterjneact:Mty:asrec:o'tdett:ey th'~ electtorucretiil.
monitor. .

The introduction of the; D~ppler ultrasouriq

transducer {Figure 18.1) imprOved the quality of .
th~ tracings~ After locatir).g Ule :fetal heart by Fi~.~ lS.l . .A. TocoQ.ynom~ter and FHRtransduc~ in
place v4th:,feW moi).itor, e. E:xtemat t~Odynanon.:u~ter
auscuitatioi'),, the Doppler Ultri:tso\Uld transducer. tn;msducef; 'C. FHR
secured by an elastic stra.,p, i$ Q.)'>plied to the . . . .tr'aheduc;er.

maternal abdomen, it etiP.ts 'Ult:;tasound waves in

the dired.ion .of the feta.I heart. Ac~rding :to ..the
Dopp!er-shitlpnnciple {FWu'el$.2), the ulb.'3.$9und
wave undergoes .a shif~ in Jr~ql.lency as it is
reflected ft:o.m the moVing Jetal heart valves aml
from blood ejected dur4tg systole. 'thes e
.ultta~oum~ Popp.ler .sigpals . a;re electronically
. mlcroptocessed by the electroni~ fetal monitor
through the process of :a~to-correlation. Auto-
corteiation is based on the pre.m ise that fetal heart
rate has regularity -unlike noise which comes at
random ~thout regUlarity. After electronic editing, .
. a much improved ptiJ;lt 'Out :of the .tracing is. made .
-a vailable, F igure 18.2. Ultrasound Doppler principle.

Scanned 8y: ~
 CHAPTER 18: NON.:JNVASJVE ANTEPARTUM ASSESSMENT OF FETAL WELL .BEING 291

Various companies h~ve hnprov~d the brainstem to the heart via the cardiac fibers of the
technology ofthc.electron.ic,fetal monitor s.o much ' vagus nerve. Stimulation of this vagus nerve
SQ ifu!,t FHR tracings of twin pregrUU1cie8 are now releases acetylcholine from its nerve endings in
available (Figure 1.5.3). Recording of m~:~.tema.I and the reEiion of the SA and AV nodes. The .n et effect
fetal ECG, pulse OJcylneter, .maternal blood is slowL'lg of t he fetal heart rate.
p:-essure and uterine contractility is also possible.
In the younger fetus < 28 weeks, FHR patterns
and responses will reflect immaturity of the
parasyt:npathetic control .o f the FHR. The FHR
baseline is faster (170-180 bpm) sh1ce at -t his early
gestational age, . the sympath,etic control.
predominates.

The Cardioregulatory Center

The integration of the FHR is the

.cardloregula,tory cen~r at the ventral .and lateral.
A B surface. of the .medulla in the region -o f the 4th
~ IS~.A;} eorotpetJiCs 129 fetal mOnitor with capabilit'J ventricle. The connections between the fetal
for FeW ECG, PulSe oxymete:-, matem!ll BP &. E~G and Carcuoregulatory center and th:~Jetal heart rate are
uterine tocodynamometer. B~) Corometrics 174 fetal monitor both direct and .. indirect: ,The - direct
for~.
-- .:. .: parasympathetic pathways ru:e viatheVa:gM.U:uclei
and the afferenteardiac 'vagal nbers>~'~d,irect
sympathetic control travels"''' frobl'i the
Cc)ntrol <f the Fetal ;Heart Rate (FUR) cardioregulatory center to ~e spmal::tiJfd, the
. ....~ ,. \ . cerVical andthoracic sympathetic; gang!ia then to
..'<Fetal heart rate :tno~on is demt)nst:rated by the fetal heart ..via the cardi8.c sym~thetic,_.fibers.
-tran~al ultrasound as Cittly a s day. 23. .,By The indirect control 'is via sympathetic ~e
, day ~}the sinoa~ .(SA) and atrioventricular (AV) and release of catecholamines "frortiiii~ -~{etal
ne.S. develop and begin to e ontrol the rate of adrenals~ (Figure 18.4) "::- :,
conQ'acti()ns. As tl;le heart eontinues to develop, .
the ,c:Qnducti:q,g sy~tem~ ~ill~.. more ..im:iemted
.with-aut0ti~micfibers;-first"sympathh~-rurd~ter
- panisympathetic;--which-nnrture~riif aroiiiiag-2
weeks. As the neUral control of the fetal heart
matUres, fetal heart-rate variability appea'i-s.
I
S!fr>.pathetic Regulation
. .
Stimulation of the sympathetic innervations of
the fetal heart increases the :heart rate due to
~atechol~ine release f~om .sympathetic nerve
endings,and from
cr..rQniaffin tissues of t.lle adrenal
--
....,. ......

gland.s. With catecholamine release, the cardiac

effect is acceleration. However, these agents also
induce compensatory fetal vasoconstriction .and
fetal hypertension.

Parasy_mpathetic Regulation

. 'fhis is . the most iinporhmt controlling

. mechanism of. the FHR. f}:le .para~ympathetic
.supply to the heart :fravels . from the cardia.-
regulatory center in the ventral surface of the

Scanned 8y: ~
292 SECTION Ill: CUNICAL APPROACH TO .PREGNANCY

. ..
.
.;,/

Pressure change's (bar:or.eceptors), oxygen

poncentration (chemoreceptors) and volume
receptor~ .located in the fetal heart, aorta and
carotids also pl..ay iigr-.Jficgnt ro1es in the control
Ol' the FHR and the cardiov.i~ular system. {Figure
~8. 5)

BasicfHRReflexNcs:

~~~J~
l ..d:~
. Figure lS~6.. Noimal h3,se1ine FHR.
-"""~''-~~'-'"- -< ,. . ---
..t;.

I ~

FHR .~ractycardia: . value~ less than n .o bp~

(Fi~ 18::'7} . -.,

. . ..:. . ~I ~- - 4~
=. ......
. ,
. :O::t: =. .,

.
:~ r'.
. . . . ... , .. .,..
: r o;. "'"'"

m
. - : . .

- ' ' .- .
_iw
~
. c . ~ .,:

,
~
.. ~
..
. ' . . .
.
.,;. ~.
.. ...
.

.

.,

'
~
--.1.
I "
. .

...
-<

'
.

.. ..< ,,

'
: ":'
- ~
. .. lll'. . . l' .i''.. ..
- -~. - : l 0 .. . ...-

- ~E :.
t:.i.[; . _'1,

... . ..
..,-- ~ :~- ~ ; .; -. ' -- ~
_._., - "' : . r ~ .

. ..,._
. ~
;_ ' .~ oi-' ~L' "'- >:,
. i - - . ~ ,.__ _. ... _ !::_ - . .....

~~~. <-.-~~:~<: .._.:. . : .. . ~;;~<: _ .-~ .::~ ~. ..

. :;;; ' : .~ '-~- . ~: .. : ~ : : ~ : :; ~- ::: ::. ::'!~ :::F-f-ti ~: :r+T+-17!-
.. ' . :' ;.. . ':; ::;.... : . : - . *.. i':!~tT{:-;-- ~- ::~ l"l{; ~ . ifrg '"' ...
., , ~ . . -- ~. . :.: ;,+ ;J~ -... ~:::- l-:J ..f-1- .- +
- .. . : : : ~~ . : :-!- l l..i_i -:: ~ ~rT I." . .f 1 -i-
rrfiit+
.. - : ; . . : . . ':' : . . 1 .-f . .. .. r.-
,-'f .: ......:r+++ .... :;;1-1-H
. I+ ,
+ +'

.tBP
:. ~.:~~ FH~ Tac,hy,qu-dia: .values m ore. than 160 bpm
{I'igure. l#"~l
~ 1~.s. Reflex ar<:3 goveniliig the .FHR. initiated by
l)_:l~ypo~~ : 2) hypey.tension an:d ;i.) h yP<>volelllia..9

Electronic Fetal .Heart Rate: Basic Patterns

"Baseline FHR

The approX:im.ate ~ean fetal heart rate over a

10-minute segment excluding d ecelerationS;,
accelerations .and periods .of marked :variability:
.Normal value:. UO-loObeats .I>er. minute {bp~) -
(Figure 18.6)
Fi~e 18.8. F etal tachyCardia.

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' -r~

~ ..
CHAPTER 18: NON-INVASIVE ANTEPARTUM ASSESSMENT OF FETAL WELL BEING . 293
.;,;,:...

Variability: FlucWations above and be1ow the FHR Deceleration: A decrease in FHR with'teference
baseline; 4 categi5rles used to quantifY variabilit;y to utenne contractions. It has 3 categories:
are tQe follm\rfug (Figure 18.9): Early de<;;eleration (head cOmpression)
Absent fluctuations Variable deceleration (cord compressio n)
Mi.nima11detectable fluctuations to 5 bpm) Late deceleration (uteroplacents.l
Mod~te (6 bpm - 25 bpmj insuffl,ciency)
M~ked~ Saltatory {> 25 ~pm)
Early Deceleration.(Head Compression): .A gradual
decreas~ in 'F HR asso"tiated . with a uterine
contraction, with rtwn to baSeline by the end of
the contraction. (Figure 18. 11)
A

.q
-~ 1i c
~ ~.
~ J
:! ~ ..... ,.
0

I..t. .-..
>!<

Late. J>ecel.~n (uteroplprent.al i~J~cyJ:

Si.milar to_early c;l~leration but th~-\fflihi"f!f is
F.p.re . u~9.
B.)~ C~)Mod~
eaiettQ.ries of varulbility~ A:)
D.)M8rlccd.:,.
Ab$e~t.
. delayed. 30 ~nds or more after.the 0n~h~4the
. co~~ ~.n,~f}ir~,aterthec;p~n
-- .. .. ~ -- --- ~ .-.. - ~ .... .,.. ... -. ...,,. . ....... ..
_ --~ --~- - - -. . ~:'~re~JQ:.~~tm~. w.b~n ~tli~..~n~o,;t
; Jl: i..~-w~~- ffi!~-~~------:-~"-- . ~- ------ -~ .. ____,: _:~ ..
.Acceletatio~e A peak in the Fim. above_ba,selfue
at least 15 'bl)m l asting 15 seco~<ls but le.ss than2
mmu~ . ~ot:* 32.weks, a~lerations m~
oJ}ly lO bpm lMtihg 10 seconds. (F'igure l8.t0)

( .
::q::;t+ +~~. ..~ + . .
! !:..:. .:! ;.:.t -rl: :

.__
;-,.--~ -
.
:ft"~:!: ;...:;::: . ~

- Variable Deceleration (cord compression): Abrupt

decrease in FHR below baseline varie$.~ shape,
duration; depth .and timing, can occ~, with or
withottt contractions;: shapes can p~eSe!~. as U, V
Ol' w. (Figtire Ht 13). Variable decelel:'a:tions are
'Figure. 18.10. Accelerations. 10 classified as mild, moderate or severe.

pctli
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~
 .'f;J,
I
[
294 SECTION Ill: CUNICAL APPROACH TO PREGNANCY

Mild variable decelerations. hav-e a duration of ~~~~-I--~-~.

<Ill
les!> than 30 seconds. regardless of lev~l or a
deceleration below 70-80 bpm, regardless of
dura,tion (Fi~re 18.13-A) ..

MOderate variable.s have a levd less than 80

bptn regardless of dun;\.tic n (Figure 18.13-B)

Sever(! :varia~les are less than 70 bpm for

greate:rtban 60 secqnds {FigUre l~.l3C)
-!1~e 18.14. ~l0rid~~raii9li.:! .
The depth and ~uration of the dec.e leration
c.orrelate to ilie degree of hypoxia and other :'~
pa.nun_e~ers oof $e Tfl1R tracit,lg {l:oss o.f variliility,
: : . e .ta~y ctq:dia)
bascliii - . . . . Sinusoidal Patterti: (Fig\rre_ '\8. 15)
..
q stable. b~e .heai:t rat~ 120-'160 bpm
:wi.~ - ~ ~P.~l:!S," , ' .
Jl.....,.. u..,"d
"'.) e...M'- r:1:s....hri . . .
:'- ;, ~'_U~J;p '-"~.. . - ~ ~ ;,.. .. "<:t:'.?l .
3.) Fr:mu~cy.. of:.2-~ cyclesfmin{as:l<)ng term
-~ty,). ' . . ..
4~) F.iXed;or:flat;$Prt tepn v~o!la.~ility.
5: ). =~~~;,pf~tiR.-~~t:rati<)ns. .
. . . .... . . : . . .
. . .,. . ..
C-auses. -sevae !etaVruicziii3_.
~ ' ' '
-~r.
~
..l ...es!.cs \~~.&.V
,
m..~..-....1J
. . I '

etc}i. ~prii:ti,s . . .. -

. . . .. . . .
~

' ' o -W
.-

1111111:illl'fii1Jl:II~JllllWII!IIII
. .- ' .
ngl,ll'e ~ '8.1.-S.Smusqf~a:LP.attem. 10

Causes - of:~etal. Ti;chy'~:

1.) Fetai'hjpo~a .
2.) Fetal a:rtemia
f1.~rc 18"1.~ . Variable-decelerations. ~l Mild, 3.) .F et;aJ.sepsis .
BS l.tod~rate and Cj. ~ere.7 4:.) Fetal -heart failure
5.) Fetal tachyarrQythmia
6 ..). Maternal :fever . . .
.Pr<Jloriged .Deceleration: A .decrea~e in FHR that 7 .) Maternal hyPe-rthyroidlsm .
lasts.> 2 :minutes blit '< l().IJ;linutes; a decrease.> .8.) Beta-sym:pathf)IJl:imetie drugs .. .. .-. . . .
to minutes is .considered a ~change in baseline 9.) Para$ympatholytic.drugs: a tropine> ...
F HR. {F~gure 18.14) h ydroxyzineHCl (It~r-ax), P.h enothiazines

Scanned 8y: ~
 '
'-.,. .. -~----~~~:-=:::~::-::-:-::-::-==:::::::-:-:::-:::-:==-"::=:-:--:-:-:::-::-:-::::::-:-::------
- CHAPTER 18: NON-1NVASIVE ANTEPAR~MASSESSMENT OF FETAL WELL BEING
------~----------~--------~----~------~------------~----------~~~~
.> 295
~.

Causes of Fetal Bradycardia: 3.) Absence o f decelerations

1.; Fetal hY,POpituitarism With brainstern injury A Reactive NST is re-assuring if the to using does
2.) Maternal hjpotheonia not have variables, late or prolonged decelarations.
3.) Prolonged hypog!ycen:iia For the preterm fetus, it has the following
4.) Beta-blocker .therapy characteristics:
5.) Second ~tage of labor . .
6.) .Matenial heart rate beirig recorded in a case of 1.) Adequate FHR baseline, 110-160 bpm
.fetal' demise 2.) Acceleration in FHR baseline 10 bpm for 10
, seconds
Causes o( DeCreaSed FHR Variability: 3.) Absence of decelerations

1.). Fetal $}~ cycles Fetal Aeoustlc Stimulation Test (FAsT)

2.) Hypoxia/ Acldosis
a~) ~e -.p rciliatutity The non-reactive NST due to fetal ~p {State
4.) Congenital artomslies 1 F) is a major source Of false-ali;U'ming test.
5.) .F etal tachycardia Stimulating_the fetus with a noxious \libratiQn/
6-f Prte:dsting ne11rQlogieal 'a bnorma?ty . noise ( 10.0105 dB) w-ill startle the . fetus ~d
',;. 7.1 Orqgs:- NS depressatitss- ~-asjrilpatholyties prod~u~e l<'ll~ acceleration. The source or t.~e
:~.
'l! (atropin~). betablbclrer:s acoustic -~tiJ:nulatiq~ may com~ from an elec1;ronic
artmclal~dcliverlng 100..1{)5, dB . .Thida a il
. ~- . Non.:S~s Test {NST) acces~ry -~ of the. fet~ lllOnit.~:,~,~ ;r!Je;:J ts .
'J!: . '. . . .
absence. an .electrontc .dnven toothbro~may
-~-~-_. .
The. NS1' :
i s base4 .on the premise that the,h eart serve the same purpo~. Either ofthe:,2;S()~,is
. .
. '!\ rate 'br:. tbe fetus that is not acid~tie or p<>sitioned on tile maternal abdomen,.ut':llie~ilfea
i- neutolagkidly depr.essed will temporarily . whete :tbefetaL head is. A . sti!n~t,ion 1.,.2 .bi
~~- accelerate with -fetal movement1t{reactivll:y} Loss $e(:Qnas l$ applied , and.,may. be- re~.3.~
- ~ -of~_reiu:fi\4ty may be Usoclated with fetal sleep up ::to:: 3 :$econds ~to ..eUcit FHR)l,~J~i~9n~
.: :;._ . cyde~:-'~Aci4o$is . or. centrai nelVQU$ system Interpretation is the ,s ame .as r~. '~7.f:r;ps
depression.. The N$Ti$ initiated at 32 weekS AOG whole pJ;OCedure reduces over all testingaimd..:.,
oil:a w:~~basis. o r.elu;l,ier and mQre fn:quent in
. very.bien':i:i~1(sitiiatiotts; . . . . '. Pretenn.infants may reqti.ii'e Io~der ~~ to
elleif:iiigiiiBcanfres.POnses; wlila.-:ma- -..rod'uce
.-1:~: a,i:E:i~~i::.~~:i:i
mort:itcir;:.1he F'liR is obseived with the Doppler
lieann~i1iifury M~re 33:Wiekii AoG.___y,_p__ :----.

~- uitrasound extetnal transducer. The p atient

'
10
should not have smokedrecentlybecau~ this may
~-
.~ affect the test ie~ult$. The Fl:tR tracing is obServed
~
fi{ 'for FHR ~c-;celer;ations
. .
that pe8k etle2.st 15.'b eats
:~ per minute above the ba~ieline, lasting for 15
~
1 ~-
seeonds."atleast2
' . . . or more acceler.ation:s, in a 20-
:ii! nlinute ~rlod sl;lould .b e cbserted. {Figure 18.16).
J $ it -may ~neces~ to ~nd to 40 rillnutes taking
' into acc<n.tnt .fetal sleep-'wilke cycles.

. Interpretation: A reactive NST (Figure 18.16)

For the term. fetus, it has the followil}g

chaJ:acteristics;

L) Adequate FHRbaselihe .-of 110-160 bpm . . . -~ .

2.) Acceleratiordq the FHR baseline ot 15 bpni-for A reactive NST reassures that the fetus
well for 1 week. . .
is99%
15 seconds N

Seanne4 ey: c
296 "SECIION lit: CUNic;A.L APPROACH TO PREGNANCY.

Causes of False Negative NST (Nonnal Test irian If there are no contractions, nipple-stimulation
Abnormal Fetus): is done. This releases endogenous oxytocin .trom
the posterior pituitary, and uterine C()ntractions
1.) Prematurity are elicited. The patient initially tolis cr tugs 0n
2.) Maternal .sm6king and stress one nipple through the -clothing until contractions
3.) Malnutrition occur. If no contractions ~Ult fon~ 2 to 3
4.j Medications minl.ltes, the patient is asked . to perfom1 bilateral
S.j Glycemic levels nipple stimulation, .foUowirig '- 5 .t iiinute rest
6.) F etal sleep states period. This.cycle of stimulation i$-1hen ~~ .
until _adequate activity .is documented. Once
Causes of False Positive Test .(Abnormal Test in a .adeq~ate -contra(:tipns .ar-.e aChieved, the nipple
Normal Fetus): stitnulation is stopped.

1.) CP.ffeine I)ifute exogenous oxytocin IVinfuSictt mayalso

2. ) COcaine
~ . . . ..
be used to induce uterine contractions~ An
i.n.fUsion pump is used starting at a ~of 0.5-
'

3.) Morphine
4.} Sedatives LO mU{minute, increasing evezy lS mlnu~ by
s~) Alcohol 1.0 mUJtninute .\Ultil ad~uate cont:ta<:tioris are
achieved.. lt is \l.llt&,$ui;d 'tQ require .an infusi.on ~te
of D1ore than 10 mU /minute.

Ttie~~r~CST'-ts~to"-'idefitify. a:fetu~at'risk for I.

a>mpromise 'by obsenrjnglhe fetus in the presence
of s~ss. S~ss is lntoodut:ed through uterine
-conti1letion whieb -_inter:ru;ptmatemal.;fetal blood
fi()W. A fetiia that i$ ~protnise<t d'~s .not t.a~e
t'hc -,o~g~n r*~erv.e nte4e.d t~ tol~rate this
',ifL~et:i:U@~i'L .'!!..compromiS te~~ Will :have a Positjve-~s~ .pe~ist~nt l!;ltc_(leeelrat,i9ns ot iate
P<).~tiv.C .~St. imeaJUiig:ala~ 'deeleration pattern .dece).tri;l.(ibn~ mmar.e 'thl\n.'balfoftbe .w nttactions;
\Vill'be:~sp~ye(t .~ or ~~sent v~bUltj. (FigUre ts;l8). .
. . ln 'th~ la~.r,<)r d~ve.ty unit, v.ith-ihe paUent
1n th~Jeft iate.fai tec:\l:hr'bent position. ntR imd
uteri.t:ic contraCtions llJle .-ec.rded by the external
..el~ilic ,fetal monitor~ . 'The f~ ~0 minutes is
r~or,dc.d to as:$.es,S FHR )>as.e line. to identify
P~t.s.en~. Qr Q.~s.eA~e O,(.periodk: ch~g_e and to
deterPilne -itthete is sp6h~eo1,1s u~et4le.actiVity.
If there are 3 :adequate $.pontaneou:s contractions
within a 10 minute period, andthe FHR recording
is ofsufficient qu~ty {withcmt-decelerations);- the
test is firtished.

Figure 18.18. Positive contraction stress .test.1

Scanned 8y: C
 ------=-c"HA:-::P=r=ER~18::-:-:-:N:::-O::N--:':1Nv.::"
.~'A~SIV;-;
----~~~~~~----------~~--------~~--
Equivocal:
Suspicious: late deceleration occurring in less
than half of the uterine contractions (Figure
18.19)
'Picwe ,l~~l.9;:'Su~picious contractjon stress test.
, l-Jypen;f:i.mulation: contractions occurring ntore
. often. than ev.e ry 2 minutes ..or lasting longer
. ,JhM~'~nds. If. nodecelerations :in gpite
.:oOliis,~.tb~ t est ia negative. lflate d~lerations
~~ur. the . ~est is not interpretable ~d is
' classified as hyperstimulation. (Figure 18.20)
! . .
f 9~t.IDQ.ra.tion_ .in .c:J.iab.e.tic ...control,..,~ot-sening
Fi~re 18.20.H yperstimulation.7
;:-E7
AN11:~
. ;;:.:;;PA~R;;T;:;-U~M;-:;A~S;c:S~EsC.s;:;:MuE:i:NiTrroii:F~Fi:ET,TA~LI:wMiEi:itiL~B~Ejp;:INir.G:
. ~-~--'' 297
~;D.
Unsatisfactory: the quality of the tracing is poor
or no 3 contractions occurred in lO minutes.
(Figure 18.21)
-- .......
. ~-
f
Figure !8.21. Unsatisfactory contractic;m stress test.' 0
<
. The correeted]>erinatal mortality Within1'Week
of a negative cdntracti:on stress test1!is~lt~ffi:Ooo
7
births,. negative predictive value oi >99.9%~.Md a
. positive preci.ictiv~ value of <35%, W!fen ~ble
decelerations ar;e seen:. they are suggesn~e of
oligohydtamnios -or cold entrapment: Scnogniln
3hould verify this;. .The .+est should;( be .' repeat~
the next day. . ..: ;.~~;.~ ;:.;~.~J;;;.;:
CST is repeated weekly unless there~'Some
~l:tanges in the ~lini<::al situation sl}.ch- as
hypertension .and ~decreased,.f~tal niov~ril:ent'-
Equivocal t;e st results should be repeated the
next day. Positive re~n:tlts . are acted on in: the
conteXt of the clinical condition and verified by
biophysical ptoftle.
Contraindlcations to perform 'C ST:
1.) Previous cla ssical C:>section or other uterine
surgery that has left a scar to the uterine
fundus (danger of uterine rupture).
2.) Premature rupture.ofrriembranes before term,
3.) Placenta previa.
4.) Incompetent cervix.
5.) History of preterin la bOr. .
,;,;;,.
.~
6 .) Multiple gest&"tion s.
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 ! .

298 SECTiON 111: . CLINICAL APPROACH TO PREGNANCY -

Computerized Interpretation of FHR MQnitorlng

There .are systems available by computerized

., .....
Table 18.1. Recommended fetal management byBPP

.s torage and interpretation ofFHR records obtained tono

from conventional monitors. There are differences '1/I O(No,_.
AFVI
in the visual inter:pretatiou of FHR baseline, III(NSTnol
variability, acceleratio.ns, thus minimhing. inter-
?nd intra:. ob.s erver interpretations reyeballing"). CiorGOoio~t.4 11'-..,Wc~-.).~i.or. ~...,
Thi$ gives amore qualityinf6nnaUon, howev.er, this .....,.,... (1..0~~~- .,.,._.., ___
methodology has not gained practical acceptance . . ""'.. .....,....
,.,.Aiolo
'JfiiUtn~-~~--~----a
There .are not many fetuses foJ' whom such hc>Oora:iot~r.., ~il!ll;il<=."l'
;.ET....
.Precision is requited. In anyway, more fetuses w?:th Clwc-icAI!ill>'11i f~l :...............-.ii'~.D ......... ~u;..,
eqUivocal.testing o:tl heart rate evaluation will be Y.<cii~Yo~Q:;~ If<~.-...-...~.
referred to llltrasotind baCkUp testing. . ~.-.~.
olll~ li>....... -~>ia.likcly , ...... .............. D ..... dii C.e r,

lJ!etp~r,siC$1. hofile {BP.P ) AFV

oliJO Qlip c;~~r.-. ...
......,'><i. >. lib~
iric)l ..- .:... ....,.,
IC=:.ll''itb,.ofoi\er,
'
U;;ing ieal'-ti.me a..
mode ultrasourid, the:. fetal lilt~ Aoolo'~-
behavioral and physiologic ch'aracteris~ics are AN
~~
observ~ ~is i~ Gn a:djunet to NST. an'C;l CST s ince 1'10 Uip ;Cior..C~

..th~twc;>. mttb~s ha~e lUgh fal~ posjtive r esults. ...

~ ~,._.

'The.l:e$tlasts. 30-60. ~Utes ob:sertring.:!)variables: CA' IO

.....,.,..
-~
t.(N~:(;bieh~':ifiall;4.~tra~):tnd10Jnponentsare.-
nonnaJ,;.may .beom:itted)

:2 .) .:.F.etid.~gll10.vem~ts,. FJ3M:.(oneormore :.' fhe .abQ\Te rtCotnmendation:. nn. p~cy .

..~pisodes ' ,of rqythmie : f:etal :bJ:eathing tC.rJilination,a re:based on the~ptioQ: 1hata
.movements. of.30 seconds .. or. more . within 30 nedn~tal.. m~nsfv.e ,care -unit i$ ,ready:tQ<take ca.re
riili.)\ltes) . . . of this potenmi.ny oornp~nrlsed ne-Wborn..

a.; ~etaJ-.mo.velJlent .:FM {3or more ..di$Crete-body Factors influencing-a PP perlonp:ance: .

odinllrm-Dv~nren~ ~thitt 30 tirinut~s).
1.) Drug~. eX: se!iativ.es - .d~ ~cti.vity '
4.) :Fetal tone, FT (.o ne or more .e pisode.s of C:QCairie - bizarre fetcl n1ovement
extep.siQn ofa feuu ~emity with. returi) to .indomethacin ollgohy~os
fl<OOon .o r ()penhig ,f:Uld dosirig ,of hand within
30 miriutes) 2.) Mateinal qgar~t1;e smo}dng- FBM aboli,shed
or attenuate4
5.) Am.Qiot$t:: fluid volume { single vertical pocket - FM reduced
> 2 em .o r AFI > 5 em)
3.) M~ternal hypergly cemia - sustained Fl3M/
ln~erpre.tation: acidosis
. . - ~:UI".ition or: al:x;lition of FM/Ff/
Composite score of .8 - 10 is norma l, 6 is CTG reac~vity
equivocal and 4 or less is .abilo,nnal. Regardless of
the co mpos\te s core , in the pre s ence of 4 .) Maternal hypoglycemia- abno~al behavior
oiigohydramnios,further evaluati?n is warranted.
Manning and colleagues . reported a false
normal test rate of 1 per 1000 {antepartum death Modifie!l Biophysical Prom~
of a structurally normal f~tus}. Causes of death .
mainly due to fetomaternal .h emon.:hage, umbilica l . . During .the ~.nd and 3rd .trimesters; the
cord accidents, and placental a bruption. ' amniotic fluidvolume is mainty cotnpa:~ed of fetal .j

Scanned 8y: ~
 CHAPTER 18: NON-INVASIVE -ANTEPARTUM ASSESSMENT -OF FETAL WELL BEING
------:-------- ......... ...._,.---""--------.....,~-:.......--------:------ ..,... -299
..'~,._,

urine indicating an adequate renal perf'Qsion. re~triction or pregnancy associated hypertel)sionj

~ ..
~
When .it becomes low, it can mea.11 a cl)ronic low pte~lampsia~
uteroplacental perf'Qsion whereby blood is diverted
to more vital organs particularly the brain, The \linbilical arteries re.f lect. placental
myocardiumand adrer..als. .circu}a,tioi); ~otmal umbilical arterY .resistance
. rani progressively through pregnapcy~, refl~tlng
Amniotic fluid volume deterttrination together _il),_cre~:$ed num'ber of t~rtiarjr villi.: R~sistan.ce
with NST is known as the modified biophysical . inb:~ases ~n condition.s suc4 a:s mr~ctlon, partja.l
! . abruptioP., placental .s carring_frQm intervilloQs
profile. dt .is much easier to do. and time of
: .o bsetvatiort is shoti;trted. A reactive NST with an
:" thrombQsls; villitis, :viral. or mtctetjal.
. . ~- -

amiliotic fluid index > 5 em is reas.s \lring. If the

modified BPP is pon-reassurip.g, the tun BPP or Umbilical co'rd irtety flow is done using
CST should be d(>ne. Doppler real~time ultrasound. A..fr~ ,floating loop
of umbilical cord "'identified, either continuous is
Like the -NSt CST, and BPP, the modified BPP or pulsed wave Ooppler is .u sed to identify arteriai
is done weekly, but .may be. doll!! more frequently now. The wavefoqn pattern is. ;ecorded and
depending on the clinical ~ituation {DM, IUGR, interpreted. The mo~t frequent waveform used is
HPN).. the systoUcjd.iastolic .rati~_ {SfP), T he Sf.D ratio
't
: ~ d~lines as p~cy contil)ues, The presence
: .i. of cl~s.tc)lic flow is better interpret~d "ihan.the
f T:ab!e 18,2. .Modified B~P, interpre~tio~. and pregnancy aboolute'v abte ,ofthe S/D ratio.
fi lila,nagetn"en,t;-

~
. . . . :.!..:.;-~-.: _.- .-l- -:'L'!.~:!-'.
: BiOPhysiCal Interpr:eWion Recommended Normally . groWing. fetus~s have ;highv,e,lqcity
~ . ProfiJe"S0.-e M~ent diastolic flew in the umbilical a,rt~~ ~~ ..?J.:~wth

~:."-': N~ Nofe~iQ<Ucationfor
restricted fe.t"\lses have diminishett; abselit: or
, 10 . ~ non~pJty.iriated in~tion; ~t test
. revers.e d end~diastolic flow. Reversal of
flow i.s
m associated with, perlnatal morbidity..~~h~erWio/
.:
1
. :__ . . '

.. .. ,. . . . . . . Weekly .a.c:tPt diabetic

"o. ..::i . ;-;-~,::.. patlent1iildpo8t-~ (Figul:es)8~:22 : &)'8.24) :,~~t.";. . , ::"~:r]f~} . ,
.. ~: < :; : pregnancy (twice Weekly)

8, Normal Normal, No feW indi<:$ti0n fer

tluid non-aspb~ interv~n;rqx:at testing
fetu3 per protoc:Ol
. " .......
8, OHg91lY G~!Jic;: .fc;tat P~Jiygij'? .37.w_
eck.s,
dramnios .asphyxia" othetviise repeat testing
su~peC.ted

6 Possible fetal If amniotic flUid volume

asplt.yxia abnqrmal, d:eliver
-~
.IC nonnal fluid :a t> 36 Fignte l8:22. Normal u.mbili~DoppleroloOd flow.5
weeks with favorable
cervix, deliver
1f repeat test < 6, deliver
If repeat test> 6, obsei"Ve
and repeat per protocol
4 Propable fetal Repea.t testing same day; if
asphyXia BPP' score < 6, d~liver
0-2 AhnostcerUUn Deliver
fetal asphyxia

From_ Manning & colleagues 1987.

Umbilical Cord Artery Doppler Veloclmetry.

Doppler velocimetry. is particularly useful in

a ssessment of pregnancies complicated by growth Figure 18.23. Absence of epd-die.stolic flow. 5

Stanned ey: c
 .

SECTION fit: CUNJCAL APPROACH TO PREGNANCY

. . . hemogl(>bin..and hematocrit to est:iirrate .blood for

--
. . . . . . transfusion.
. . . - .
Other Nou-iil.va~ive Modalities

The following .are non-i.ri.vasivc modalities to

ass~ss feW health.but are still under inyes.tigation:

L M!'\gnet9cardiogr.aphy .. .The instrument, a

. ...
.--.. -.- -..-:-
~ .~ ~~- ~---~--~-w magnetocardiogram; contains biomagnet.meter
.
~---
..
.. - .
.
. . .
..
.. . - channels that.permit examinatiori. of the I'etal
cardiac conduction system -on ':the basis of
electrophysiol~gical signals. TP,e instrument
is ccmpad and .easy to handle~ lt is claimed to
, : . . 'be helpful m. detecting fetal arrhythniias, IUGR,
Mi_c1clk Ce~ral A.tte~Dopflit' StJ,Ldies-(MCA)' arid fet<;\1 acidosis. This .can -~upplernent\fetal
electr0ca.rctio~phy. .At _pi7e8ent, t.'lere is'not
, M~surlng thef'etalmiaiD~- ce~btal artery pepk enough data to establish standards for its
$tolie ~lGcity'i~ very iieii:Siti\.efo~ detecttng. tebll. acquisition .and analysis.
anen:iia.. This:i-s .usti~y-'done in:th,e -lUI-sensitized '
.fetus.. lt js less costly. 2. Venou~ D'oppler 1Jltriiso'..md Waveform. The
no fiSk to :worsening fetal
~emia d11~ to: fetoma~ 'bl~: rr!)n1' .invasive . . use of. color and _pulsed Doppler ultraSbv.lld to
=;!=~~rntr.i~ntesi~--~e~~is ,:Mw no . .... _ ide,n:t:ify: ..nor,mal ..anc} ;a'bn:pr.ma:h.-ie~ous
.
waveforms.'Iliay ..predict adverse outcome in
.:

,.. :
.. ~v.<ievelS :of.fetalh~W:ogi.obmcause'-adecrease
.L!) ~ QUtput ancifdlffl-Jtne;m ljlOOd ViscE)sity,
A fetu.s:i~-<WP"iiden~:bm~m1ie if'MCA:v.iu:ue'is.,. ~Ls
tQ.:ultipl~- :Of the tried:ia:n {MGMJ~. '!he mother.
high .t -isk. Jet4ses. This wiH add to the.
k;nQ"W.kdge ptovid~d by th~ \l:rnbillcal artery
. 'p'lo~d :._fi6W:' ~.tPdies. and will . give .a c~~ar
. ~r~~v:e qf.the hemod~ruruc-changes of the
. .feW caidiova,scular system. This is still under

,:.~~:x~r~~!.c:2~:~~~~;:~
.. ..
-. :~:: _;:.;~-~~:~--.
. .;.: . . ,::
.: : ~ -~-,: P'Ofms:re)i~EME~~-iR
fe;t.al
,inV,estig(ltiO!f. ..

--.- :-_c:- i.: -- .-::

' : .. .~ . -~ . . . .. . .

:t. Al:l~~part~M'.tesW..;;l(.e!etf~~ :for:predicti~g fetal w~n~eingbutare not capable of m~king d~finiti~e

'.' diagnosis of .fetal hypoxia . . . '
..... . .. ... . :. . .. . ' ' .
~ . ' '
: ~ . .
Antenatal "Qssessment be~me.svalidcaft~r:the tetal autonomicnervou.ssystem mCltures at ~2 weeks
age pf gestation

ly1atemal perception-of
. . 10 fe~l movements
. .
in 2 hours
. bbservation
:
is reassuring.

... .._:~~~~~-re~t'.(~sn .: .
o 3~ W.e.eks~n-Q ~bO,v_e . :'' 2 or mpre.fetal heart rate acct;)leration;:: 15 beats above the baseline,
.'tastlQg'fo~ ~ 1:5 seconds in 20 minute.time frame. Test may be extended
.. -~- to40.'min.ute because of fetal sleep cycle. .
. o .leSs-than . 3'2 weeks : same.as the. above with accelerations of;: 10 beats I min
.. l_as~n_g f0r . ~ 10 seconds in 20 min time. frame .
-:: .o J-qt~rp're~tiqn_:. :. . :reactive & reassuring if no decelerations
~ rre~~~.~-~~~-~~ui~tlon . Test.(FP-sh: .
.6 The}e!a.l..acous~c stlrpul~tods..plac~d on the maternal abdomen in the area of fetal head. for 3
. se.cbnds. stiiilur,us: . :i
o Jnte;pretation :same as NST

Scanned 8y: ~
 CHAPTER 1~: NON1NVASIVE ANTEPARTUM ASSESSMENT.OF FETAL WELL ElEING . 301
--------------------~----------~----------------~--------------------~
,,.-.:
' ------~----~----~---------------------------------------------------,
.....
. Contra9Uon Stress Test (CST) :
o Observation Of fetal heart rate response to 3 uterine contractions {spontaneous or induce)
within 10 .mln time .frame.
. o Interpretations:
Negative : no tate deceleratiOn
Fositive : late decelerations in 50 % of the tracing.
suspiCious {equivocal) : Intermittent late deceleration
Hypen~timulation : deceleration secondary to contraction
occurring more then every 2 min
Unsatisfactory : inability to achieve 3 contraction and/or
tracing of pcor quality
.::
Biophysical PIOfi!e {BPP): . . . .. . . . ---
o Evalu~tio:l of the fetus with 1h.e use of electronic fetal monitor and real time. Ultrasound. 2 points
aie awarded for :each.criteria.
o Presence orabsence of :
1~ R~e NsT
2. Fetal Sreathiog Movement
3. Fetal Movement
4. Fetal Tone
5. Amniotic fluid volu:ne

.- ,.;o' Interpretation .:
1Q.J 'iO - S/10 : reassuring
6/10 : equivocal
lessth~n 4i1'i) : noil4"~assuring

...
.
Modified BiophyskalProfile :
..
' o NST and AmnJOtie fluid \'Oiume lnx(AFI).
,_
o It presYme$ that if ~ .NST is re;ave, fetal movem3nt and fetal heart tone are present
o lnte!'P~~Q!l; e/.10~:r:eASSudng.
, .
Umbilical Cord Arrery Doppler Velocimetry :.
o It is the BESt diagnostic tooHo assess Intrauterine Gr~ Restriction {IUGR).
o Interpretation : UmbiliCal Cord .Artery End Diastolic Flow js diminished, absent or reversed

Frequeilcy o.f doing mentioned diagnostic tools will be dictated by the. overallclinical picture of the
pregnancy

3. l3ascha t A, et nl. Cotaputemed fetal heart rate ~alysis

1. Antepartum Fetal Surveillance. ACOO Practice BuUetin
Number 9.199.9. American .College of Obstetricains and
Gynecologists. The :2 001 Compendium of Selected
Publications.
(CTG) for prediction of acidemia in fetal growth restriction
(JUGR). Am J Obstet Gynecol 2005; 193 (6): 320.
4. Crea sy R, Resnik R,lams J . Maternal-Fetal Medicine:
Principles
.
and Prn.ctice. 5th ed. Saunders . 2004.
-~

2. A:rya A, Stuart B, Daly S. Absentfreverse flow in the

umbilical artery: A very ..poor prognosis. Am .J Obstet 5. Cunningham F, Leveno K, BloomS. William'.s.~b~tetrics.
Gynecol2005; 193 (6): 319. 22nd ed. The McGraw Hill Companies. 2005;.<.
-
Scanned 8y: ~
 ~~
---........;...,:.._;_____,s_Ec~-n-o_N__-111-:-c=-u.,_N-,c-A""'"L-A"'t""PPR..:.. .r.....,o,.....P_R_EG_N_A_N7"'""t_Y_,___---''----- 1~1'
. _O_f\_C..,..H-
302
~

.
6. Davie11 .G. Antenatal Fetal Assessment. SOGC Clinical
Practice Guidelines ~o. 90. SocietyofObstetricia.nsa nd .
Gynecologists of.Ca:nada. June :2000.
7. Freeman R, Ga...'ite T, Nag~tte M. . l!'etal Heart Rate
11 . Rolfe P, Scopesi F, Serra G. Biomedical instrumen.te fori :i:Q
fetal and neonatal surveillance. J QU.mal of PhJ'3iC3: : f.i
Confeience Series -48 (2006) u:h-1136. Institute or: /~
Physics Publishing. . :;z.
":-$

Monitoring. 3rd yd .Lippincott William~ and Wilkins. 12. Van .!...eeuwen P, Lange. S, Hacklnann J, Klein A, ).
. 2003. Hatzmann W, Groncm.eyetP. Assessment of intrauterine A
gr9wth -:etarda~ion by f~tal mag~etocardiography.
'8. Gilib D, AruC.rum.atan s. Fetal tncnitoring. iri Practice. ~ecerit'Advances in-Bh::ixD.agnetism. 2000.
Butterworth-Hei,n~M 1994.
13. Van Leeuwen P j Hailer B. Fetal arrhythmias:as detected
9 . Manning -F. Fetal Medicil:i:e:, Prinqp!es and Pra,ctk:es. py magnetocardiography. Advances in Biomagnetism
-Appleton andLange. 19.95. .R~a.rch. :20oo.

10. Menihan C, 'Zottoli E. Elect'onic Fetal Monltcring',

Con~pts and Applicatio~ Lippincott W.illliun.3. and
wuians. 2001

Scanned 8y: C
 19
PRENATAL DIAGNOSIS AND
INVASIVE TECHNIQUES TO
rdONITOR THE FETUS
"
LEAH SOCORRO N. RIVERA~ MD

Principles of Screening Test

lndlcatbns for Screening and Dia~nostic Testing

. '

Screening for Common Congenitai Anomalies

Neural Tube Defects.

DOWI1 Syndrome .

Diagnostic Te9f:iniques
Second Trimester AmniOcentesis
Early AmniOcentesis ,
'.Chorionic Wlus Sampling
PerCutaneous--UmbifiGal Blood-Sampling
Fetai TI~ue Biopsy - .
Prelmplantation G~i')etic Diagnosis .
Fetal Cells in the Maternal Circulation

Current Status of Prenatal Diagnosis in the Philippines

Seanned lly: C
 . ~--------~--~--S~E~C~TI~O~N7-~lii-:~C~U~N~IC~AL~A~P~P~RO~A7C~H~TO~P~R~E=G~N~AN~C=Y~------~--------~~
~~~~----:;-::-----~--------------------------....:. .-4....;,.

-
INTRODUCTION the te~t become~ positive ..This is where the' other 7$,:.
two m:asures come in sa L"l.a.t _positive ~redictive NJ:
:Prenatal diagnosis is the science of identifying value 1s de(med as the ~rcen tage: of pa,timts that:.&~
struct:u.rtil and functional a;bnormalities in the . was _positive for the tests th~t actually have the :t~-
develO-ping fetus.1 Act.vanc~s m t.1-lls ar~ esped.ally c!ise~e. While negative predictive value is the .:?:
in' .t he refinement of screening methods and _percentage of-patients that has a negative lest that ~:::: .
:di~-gjlo.stic techniques has sign-ifican9Y.. do not have th~ .d:is~se. Both tliese two valu~ .. .
-eontn"buted- to the management Of the ferus as a are dependent on the disease _p revalence an4 .are
Pa,:ti~np With this <l,YailalJle. i.nforrnation, the vital to the interpretation of the test results of the ~
. clinician is now'aQle to off!!~ thei,rpatietits-a :wide individu?Jpatient_.
:~y ~f fetal ~urveillart~ and tr~ent as well ..
:as .estttbJiSh :th~ ~anproP,riate mOdi:- -ana. tijrte for . 1-N.JHCATlONS . ... FOR S~CREENlNO .. AND
:delfv:W . D,lAGNbsTIC .TESTING.
.l
... ~ O.F sc~ENING TZ$'r A. Mothex:s wllo are }:;Ugh .;ris~ of qmyitig an
:. . .
. .. .;
~-
.; aneu.ploid fetus enough to prompt invasive
/Sc::tecilln.g VL Diagnoa-tlc Tests diagnostic .test.ing include the ff.: 1 ' ': '
. .. ' ; .. .,
,.. ... : 1\n::.underst:an:Q.ing of the difff:re~<;:e.s between ~.At. lea:st 35 years old ~:t delivery of their . . :
. ~~,p.i'~ti~ ancl 3c~e~ning_ t~st i~ the basis for singletor:<ptegriancy.
~g for .sny :disease process. The goal of the 2. Women at least 31 years o1d at the d~livc.ry :of
~ ttst. is to: de teet or define fh~ risk for their dizygo.tic t\vin 'gestation.
-- : 41~8e:-in~asy,m..p.tQmatic.- low:.r..S~j>op;u.lation, .. . . 3. W9.:me~ .who .hav~;prev.i'~.'-lsiy_,~ a ~tus~.
. :WhiJe,fhe aim: of'd!agno~tic testing :1$ .to confirin.or wtt..~ an auto5p~al trisomy,
1deritify .fue indiVidual With the d.iS<!ase.2 :Sillce . A.Women who have.;pr~o'J.sly ~a ferua .
~ tests are ge~enilly ,pffered ta the eritLr-e with. Triple X (4 7 , XJtx) Cr'Klienfeltet Syndrome ,
- <~t -pop\14ilioil, they -sbould be e;con.omical, (47:XXY.l. . . .
.. ;~;.i.O. use ,8.mi.interpre:t.:Dia:gnpstic 'teSts ,on the . . . 5 . Women or tP.ir :par,to:er's: who have-a . . ~

--~~~~;hS;Ij.4:,.,.m...g~Pt.~~~.:9.IIiBl~.~:~ci..,r_e,<jy.~~ ' . chromG.sOmal tran.slOca:tion

~~p~cated analysis an~ inter.preta:tion. These
. 't~!~:!~afi t!> 1Je expensive and are. u.sti:aJly
~,~~~eq-onhi&Jt-nsk-F>atien~ but-thgy ean-gi.ve.
. -='ai;te!iriitiVe-answerthat the fetus~has thedisease.
.~gt~st is by definition not <::onclu.s ive that
:tl:i"C p atient ha-s the disease bufr ather the patient
. :~s further testing.
:. :.M iaames in tlie EValuation of Sereeni.ng
.. Tests .
...: .
. ... .
;.:Th~r:e-arefour key :measures in:the evaluation
' ~:orsdietili.g tests: Sensitivity, Specificity, Positive
. P.i":.e~lk;tive V~ue, and Negative Predictive Value.
. . :;Sen~itivity a nd specificity fundament a lly
-ad<tte~s the question from an epidemiological
:s~_i;lpoint. Sensitivity is defined a:s the percentage
9{-~ple with the d isease that was identified by
-th~.t_esL While specificity is the percentage of
pafi_e*'ts who do no.t h ave the disease that te"sted
negative Jor .the test. 3 Both sensitivity and
: specificity a re independent of the disease
. fr--equency. and describe. the antidpated
a
per.fbrinanee of screening test in the population.
_-_ J::I.o.;.~ver ~ what is more relev~nt clinica:lly is when
. 6. Wo~en O~ their :partner-s -who care carriers oc
<;:hromosomal inversions.
7--<.HistGl'o/-- of"h:iplOidy... . . ..
8~ -R~p-etit-ive. spon;ta;n.eous .fir.st . trimester .._. !
abortions.
9. Paten~ ~uploi4Y
. lO.:f'etus 'w .ith .;1 major Sttucfu.raldefect identified.
by ul~sonqgn;~.phy.
B. Isohted Str.-uctural Anomalies:
The recurr ence risk of .structural
malfoni:la tions is about 2-3 percent sb that any .
parent who is p.ffected or has <Ul a.ffected child
should be of(ered prenatal counseling and
di2:gnostic evaluation. 1
1. Congen ital Heart Defects:
They a re the most common isolated stnictwal
defects o<;curring in approximately -8 in 1000 live
neonates.~ The rate of recurrence .for a woman.
who had a child. ~vith congenital heart- cli~ase : . '..
ranges .from 1 to 3 percentwhen there is .One. :
a ffected s iblin g, howe:v.er it increa s.e s to S-15 .-

Scanned 8y: r-.

~
r

CHAPiER. 19: .PRENATAl OlAGNOSlS AND INVA$1VE TECHNIQUES TO .MONITOR THE FETUS .... 305
-----~------------------------.------~-----,.,.'ll'

.: perctnt when there is more than one 8.ffected chUd
~-. or when the parents has a congenital heart
{ disease. 5 Investigators rep.ort that the
abnonnalities most likely to be associated With
the recurrence of same df!fect wl!te AV septal
defect (80%) .a nd lateraiity defects (64%) .
Recurrence of a similar defect was most likely for
left heat:t defect "f47%), outflow tract defects (47o/o)
and septal defects {60%), all of which involve
abnormal bld flow pattem.6
Prenatal diagnosis is us"QaUy done using fet;al
echocardiogr:ap.h y at 20 to 22 weeks age of
gestation because at .t..lrl.s age of gestaticn, ~ost frequency in ethnic .g roups living L.& the U.S.
of the cardiac structures are well - developed.
According to the Euro Scan Study Group the
prenataldettction rate .o f ~ongenital heart disease . Table !9. L RiSk factor.s for neural-tube defects. (Adapted
in~~s with t.'lree scree.n ing...~cans ( 55.6%) in
contra~t to. 46 percent with only one tou.tine scan. 7
4. Ethnic Groups at Risk
There are rare rece3sive .g enes that are found
with increased frequency in certain racial or ethnic
groups. The teasori for this is because -o f interracial
or interfamily marriages .because ofboth religious
or ethnic .prohibition and geographical isolation.
The founder" effect is.a phenomenon when a r.u-e
gene is Jd'Und with increased frequenc; within a
certain population and can be traced back to a
single tamlly member or group of ancestors. In
Tables 19. 1 and 19.2 are some .auto.s omal
recessive genes which can be found with increased
from Willliun~s Obstetric:l ,22~ cd 2005):
Family history ofneural- tuhe defects

.Expos~:t() ~rtain envU:on!llental ~ents .

.Neur!.1 'rube Defects .is the 'secC~nd most
comnionDla.jor eO~geirltal ~omaly worldwide and
Ofu.bctesP,.~glycenrla)
. Orugsand .$edication~
.
Z~;~~ ,
in isolation is said.to occur ln. 1.4-?. pe;: 10.00
Get)'etic Syndrome with known recurrence rislC: ;.:
. . . .
'/'!:f1
. ''""
.':
. ... : ...:
pregnancies~ Women at in~:;ed risk of having Some .~cial or ethnic.groups and/ or living in high-rlslt
a- -}?abyWi!h NTP .a n; advised to have alpl)a-feto . geograp~cal regions . .!. , ; .,...:,
:pro_t~9'l:~g..asput.ofdiagnost:ic ev~uation: . . . -.:-: -.-~ .:.-.--:,..\;;c.
wamefi..atincrea~.rlak for.N'fn are .~ in Ttible PrOduction ora ntHoia.te receptor a ntibcdies_.' ' . y:~~ }:',:
1-1. I( ultrasoUnd screening is positive th~n
. anmiocentesis is done to confirm karyotype and
the pre$Cllce -of ~e -. defect.
' . - - ~ --

3.. :F.rumliaLGene.tic ..Disease .

Diseases Heritage of Groups at Incre.a sed Risk
A personal or .family histGry of a heritable
genetic disease is . an ind.ication for genetic Hemoglobinopathies African. Mediterranean, Caribbean,
counseling and tha~ the COl.lple is.provided ~th a La tin American, ~ddle Eastern
calc;~lated risk of b~ving _ an affected fetus .
~assemia Mediterranean, Asian
.P henotype detecticm .is a major issue in many
g~netic disoi'Qers. Ident:ification of a ~pec~c gene Inbornerrors of
is not su~cient to ...,allow prediction .of phenotype m eta\>ol..i,sm: Ashkenazi Jewish
.of affeeted fetus even when fc;u':n.ily members are .Tay- Sachs,
affected and
this is because 'of tWo factors: Canavan,Gaucher,
Niemann- Pick.
a. Variable penetrance and expressivit:Y. Faconi anemia
(type q, Bloom
b. M~ification of phenotype by pre.and syndrome
postnatal envll:opniental.influenc.e s.
. Cystic Fibrosis Caucasians of Northern
Another area o.f difficulty in phenotype Europede<:mt, .
prediction is when there are no livi-ng affected Ashkenazi Jewish, Native Airierican
family members or when the disease gene is (Zuni Pueblo) ,~
identified as the re. ~ult of _population . ' :Z~ .
Tyrosinemia; fragile X. Fren~ Canadian
screening.

Scanned By: ~
306

SCREENING . FOR COMMON CONG'ENJTAL apparent p~do.xical rise in matemal seru.m AFP
ANOMALIES levels when amniotic and fetal serum levels are
decreasing is believed to. be a<;XX>urited for by .the
Limiting prenatal evaluation to wotnen high increasing placental perm~abUity to feW pla_sma
risk for congenital defec.ts would fuil to i<!ent"y proteins.
most affected pregnancies ~1,1se in majority of
.ca,ses they are rol.Uld in families Withno history of
birth defect~ .. W.ith tbe current advances in
technology, a wide .variety .o f prenalru sereenins
tests can now be offered for~ fetal :disorders.

Neural Tube Defects

ibe incidence cf NTD vati~s em~:mg different

commllili.tie$ around the wot!tl'l'he~ 'tTariat,ions
are functions .of genetic background. location SJ?:d
nutritional status. Historically., before $Cr~ning
\Ytls implemented~ the m,o:st. affected in the world 10 .;zo

was Northern Ire~d where ~~ incidepce was 1

in 130 live .births ~.to .Ant~$ c;>Ut-ish qn~estry Flpre 19.1: Maternal e.nd fetal &~m e..<d .atnni{!tic fittid
have .alower rate~ b 'trela!nd t but s till have a alpba,fetopt'9tein {AFP) levels ~rttsp<lndingwlth ges~tional
hlgher. incidence than whi.tes in tli~ - 'til.S. T)le age.. (FroJit Robert's and eo~-uC$ in'\lrilliams Ob.stetrice
22.. ed.2005)
.Japaneae=U.~Japan.)l:av.e-,,the~loweat;lricldefie.;of~ .,.
Nm 0.23t::lOOO..livc:birth;,yet tbe"~apat)e$e:.in: .
Hawaii }\..a~ an incidence double.tbat:.ofJapan. u

:Scrctning;fo.r .-NTD's has two nuUn sttps:First " .. Ma,t~rn'al _serum levels .of M$AFP can .be
l M&tema:i=r.S~f.\itn :.AlpJ;la::~ . .Pio~in. i~ .t he:2:1>4 ineasu~ed -. ~:. eru-ly ~s :t he ld. :trimester~ For.
~fer Of pi-egr~cy"'llid second; eatly rliagnosis 'stt~enin,g.":'put.po.ses.,..:.-.~aterna! . :&et:um' -AFP-is
.by ultrasoUnd eXilinina:tion.; Btocl(and _ooll~gues .- measured 'P etwten t4 - 22 weeks.g es.t ation when
. d~ the meourement t>f anmiotic fluid AFP the inf1:ta:se is linear. Since lb- distribut;ion of
. ~to-~NT.i)~,U,su~u~ntly, A$-:P-m.:rii~ternal . MSAEP .. values do . nut .(QJi.Q:W. tb~. EPJ".m:~ :,~e
. se rum wasUtilized c{ or prenatal Clfagttosi$ of parametriC statistics.~:n6.tAppropriate..th~fQre,
N'l'D'a. u the resUlts are 6cpres.s ed 'in ti:iultiples of median
(McM) for .g estational age.
Alphlrfeto Protein
In m.<>st labotatori~$, a MSAFP result of 2: 2-
AFP is a glycoprotein synthesized ~equentially 2_.5 Mo~ 'for sitlgld;>.~ o:r 4.5 MoM .in ~s is
cy tile yolk 8ac and the .fetal GIT andliver. A?.P ~onsit:~:er.ed. abnorrti:any\elevat~ ~d inl;lieates the
leVels in the fetal .plasma are maxinial at 12:.13 ne~d. f:or further test:m:g.. Reqently, there is a trend
weeks. After the maturation of the fetal liver, toward choo sing a lo~er AFP threshold to gain a
plasma AFP levels declitie and alb\lmin grad\tally higher detection rate . with slightly more false
~~me~ the principal plasma protein. in t~~ fetus. positives. Using these cut..o.ff's, most laboratories
Fetal AFP values enter the fetal urine and will yietd a detectio.rt rate of almost 100% for
c.onse.q uently, the amniotic nu:id. Peak aneuploi~y. 85-92% for o~n spina bifida with a
concentrations of amniotic flujd .AFP a.te reached high false positive rate between 2-6%. 2 Women
a.t ~2 - 14 wee~s gestation and stead1Ly decline with M$AFP lc_:vels h igher than the ptedete.r mined
pariillel to the.fetal $efUID. concentration. Amniotic cut-off should be referred fot genetic counseling
fluid levels . pass into th.e matern~u dt:c'Uhition, and considered Jot diagnostic testing.
probably by diffusion .through the membranes of
the placenta. A:FP appears in low concentration There are also other (;~>ndition13 which may be
in the tnate~ sentm. Its concentration peaks associated with al;mornlal maternal serum alpha
at 28-32 weeks gestation {Fi~Ure 19.1), 'fhis . -protein concentration fl'able. 19.3). . .,

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 CHAPTER 19: PRENATAL DIAGNOSIS AND INVASIVE TECHNIQUES TO MONITOR THE FETUS 307

Table 19~. Corn;iitic;,ns as~ated with abnoOXI:al maternal As opposed to AFP, which is a f~taLserum
~ ~pba ..;., !etdpn:Jtdn :e oucentrations (Adapted from analy~te, acetyl choU:nestera.se is predominantly
wunama :obetetric8';~:ed 2005). <

neu.rorially derived giving.it additiorial specificity

-for nervous system lesions. A combined use of AFP
and aeetyl cholinesterase together _.appears to be
~~'~i= .
Neutal- -tube defects . . the most sensitive and specific .deterniination for
Pil~.;yat . . . NTD. In a study of lO,oOO singleton pregnaflcies at .
ESopha#al orinte:~linal obstruction 14-23 weeks of ges~Uon with known :Outcoll).es,
~n~s the amniotic fluid a~tYl cholfu.estera5e _levels
~tie h18rimla identifi.ed 100 peroe_ht ofease.S of anenci:plUUy. 100
SacrQc:ooc.)rge~heratoma . ..
A.bdomirial.w811 defc;tts- ompbal~le, gastro"S<;hisis percent of cases of open spin.a bifida 2nd 20% of
lrrltWy ol>stz:uclion . ventral walldefects with a false positive rate of 2 .2
Retl8l~e~-~. orab:H:nt kidneyiJ per 1,000 amniocentesis. 14 One .advantage of
Con~ctat);leplu'OIWI . . . '
amniocentesis is that :amniotic fluid can be
Oste.08entat3 iinpenecta obtained for detenr.ination offetal k:atjotype. Some
Co~tal J)Q.n '<ief~
Cloacal~pby clinicia."ls would pr.bq:ed to doing fetal kaiyotype
ChotioanpoiJl& ofplS~nta when both maternal serum ;and amniotic fluid AJ<'P
.. Piacental abruptioil
J:>lacql~~tC:
levels are elevated, even if the amni(jtie fluid acetyl
cholinestem~ as~y is negative.s
~' O~a
~

- ~*!:~ J,Jltra$oMgraphy

lf Low~t
F.~:i!~ .:
Imp~it4JustinC:J\t IM-Jowlnatemal wcigltt
U~atedgea~Bge .
M.iiiem&lh,:epii.toti:U\ot~~
. . . .~ _: ,.:~~..:;..:"i-.._:1.~-r~-~ . . .
. . Ultr-as\):u.nd techp.ology has ,- .~pr~v~d .
remadcably sillce.-MSAFJ>scrtenirifi.~ il4i.P~.
Le vel m u.ltrasounct center$ rei>Ort::-d~l\ent
i ' ',. . sensitivity ~d .specificity iri deteclirig }iTIYil. In
the .. hands: .. o(. e:xiperienceg .. ,~. ,.~R~!~~or,
ultrasonography al911e h~ up to 9,1:o/o\'set].siliVitY
and lOO% ~pecificity i~ the rusgno~!~f:~~fp. 15
F..etal~ . However, Wlth those ~th lesser expemse~tf.~.
Impro~fldjul$tmeatrorbi_ghmat~nahvight.
r .
I . 0'*~-~~.,~.. . h ave a hlgb false (+) ra~ In the 'RADIUS.tiihl_'which
<is a large mUlticenter trial ofultra.sowni"sereenjng
in-low~risk-women, ~only:. 35"pe'i-eC:ilt -()fcmS:jor

I
Rerommendations for Screening
j' . The . ,t\~erican College Qf Obstetrics and
Gy.pecQlO:gy --lu\$.' reconttnended th:at MSAFP
..scri:eniJ;l,gbe oft~ to-~ PYegfiNltwomen jri'H1c
seco~<t t rlnte.ster."8 It ..sho v,id ve
perfor~ed
pi-O.Vided it is aOmpartiett :~;ty adeqtiatecouQ.seling
and.tol1owup. ~et:il).ore, it should l?e done in
. areas 'w jth qualified di:!lgrtostic cente r's -~d hiSh
qualjty standard laboratories<
.AmltitX;enie$s
. . . ~
Tht tra,d.itiottai tJ..iagnostic t!:st ,o ffered to
womeii .witli a :pos1tive MSAFP test .rt: stilt is
anin.locentesis With e:v.hlua tion ,(jf _
ruxuiiotic fluid
AFP. anc;l-acetyl cholinestemse.:iAchE) levels. The
a.ccu:racy ~f .amniotic -fiuir:l d eterminati9n 'iS
of
enhanced bythe addition a cetyl'c holiriester:ase.
anoma'lteswere rre te-cteu --in tertiary--hospital
setting and cmly 13 percent.in nontertiary settings
were identified Y
Anence pha ly wa s routinely identified b y
u~trasound a s early .as 11- 12 week s a ge of .
gestation but should be -COnfiiP.led by a scan a t
around 13' weeks because ossification c>fthe skull
in s~me cases ma y n ot be completed at this time.
In 99 percent of casee, o~Ii spinal lesions are
a s s ociated with one or more 5 spe cific cr a nia l
anomalies that can be detected 'b y' ultrasound 18 : .
. a.) sm.all biparietal diameter.
b .) ventriculome_galy- the .lateral ventricles are
dilated> 1cm at-the -level of the a trium (Figure .
19.2) . ~-:... .
.c.) _Lemon sign - indentations at th~emp~ral
portion of.the fe tal .sk:ttll will_g ive th~~varium
a lemon -like con~guratioi:l,. (FiguS~} 9 . 2)

p-tli
Scanned 8y:
~
 ...
308 -..
d.} Banana.sign- the tere~itar h~mispheres are
depressed ihip .t he fc>r;artien: ~agnum, e tther
beca~se of.loss 6 CSF fui:Qugh. the open ~pinal
def~t into the amniotic .flUid or: t~ther:iri.g. uf
the :spiriill cord , cr~atin-g a.. bfffi~a .like-
. corguration. (Fi~e 19~3) .
e.) Ci-sterna magna ls .compressed -"als<> kno'Wn
. as
An~:pld Chiap abnotJnality this occurs in
virtually-~.cises ~f:.o~ tf;rt> -~ 16 weeks
.age ofgeslition the
,flujd 'space tepre~ting
the ci.sterr.a magna ~ ~ obfitera~

* .B~: ~d lemo~ sign may not be present

.. i.fter 22 y;eeks .. d
Fip.re 1.9.2. Vet).tticul(imegaly: FH- Frt>nt#hOm:;, CP--
Chor.oi.d _plexus, 'Block arrows- Dilated vc:n~ (A.Gapted
App~a~h to. Diagnos tic Te~g fro~ ~nowapl:+y in Obstet:i.ce and Gyne~~
and Practice 5th <:rl.Fleischer, 1996).
..To t~ke advantage of 'J?:oth :J.Utra:~()und, .. .: \

. . , and tO p:iinilliize the

amn.iOcenteses
. . ~.a,
~~~ .numy
.
~enters .n!Yw oifer .spec_ial~ed ultraspun.d
exami~atiorp:initially b;l.: aU. ~- :ri~J,C :wOm.61: al).d
:pe:i:fcan:~t~:S~owJt-1h.a:~u~t'P~patl.~.t)ts~. ... .
. . . . ...... . .. :. ~ ... :.~.1~..:.:. .. .. .. ,_.. \ .... : ~ . .: .. ..;. . . .
'lf a : mglb:q~:icy~ O;Uud.~o~~~m):.n.~Aon:r-,Is:~ .... :
~~ed'~d!no:--Ae~~~:id~p:ti:fiCi'itli~.;~~~~,:
and. oenent.S':.o{ afuliioeentehls.. <:an ~~ . d:iscU's,sed
. :-.;., .. ;.:. t. ~ --:.,.. ,, .-.....::..::.::g s.ct ~ ~;;.:e t .be
:to. th
. . -~-~uQ.l, . :' ue. 1.'-~.wlll . . ""~~ 1.:~V ,?
taken. mto:,;a~.co:Unt~~beifor..e;;.a:-:de~isio lli~ab'o.ut;.: .
~~~~,~~::~:lli~~;.;_:.:: . ... ' ..... :_:. . .. _:-:; .: :. . :.
.: . . . - ....
-a,.) . ~ :<ff..risk .~~e,d willi MSAFP_levcl
b.) Flifi~t's histo'iy . . . . .
cT-Fi'lidmi$ortne sj:>eCI~11zeq: . w;tr:a':-n:>11P~
--damka:tion.- Ffbr~l9.aS:...Lecion..S;~-.IJ\denktio~~ J.
. q_;J {\.g~.-p.f. ri,l<;. w~ent pQ'rtions :or th.e f.::t a l
www.m edscape"c.om).
skull {Adapted fr.orn
e.) Decision of the patient

. . Co.f.l:$iderqt!o~
$pec;t; .. .
in the Manag~ of NTD '
. . . . .
i . . F()r i~th~ a~o-P.la.Iie.s {e.g,. arienceph~ly,
exencephaly).... iU.aiiagemt.;{?:t may ~ .iiinited,
routine .pr~na:tal' care 'is given and .Pren.atal
interventl.on for fetal i'ridications 'not
-recoml:n~tiaed ~cause :~ey w$ -~ot ~~artge
~-e :!?~~ogn9sis ..

2. Team appr<;>ach i-s essential ~O\lnseling from

a-~dlatrl~ surgeon, .neurolo:gi~t a.t:t4 other
s.pecialties ~n pedia.'tiic development is
~ssential.

~- Good i!Iltenatal care

.that Will 'dete-Ct oChanges . :I _,
Fi~te ~9.~b; Banana
.
sign. CerebeUar heiiili!Ph~ are

. in.rei.al . :~tatus tliat miiht alter the .fup.ing o r dep~essed into the fo ramen magnum-{Adapte4 from
route of deliv_e ry.. :www.~edseap~.comj. . . . : :. .

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 CHAPTER 19: PRENATAL DIAGNOSIS AND .INVASIVE TECHNIQUI:S TO MONITOR THE FETUS

4, Adequate rieonatal care.. - available facilities 1:270 or higher. 25 The cut-off level and sulj'"!iequent
and perSon~et capable of managing im:mediate public policy was determined over 25 years ago
complications. and this was based on the maternal ege risk of 35
years at delivery. The factors coiuilidered in
5. Delivery at term- if possible unless determining tMs value h,cluded the prevalence of
deterioration offetal status is pr~sent that may
the disease; a perceived sigriificant increase in
pr~mpt immediate delive ry (e .g. rapidly
trisomy 21 rlsk after this age the risk of invasive
in~reasing .ventriculomegaly necessitating
testing, the availability -o{ res:ourCC?S. arid cost
shunt placement)
benefit analysis. Since that time; a number of
6. Mode of delivery- For breech presentation with .i iddltional screenirig t~sts for Down Syndrome
.f\'TD, cesarean section is the standard." For ~ve become a vailable that cha:llenge the validity
verteX presentation, the mode o(delivery is:still a
cf maternal tige aa single indication f or invasive
controversial.Thue ine no :randomized control tes~~
tr.:Ws do~ conipanng the outcOme"for.\taginat
. vs~ cesarean section for fetuses .with spina Mu'ltiple ~arker Screening jSecciuJ. Trim.e$ter}
b ifidai n verteX pres en tatio"n. -.M least 5 studies
repre~ntmg a total .of" 400 patients suggest Biocherilical serum screening .f or 'Down
that vaginal delivery does not adversely ~~ct syn:dr6me in woinen you11ger fu.an .35 year$ was
I
i. neonatal outcome, while one large study Qf200 intrQd.u ce-4 in J9_8.4.,. when .an . as.sociati'on.
patients suggest the. opposite. 1 9 24 Some betWen low maternal.serum alpha -feto~:oopteirt
"" studies also suggest that the size.of the lesion (AFP) te\Te1~ and "Down .'ayJ)drom~ w~~ reP?.r:tt:d,,
"f.
)

.. : . lictatf~ the-:~nte of the Aeliv~r:y. When -the In thi ~1.990~s~ HCG and '!.incortjug'flted~;e~t).'iol
'',
. :~.... lesiPJl:xoeeds 6 -.e m, cesaiem s~tion- may" be were ft~d in 6ottibmationwith: m'afi:mat :'~)Um
. justilkd :tO Aedrease t..'"l~. ri$k:of disruption of AFP to improve the "dete~tioi) rateif.>fo~b:o.\irm
' . cysl1:}lyg;:ciila. Ce~ean section may als~ syndrome and Trisoiny 18 ( Trip;e ScreervTestj.
; . ,,, .inffei,- :o~tiinal ci>nditions for inanage~ent of .T he average niat~al setilm 1\FPl~et ixi._R<>wn
l , .'Jatge ;a:~terior . Jy~phangioma that 1]1ay syrfciroul'e pregnanc.h~s is ~:edu'~-~~';_,t().:i:0~~7~ .
~
. " ..
~ ~\,,~bs-t ,the :airway.~ rn a .fetus with
multiple.s ot mecUan {MoMJ": Intatt "HCG'' i's
~
I
. . sa~geai teratoma "L, tumor <_:Scm, increased in affected pregna,n&j~s- *itli' a n
l vaginal .delivery may be attempted. Howevei', average level of 2.06.MoM whereas uncC>rijugated
most of the stu<lies done are retrospective .tm<1
es~~f i~ reduce4 to a~ ~vtrag,e ~~vel .irl"Q.?S
suffertrom. bias and limited by lack of long 4
MoM-.lL,Whe~rthe-levels-of-al1 of-th.ree'-mark$
fenn . lono:w~u.-o. -sliice 1t'Ts sun iioi.:dear u'Sed :1:0"" modify--cthe-ttratenntl"ll~;;rela:t~cf .
whether or how .til"e m e tha-Ci"""or -:d eifve'ry . are--
Down syndt.oree risk, the detection rate of Down
significantly affect3 n eurologic outco~e in
syndrome is appro.xima~ely 70 percent.
these infants, decls1ons about the ti.tn.in,g and
Currently, the ~ost common s.e cond trimester
route o! delivery should be made individually
,and .in consultation . with pers.cnnel with screening protocol. used i s the Multiple 'Marker
e~p:ertise and knowledge of .s uch ScreenP1g test or the quadruple screening test.
co~plications. This te.st makes .use of an -additional fourth
marker which is lnhi.bin A, the addition of
inhibin A. improves the detec tion rate of Down
syndrome by approximately 80 percent. Tne
~own's Syndrome
median V?-lue of"the ma t erna l inhihin A i s
.....Hl~~QnCally , maternal a ge .~s _y~~s, -or ..older increas ed at 1. 77 MoM in Down syndrome
a.t~~-time. . markers,
27
ofdelivery has:be~~ . ~sed to ide~~fy pregnancies. Screening with these biochemical
ultrasound or both is being. offered
women a:f""rlsk .of having a child \vith 'Down
syndrome arid .these woinen have been offered increasingly. to the entire pregn~t population
g~netic eouns"eling an.d invasive testing to provide a more accurate estimate ofindividual
(amniocentesi.s and chorionic villus sainP.ling}. Down s yndrome risk. Higher sensit,ivity or
There is 'presently a general consensus in the U.S. de~ection r a tes at low. positive rates h~e led to
that invasive testing for Down Syndrome can be increased u se of s c r eening and a declffi:e in the
offered to those w ith a second trimester risk of . number of amniocentesis performed. ::.~, .

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 310 SEC'nON til: CLiNICAl APPROACH TO PREGNANCY .

First _
Trimester Screeni119 2. -Fully integrated screening ... u~ ~th lot
. . and 2 trimester ~arkei'$ to ~just a -~en
A significant breakthrough in firSt t.ri:rnester age~ related risk of having a child 'With.Down
screening f(;?r Pown .syndrQtne was achieved when ~drome and results are reported after bOth
lar;ge st~dies in thf? U.S. . and .. the U.K. tests are completed. ... -. .. - .
demonstrated that meas urement of tt-vo serum
analyS.a,tes pregr1ancy-:assoeiat~d plasma protem 3.. Senun Int~_grated Testing (identical to fully
A.-a ttdfree P>:- HCG. These tWo marker.s.can be u~_e_d integrated testing -but without nuchal
to 'S(neil for Do\Jin. syndrome .mthe ftrst trlnie$ter. translucency).
Pregn~cy-assodated pla$illa :protein A .tends to
be decreased and free.:p.:HC<Henda ~ bC ilJ~sed
in nown syndrome." The -dete(:tion.rate vr.1tb fir~t
. They .found out that the best iesulta were
~;nimesta- biochemical screerungis
Sitnnar tO-the.
ob~ed .wh~n w:om~ .had.-c:om~ i ~ 2 114
second trUnestet, appndmately no trimester scteening;.. the tully m~~ '-I1d
pe'l'Ceilt With
a posiij:ve scree.ning .mte o! S%. ._ ~ m\.\1-ti~ter . then und~twent def~tive 'testiJ:lg it the n=sult -was
21

study of 851~ . patients With aing\tton 'pregnancies positive_. this test ,jielc:ied .a DoW!l ~drome
in the US ( BUN Study_) .de:monstrate:~ that detection rate of 90% a.nd a scre.en pc~tive rate
(:Oml)mip:g .fir.St trlm.~stet mii:te~nal s:C'!'um - of '5.4%. . . . ..
~er~~Jrin~- Jiiarker~ with -n1.1~hal tran3_l\l~cJ1~
~~1,1~ent b~. a goOQ; -~tem~tive to second -Ct~Wtt Recommeittfati~ns:
trit.&iet,ter. :~g~ _'f}le :de~tion late tor -1;)6wn . . . .
~e'W1l-- U8.7-:pei."~nti{9$%: ' Cl::66;~'-88.,H . :'l1)e current repo~enda,qon9fA0G*!' . ~d
at,;a,'~t~ff~~~r-t:Z70'~Wi,tl(i\!VP$i~tdrtg.' ---, NiC~'~ts1lia.t:all.1p~t.:~~~'or'-'"' .
rate or s pe~t?9 -
. . . : . "_.-,. -
.

. . thm!lte'olfere-daereening"or.'llP91n~
-~ Fuiiyintegrated i~-:ll}l2,..,triin~ter.~in_g :i~-
. J~ii.St ttil1te:$ ler .se.r~ellin:g _qsin:g ..n\l~.h"-1 . tht.:.~st-.~sitive.wit.ldow1", faboej)()~. r:a~

~ f~~J:~~- :!- . :. ~ ~~~~t:;::-:::~~=t4}=~~~---

.::~:~d~~b~;~~~: 8

ge~tiltio.nW .
p~~-Gf'~~~8;ney:-.as'Weite.a.- ,, _prep~t::,l'l.Qmen~-w.nert fini-Chat~ :tr~l,ieency~
tri!e: ...,
p~ pro~a lih.:~ :~.n:i~ble deteet:lo~- tat~s Jne&#UfeJnent .. is . not av.ailable or cannot be
an<lltl.~J ~te'IJ. for lm,wn ..sjn4.n>tnt: a:s o.b~ed.
. ~~-~s:eeAir\g:.u..mg.-'th&-.ftuadt:uple ....
.-~.;..(w.pha_ -~J~toprot~bl.
. : _,..- R
_,..HGG.-u. n.~n-i~ga_ted --
...~-- Ult;n.so~d Sc_ree.n mg
estriol and iri}-.:ibin ~A).The fCCnUy .completed
t-! ' "

Seni.m Urme and U-ltta$0\ind. s~reening S.tu(\y

~ (SURUSS St:u:dy) ;in :the OK sugge~ts that
mt;.~grated- screening te.-g. - 'combii\~4 .n.r-st 8.:1Jd .
$~pnd ttinle$tet scre~hlnt)_ .iS the m9.~t sen.S.itiv.e
:and . cost -tffective ':t~:Si~ 30 - Thi$ :fin.din, w.a:s
<:b~e4 by -~e FA.ST~R {Fitst. :and Se~ond
Tril;nesterEvat~ation ofRisk) Ti"Uit:)l :T his NtCflb-
sp'on~ted trial -included 33;557 woQ:ten. 'They
evaluated 's qeen :pc.sitive ~rt detectiort _rates for
the folloWing:--
1. Stepwise sequential screening - wherein
:women determined to be :high risk -(Down
. syndrome .abov.e the predetermined .c\ltoff)
fi{ter the tat :trirn.ester .screen , ~re offered
gene.tic 'couns~ling and the option of
invas.i ve diagnostic testing and . women
bel:ow _the cut-~f( ~re _offered . --~eco:nd
trimest~r : screening.
Nuchil Thanslucencri Measurement
h1h.is-~(}estrlption:ofth~ sYndroriu:which
bears his name ,tangdon Down -d~bed lhtlt in
these fe~ses "the skin appeani wo ~- for the
bOdy"' .3 This was particularly notiCeable in the
neck are~. The skirt in the fetal neck-can be seen
by ultrasound as an ech:o free ar.e a at :tbe:b ack oi
the fetal neck. :(Figure 19.4) Although its precise
etiology: ..- an<;l_prognosis 1$ unknown_. nW:hal
translucency is believed 't o rep_ reseilt one ci:id of
the specti;u:m .of lymphatic ob~tructlon sequ~nce .
The optimal gestational age .for ,mea$'\l~~I}t qf
. NT is n + 0 weeks to 13+6 weeks which
corresponds to ,a .CRL of 45-84 .timi. ~~lower
g-e stational -.age- lini-i.t . allows . for .sufficient
_e_ptbey.o nal development .to -dete~t .mo~~ . m_a jor
anatorirleal d efects. In addi-ti9n , .Cv$ be_for~ 10

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 CHAPTER 19: .PRENATAL DIAGNOSIS AND INVASIVE TECHNIQUES TO MONITOR THE FETUS ''311

we<""-ks was.associated with t ransverse limb defects, quality control programs, should be dC'flleloped
so NT ~tween 11 - 13+6 w~ks gestation provides before this techniques .can be used in the-,::neral
risk assessment at a gestation where invasive population.40 Strategies restricting assessment of.
tasting .can be immediately offered. ~ s NT 3 3
nasal bone to a subset of pregnant wo::na at the
iflcreases with gestational -age hence a single cut- highest risk after 1 trimester combLed sauning,
off value should not be defined as abncnnal. The rather than the e ntire population appear to be
largest prospective study examining the more practical and are currently bei.ng
assoCiation betwe.e n i_ncr eased . NT and investigated.
cbrwnotnal abno.nn:ilitie~ was done by th.e Fetal
Medicine Found~.tion in the UK.36 It involved . Second Trimes ter Soft Markers
1(>0,311 sing!e;ns nnd wa3 done in 22 centers.
NT was more than the 9~t11 percentile in more tJ:lan Sixteen potential second trimester soft .
70 percent Qf fetuses with 1)i$0my 21. The risk of m~kers for fetal ane'Uploidy has recently. been
Down syndrome was calcUlated by maternal aric:i reviewed .41 Orily five markers are considered
gestational age _preYalence multiplied by the useful mthe evaluation for fetal aneuplo~at the
likelih(IO(ixatio. A cut-off of 1:300 was used. time ofscreeni...-.g ultr asound done at 16-:'20-.eeks.
Increase d nuchal fold, echogenic boWd. mild
ventric'ulomegaly. echbgenic ted ~ ihe ~ and
chotpids plexus cysts are associ~J~ with .
increased rfskof aneuploidy. Choroid plemacysts
. ar~ only associ2.ted with trisomy 1&: t\Ild in ..tbis
circumstance, adjustment shouid.~pp,l~ :~~de ..
for..this .: s pecific .r isk._-: The. marker&,elin~#.l.Yi
short humerus, short femur. and)1YP.O~c,:,_or
absent nasal bon:e are all as8ociated ~-with
. aneuploidy :but eho'uld be used in a tert:i&.TI~vel
ultrasound or in research .tenters.- The.:eV8luauon
for.. short/'long:bones:.is>not' part cf .fhet~g ; ..
process and the imaging for clin~~Y~.ttJle
nasal bone are not established-as a -standaidcpart .
of the 16 to 20 week scan. Three other :.rkers-
~i!t~C? .~~~ill~-~~. ~~~ --g~~~
~tDD.l.Milhlcbal.n.:ensluscencyfuickness..~-!daptedfr.om ~4 .PY~!~~~~i~- ..9.9 J:)...9t . hzy~. .a. _w~U . eAtabtished
www.med~.com). association with aneuP.lQjdy when seen in
i:s,olation. It should not ~-uSed to adju:rttbe risk
when no .other ri~k factors exist. Howewr. the
Ncrit -~lW:ttion .of. the Nasal Bone presence of these markers hav~ other potential
... pennate.! un.piic~tions hence should rtond,heiess
Studies in tile .h igh nsk pop-glativn bdieate a be reported. FoUr markers - brachycephal,r, ilia:c
t. of
high rate of nou'-visualization fue na$81 bane In angle, ~ar length and sandal gap sign: .re not
fetuses with Down syndrome. Three European. established markers for screening of the l?w risk
studies report;ed a 66.7% - 80% Down synqrome pop~lati<?n and should not be ,evaluated ocept i.il
dete~tion rate at a .02 - 1.4% false positive the research setting.
mte.36-35' Howevet, its value a s a screehi.rH~ test in
the general p.opulatjop ha~ .r.e mairie.d A major limitation of the use of 2nc1 mmester
controversial A ltr$t trim!!s ter. study performed in ultrasonogra phic markers has been the lack of
th~ US did notfi.nd it usefuL31 In addition, there standard~t.i.on in measurement and ddioitions
are co.nsi.9.era.b le .e thnic differences in. the of what constitute abnormal findings. 'Dris -has
prevalence of absent nasal bone. Its absence in a contributed to . vadability in the diapostic
.euploid fetus is found only in 2.8 percent of performance reported by different groti.~
. -~
Caucasians, compared with 6.8 percent of As.ians ~
and 10.4 percentofAfro-" Caribbeans.39 It,has been The current recommendation is _th~ the .
~uggested tha t standardization of n'a sal b one event that multiple (>2) markers are jdcitified;
assessment 3.long with extensive teaching a nd patients s hould b e r e ferred for confinna ti<;>ri,

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312 . SECTION Ill: CLINICAL APPROACH TO PREGNANCY

counseling and possible "further investigation.
These iridiVi4ual marke.rs function independently
however when ciuste~d together m~y convey an
even greater risk. This is also trUe for markers
that do i).Ot h-ave statistically significant
association with
. aneuploidy when seen in . recommended. If the. procedure is urisu~
isolation.
DIAGNQS1'IC TECHNIQUES.
Second Trimester Amnlocenteds
.. . operator- experience.
Atnnioce.ntesis is an wtrasound invasive
prenatal :~ostic pr9eedure usually performed
at 14-:20 , ~. Thro:u.gh the years, a m:,un.b er o(
multicenter'StUdi~$ have contmnecl its $a!etv and
its more -~ -9-9.%. 4~~osijc ~ccu,r~cy in D~W:n's
svndroiJiC. 42':4S the tWO lll(>S.t coD:u:non tests
per:{(;)-,:mtd :on ~b.e a.~nio_tic Quid .are fetal
kary,;;.typjng ifroJl1 !eta) ~d . ~em.l;>ranc;-..ceUs a:fter
tissue culturing or .diTe.e t fluo.res~~nt insitt1
hybridization (Flsa) .a nd Ul.e dn-eet measure~ent
-of:~~- R~$ll~ ea,n,g~ernUy.;~,ob~~d..poQr"tQ: . .
th~ 20: ~kge~tionalage. ,: ~ete_tal Jciu-yo~
wi)l.u sually Wke .l ."to :3 weeks. fiein the ;tUne: of
ammo<:e);l~esi!i 4epen~iing c:;m the CYt,Pgen.~ti~.
l~boratory. The.. -~aJQr . di~advant:a.ge. .oi
.attu'rl~.C.en.~~ii. ;ts.~~t: ;the.! r~.S;l.l;lt~ ,_o,f, pFe~ritHaJ ,:. eoiupli~~nv'.ar~ es~at,~ ~ :~\Jt..hi: t10" ~<,
~osis !i1not.avell~ble .u~~'. l1 . to .20 Y,.eeks - p~f~nt.::.ot;':proce<iu.-~'~:,~ma-.iilt'.e{ g~n~ ~; ;
.ges~tio~~-'i!.ge~ , ,- ..,. ' ' " ' ' -' -. ' lliriltediso' ' .
~~r.t:.
Baseliri~ u1tra~~d s::~ is perf~rined prior
to the proce.d1,1r.e . The needle insertion site Js
identifi~d ~nd .avoidance of .th~ placenta fs
.recomm~nd~. However, ifa clear pool of a,.roniotic
fluid .c an:\>(reached only by passa,ge tl)rough.ihe
.p~nta then thi~ is-the approach of choie. It is
.essential. that tl:le ,rteedle be pl,ac~d through the
thinnstavailable pcu-t of the placenta. Three larg~
studies :hwolving over 2000 cases have not
demonstrated .any increase in
miscarria,ge When
this approach ~s been used.~4__.6 Strict antisepsis
technique is .done. Use. of local anesthes.ia is n ot
g~nerally.necessa.,ry. The procedure is u su ally
perfon~ed '!lsi.ng a .2 0-22 gauge. s.pinal need.le
using 8. a4'tgl~ co.ntinuous movement of the ne~dle
through the abdominal and uterine wall unqer
ultrasound gUidance.The initial 1 to :2 ml
of fluid
aspirate may"beeont.aminated with.maternal celis,
so that it is either discarded or u sed for amniotic
fluid AFP.m easurement. Anothe r ~o m1 or:nuid is
..
removed . The amniotic fluid is similat in
appearance to dilute urine. The preSence of
discolored fluid on ~ocentesis is aSSOciated
with an increased risk of pregnancy loss.3~ No more
than two uterine needle insertions are
furtl1er attempts can be made with a delay of at
least 24 hours. After the procedure, the patient is
observed for bleeding and hooked to a feW
moriit<ir. The inCidence of bl()O(iy taps, ai:nniotie
nu:id leakage and multiple .puncture is related to
COmpliCations related to th~ -procedure ar.e
reiative.Iy infrequent but they do occur. The
pregnancy loss tate is usuaJly . quoted a a 1.
percent.47... 8 The risk of i..UecUon. introduced at
the ~e of-anuUOqentesis j~ e$funated t,o Qc: Jess
than 0.- rpe~"lt .. <:>r l to 2:in ,3~.p~~:t~
Seric:>us. feta'i.tnJun~:t:~e 'Ulti~of.~~~
arc .rare
Witb toritirfuous ultmSQ"(md gUldaiJ.oe.
smau $lQ.ri :<Htnplirig .l$i(:,ns 'ha~e :~.:repcrt.cd
. foU~lff~P~- Q.r ~ tetus :a:n:d .the~~ .wt
th~_se are:, ;g~nerany: ntmbii~,i~d .-~~ . ,1J~~- ;
an.atomje.l~tion m~y -,l:iea c!Slderatiort :~
c~mplicatiort$ inchid~-le~~.:of::~oti~
b'lee.tl.J~g. :.: ~nd : u~et"i.ne ltt~t$:bllity,;. T.b;e.~c.
: .,
:' .. . .
: ..
: . ~ .
This proeedtlre is done in the first triineater
befo;:-e 14 weeks (11+6 to 13+6 weeks).
The technique is the same as 2,.. t:ritneater
amni~nte.sis, although if done before the fusiOn
of. the membranes .to the.uterine w;ill, the punctu.re
of the sac tn:ay be more -difficult and lesser flqid
are draWn. .
The enthusiasm to do e arly amniocentesis
stemmed from the fact that the earliest~
available for pr ertataldiagnosis which is chorionic
villus Sai,npling has several-disadvantages, namely,-
absence of AFP. and plaeeiltal rnosaicsm testing
and increased incidence .o{ maternal- cell
contaminatioii Early obs.el"Vationaf-studies were
not.able to identify the risks of thep~ure.: :Aftd
a series or randomized controlled :t rials, the true
risks. were identified, Th.e Canadian Early and Mid
-Trimester Amn:ipcentesis Triat Grpup ~ reported 4

collect ed fo.r fetal ka,ryotyping . and

the needle is a spontaneous abortion rate following early

Scanned lly: C
 CHAPTER 19: PRENATAL :DIAGNOSIS AND.INvASIVE TECHNIQUES TO MONITOR THE FETUS : "'313
----~--------~----~~----~--~----------~~~--------

.~
' amniocentesis to be 2.5 percent compared with . .
t that of0.7 percent after traditionahunnioeentesis.
~- The Italian Single Center Study reported a
miscarrla.ge rate of 0.4% artd0.3%, ~vcly. 111
in the recently reported RCf by L'le NICHD Early
.Alnnioeentesis Trial Group, where women were
rando11Uzed to either e.arly amniocentesis \'s.
,c horionic vmus sampling at 11 - 14 weeks, the
1.. -spo~taneouS lOS$. rate befo~ 20 weeks w.a s 0.'9
~- and 1.5%, reiipectively~~a The othe early
r. amniocentesis rl$ks identified in these -s!:'.ldies
inClude a31de fro_m .higher totl\lpregnancy Ios.s is .
~ a signuicant ~erea~ .pf musc\lloekeletal foot
defonmty mere a sed
culture f lillure tate. d .an
increase post-amniocentesis rate of leakage
compared-to the traditional ,amniocentesis group.

1'hree recent :reviews evaluated :early

amniocente~is com~ with CVs . These meta
a nalysis .concluded that~ly amniocentesis is ........ -~- . :

assoflilt~~- with a greater risk of 5;p0ntaneous

miscatrl~e and neo:p.atal talipes CQ.mpared to
'!
.
... ,:'.
."

CVS.~~:'the Ca.~ Stu<ty Group also found

. . .. . .f:-:~: :<~d~~;t.
Fipre 19.4. Trtinscervical chorionic .vo~us :a8%;piipg
. that merilbl:ane" :tupture mmost likely.after early (Adapted .:frt)m William's bbstetris 2 2nd t:d:i:roosi.;._~~~
annnocet'l;te&is and that the inciQence of talipes
w~re~, l~~perc~nt in cas-es with ea.d y post-
~utiil. leakagc:4, Sin~ ollgohydtwnnios was
.i

. . : ~:.~._+.:.. .,~ F-:-~, :i

t:ranai~an ritost-~ at least'~lrle -of the foot
defo!irrltie"~'"more likely Te~ted from damage to
the vascular supplY of the developing limb, !ather
than from compression effect of the
oligohydr"am._nios. J:)~e ~Q !P.:~~~..~.~P..~~lj.C?!1~ ..
i~. tri~~y c#f~~ ~~ lon~tP.t:t.?fe.I' !-Q_t:l_C?.?JJH?i~nte.~i.s
before 14 weeks.
~
if Chorionic Villus sa-.pUng
f discomt:ort or cramps.~
CVS is the most common first trimester
invasive pren.atal diagn.ostic technique for
evaluation of fetal ka.tyotype and molecUlar.and
biochemicai abnorm.alliies. CVS is an ultrasound
JWiqed teehnique .that utilize.s either a catheter
(.tr~nscervical . meth()d.) '?r a spinal ~needle
(transabdominal )nethod). to ~et samples .of
placen4ll tissue,it ~s l,lSJ!ally ~ifontJed 4:1 the 1ot
trimester between, 10 to 13.:t6 weeks gestation.
Although the procedure was Initially deVeloped as
a transcervical technique, both transabdominal
and.transcervical techniques are currently in use
depending-on the route which allows easy access
to the placenta {Figurel9.4). In contrast to
amniocentesis, which obtains amniotic fluid, cvs
obtains chorionic .tissue from the developing
placenta.. Relative contraindications include
vagiMJ. :bleeding .or . spo'ttmg.~ctive {g~~t~ct
infection ~eme uterine ante or
retrof)exion,
body habitus preventing -easy a~3:
..lmtb.:tran~~...and.transter.vk:a.LCVS
.have .similar_accumcy_.:The...transcemca,L cvs . is
associated with a greate :r isk of post procedural
spotting or Jl).in:imal bleeding (10~20%) while
transabdominal CVS bas h1crease ute.r ine
Infection has not been identified as a
significant factor in a large number of patients
haVing transcervical CVS.
Several RCT's and case control trlals have
c~mpared .t;he ~afety of cys with eax:ly and
midtrimester ai:Il.niocentesis as well .as the -'s afety
of transabdoJI1inal and transcerviciU CVS. Wald
( 1998) and colleagues summarized eight RCT's and
found that :TCCVS has .a procedure .relat,.ed fetal
death rate of 3.7% greater than either 'i.ACVS or
traditional ~ruocentesis. 56 The rate is~.knllar to
that of e arly amniocente_s i.s. Alfiveri~ (2003)
concluded in their review of .14 RB~s that
. . "' .
m1dtritnester amniocentesis was sruerthan either
transcerviGal CVS or early amniocentesis. 53

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 (
SECTION 111: q.JNlCAL'APPROACH TO PREGNANCY

Advantages of CVS:
The . major :advantage. is .th:a:t the results are
obUJ,inecl.:at an eaqkr age :of gesta:t:iQn. Sei:Ondly,
speci,fic melecular ~<n>is with'DNA is extracted
directly: from. the villi, allowin-g .eailier result
without eeil culw.re far these g~etic. disorders.
Thirdly, ~ ~hromosot:n:a1. ~Slt3 :may be used
41 ertain. siwations:for. -rapid .results l~s than m:
24 h outs by e~th~r. cytogenetic or JJuoi:escent
hybric:lif.ati.on tecll,hiq~e {FISH}.
Disadvantages an_.d:-Risk~ .9f. CVS:
a.) Confmed :PJa~ent?J. MQsaici~ .._ the:dmgO.ostic
accuracy Gf .CVS for this disatder .i's lillrlted
a
be<>ause Ulore is --discre~cy ~~-~n the
m
ehrornpsem~ theChotjo.tiio $.d-l'eta1.1ism\es.
.This bio1pgi6 plaep.Ml.fci.ctor :i~ :preseiit iri...I' to
2percent of :P.regnancies.5o this:Iip.dmg is
usurciy tin:ri.t.~4 to the .p~tal tissue and is
u::iu~:; ngt.;.;pr-esc;n;t-.-in.~.ttle-4'etu.s;...;AddiUonalr. ..
am;;"ioeentesis.:sl'ioU!aia;e~:-o:f!er.di'--for:;fu.tt'1er '' ..
-~uition"~d:; t:hl:~:.nl;a_y.:M,~~~~ p~an.GY''<
. compli~tion ris~(>; . : .
d.) L.imb ot Facial Anomalies -the risk for limb -or
fac;ial anomalies .is higher :if CVS is done. at a
gestational s.ge <rlier t..lJ.an. 9 weeks. ~ 1 The
mechanislll mo.st frequently suggested is
transient fet~hypoperfusion and. uteroS:pasti~
phenomenon. second~ to vascular dis.tuption
to the pla~e.ntal circulation . .However, .w hen
CVS is performed after 9 ~eelrs the inciqence
oflimb-r:edu.ction d;ef~ts ~m,~. t~.~ no.lll.gber
than in the genez:al popwapo.q.-~
Pr.cuta&coua UP;tbll!<;al .~!<>od .Sampling (Other
N~~>! ~etal :B lood Sam~~: Cord9een~s'l!:,
an~ ~nlcUlocentesis~) .{Figure 1"9 .S) .
Lt is an ultrasound ~guided p~oced\rre .that is
use<;! t,o get samples of fetal blood through the
umbilical cord.
........
.

p.) M~te~ .Cop.tamin~titin. ~.on~~~on,~bj, .. :

:~~trii#::tleci<hi ~rfiss!,le:ica,wS8~b~~~bQ;t.i!ii's ., . . . .. . .. ;--,......:..:::::.......,,__'--, ..
i>OttD:ti81.ptoJ;leni~aan::be'n1in~mJ;;e!i";;..th~el',~ .. . A ..
cate:f\ll:it.ttentfon: .to .cl.~g a pd stripping pf
_th_e_.:.Qh.Qtlgn!~yi}..],L:Q!.:m,.aternhl decidu~ ~g~
.:.u:nd.et,..,.d.it:ec.Lm.i~,r;:_o.AQ:P.Y.. .Pl.:t.9.f... ~.9.. !-].~~-~ ~ .
. . . teSting:

.c~Y Pregnancy ~Los:;;- t h.e risk of.Pr~c}r Joss in

the advanced r!laternal age ..grop.:p after
a
.. :copP.rmation of ;..iable pregnancy eveh with
no procedure undeitakeni.s 2 to 3 petc~nt.
Th~ ~IS :proeeciw::e pregrtfUJ.ey.lo.s s rate is l to ...
.2 perent a:'OO:ve :th,e .backgro~d com:pa,iison. B
Vaginal bleeding -. occurring prior to the
p~ocedure ipc rea ses the riskof.pte'gmmcy loss Figure 19:5. j.Jm bilical cord ;;a.:mp ling. Access tothe
. folloWing :c.vs 'b y either to :lite. :Ptegnapcy Joss umbili~ artery or
vej.i1. '~>:aries, d epen ding On botli the
likeWi~ increase~ with :the nuni"9er of attern:pts
of
placental location and the position the .toni iitserticininto
the p~centa. A. 'with an an tenor placr:nta. thenecille may
neetl'ed:.to obtl'liitl the chorionic tissue and transverse the pl<l.c erita B. 'With-w steriod mplantation, the
shouiii be liro.ii:e.d :to two attempts~50 :uterine needle.usually pa.s~~~.t,R..e.arirniotic fluid before penetrating ..
: factor-s suph . .1\l.s p.re~ence tif fib:rolds a:nd an 1,J.mbi).ical v.e ssd (i?:dapted'from William~s Obstetrics 22nd
plaeen~l0at:i;on.may...cause. so:me::ad~tional _ed., 2005): . .
. __piocedt1raf risk factors deperu:liQ.g. on CVS
technique-used.. Prevj.ously,. it wa.s thought that lnqications:
. tianscervkal cvs .had two t:iiDe"s .the nsk:for
pregnaney:ioss lh~ .e..Jransibdominal ro.ute. . .L Cytogeneti Oiagno!:>~s:
More recent r~,Ports demonstrate that .they
h ave similar ra:tes.~-sa. a ,) Heritable .Dis.eases

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 CHAPTER 19: PRENATAL DIAGNOSIS AND INVASIVE TECHNIQUES TO MONITOR THE FETUS
b.; When there is a fetal structural anomaly
since the incidence of -chrotnosomal
.~ abnormalities.1s 12 p:ercent in fetuses with
. ~
isolated structural anomaly and 29 percent
: .
in fetuse~ with m~tiple ant>malies. .
c.) To obtain fetal blood cells when CVS ail.d
amniocentesis results are conflicting or
w.hen rapi_d diagnosis is neceesary. ~ince
rapid kazyotyping of fetal blood cells Can
,,,. be accomplished within 24 to 48 hours.
;.
!i2. Diagnosis of Fetal Infection~ it is useful in the
i
f. . pre~ce of fetal hydrops followjr~g parvoyirus
infection. which i~ usually caused by severe
aneillia :but has limited role in t.'le diagnosis
of (X)llgenital infections such as toxoplasmosis,
rubella, cytomegalovirus, varicella, and
~.
syphilis. A.nullocentesis is the prlinary tOQl to
..$'
diagnose retal infection beeatlse the PCR
'iechnique a:n(l the traditional inicro))iology
techniques allow isolation of the infectious
agentin. amniotic, ascetic and pleural fluid
i
a.. witht>ut'the need to acce.s s fetal blood.
f allow asy access to biops-y sitd.~~a:i.fh.e
~. 3. DiagQOsis of Coagulopathies e.g. Von Will .
1 bnm,ds::Pisease-arid
. . . ..:
~. ' ~
Hemophilia
.. . .- .. .
:
..
4.:' ;~Pl~tele"t Dlso'rd.ers -:-.useful in p i-ena tal'
~gnbsis .and filanagement of immun~logic
throm~openia
~ .
5. F.etaLTherapy ~ for re.tal anemia or in .utero
platelet .transfusion.
Complications;
~~ure related maternal complications are
0 unusual. The most common 'Complications 'which
; occur in .SO percent of cases is bleeding from the
i
I
.
puncture s.ite, cord hem atoma (17%)is less
common <U}d asymptomatic but can be associated
with fetal bradycardia (3-12%), Expectant
management is recommended when there is a
reas~uring fetal monitoring and a non-expanding
bsm~tomaiThe most important risk factor for
proeedurirretatedloss 'inducf~:e:per,atot' e,cpeiierice
and indicat.ion for the proceciure. The risk for fetal
loss is suqstaf}tially higher in the presence offetai
pathology such as iUGR or non-immune hydrops.
Fetal Tiss:u~..B~cpsy
With adyances in technology there has been a
trend to shift away from the need for.tissue specific
Scanned By:
'315
diagnosis to those that can be accomplished by
DNA technologies. Only a few of the serious
dermatologic disorders are associated with
chromosomal abnormalities or enzyme ddects that
can be det'!Cted in amniotic fluid or villL Ther<":
are also many genetic disorder for which only a
tissue specific histological or . histochemical
examination o f the tissue will proVi(:le accurate
prenatal dia,gnosts. Furthermore .in the majority
of serious cutaneous ~bno~alities ultrasonic
visualization is uselc~ Actual visua:liz'ation of
the slcin an~ hlsto1ogy are the only ways to make
such a diagnosis.
. .
Skiri biopsie~ can be obtained in two .ways:63
.a.) US guidanc~ - .origin.ally a blind,procedute, a
t.eeently m.(!)difi~ ,approach includesobWnl.tig
percutan'et>us U.ltr,asound guided r~ta.t $kin
biopsies uslng a fine neee. ~.sten;l .or 'by the
- 'use .cf.a. core'biopsy needle. ... , . .
b) Under diiect.Visuat.ization by.aietoscJ)e\~1:he
site and entry of the fetosrope is' cb~':tc
back, thigh or fetal setu'p. Fetalskinbiopsies
have . h~en . o~tained by fetoscqpic, me_thod
'which.~e-~ a 2-5% risk C)f~.:-~e
:sigriificttnta;dva.iit.age:()f:.this-tecnmque!~~tt>:at
the S pecimen caD be Obtainedltif\:.the/Slfe:i(>f
obvious pathology.
Hereditary diseases such as cystic fibrosis,
sickle cell diseases and thala,ssemias can be
diagnosed prior to implantation and this is
pos$ible through L~e identification of the genes
responsible for certain severe hered.itaxy diseases
and in vitro fertilization .techniques. .As a result, it
is only the. healthy embryos that are selected for
implantation. Several variation in the technique
has been reporte~ either by using. the first and
second polar bodies or by usirig the three day old
embryo at the 6-10 cell ~tage. 1 This technique is
currently investigational.
Fetal Cetls in the Maternal Circulation
One of the most pro.mising means fbr
developing a non .invasive methOd for,w.:-enatal
diagt)osis i~ the isolation of fetal .cells J:f9m the
blood of pregnant women ..'iri. the Je~flt!i990's,
there were reports that the detectioi:iof fetal
aneuploidy was possible using fetal erythroblasts
~
 /

.f
316

derived from pregnant women. They focused on
cell -sopmg techniques which take advan,tag~ of
unitj_ue cell- s\lrf'ace ,proteins and other
chat:acteristks that distinguish materruU from fetal
cells. These teclm,iqu?s include densi.t y g raOient
or pro~in s~.partition, fluorescent activated cell
sorting .{:f.ACS). an# . .m~tgnetic c:ell so.rtir;.g
{MACS):~These ,results care .so :~<;our~gifig that
the .Na:~nal:inst;itute Jo.r . Child Healt.q,~dD.ISC'~
w43 prompj:ed .t(,- inltiate a l~.ge. ~e trial ('the
mcHD Fetal:ell lsoiation Si:Udy) to ~ t,he
feasibility ofusing !etal:c~lls ,from .mat~m,nl plood
for G.~tion <>f fetal aneuploi9.Y The prd:iminary
r~~~t.S from. this s~dy .indicated that there ate
s.ign:i.fu;:aritly lower -false J>o.~i~ve rates wit.;. Uiis
:technique f~r detection of fe~ .aneuploidies _.t han
curren:t nominvasive ~rum. marker:$..'(ti However.
~.~erii pt~bi~ni~ mu~.t be .rC.s6.1ve4 befqr~ thi~
. t~que ~ be .UseP . ~~y. tl..~t, there is
difficultyin isoffi:tion.of'~tnet;).t ampt)i\tof ~lis.
:second, ~ puricy:~'fthe~pl:t:nust::}?e ~ured.
Lastly,, th~ 'is in.cefiP:ite:persiste.~e:e, :pf.fetal
1Ytnp1roc~s-:oi:st~~. .,c~JJ~:,inJ tn~ ~at~rnat~
.cireuiati;Qn :.so... that :,tb~r.e: .,l,s. di:ffi-g:lty in .
-;. .. de:te.~oon .wheU!e.r: .the..1f~ll~ ! ~ fr-Q-IP: ;t he
'for_p~~ta,l' diag:r1osi.s
._.
is st;ill in its infancy and this is beeau$e of the
'following reisons:
a.) S9-eioecon? mic ~ the CO~ts of prenatal
diagnostic testing .a re so prohibitive to be
afforded by the general population.
b.) .$,t rict.teligious and moral valu.e:s "'"'manY.of the
patients fed that 'lm~:>wirig 'Whet;her they have
.an abnormal baby is useless since terro.ination
.of p.tegnanc y is not an optimi in a
ptedom.illantly Catholic c6urtttY.
c.) Poor awareness n the existence ana utillty of
such ~r.Vices..
d .) Lack of t.r.ned ~r:Sonn1. whQ .. are aAq>t..in
pet.!~~~ the :im.~a~ve . procedm-es..:i:JuYc#ty
. of'the ,t nilned ~iali;;:ts.. IU'~ eoncmtra.~ in
the .:National C?,'Pital ,Region .at).d ,:qnly in the
.'tr---..i.t:Ung.-:ce~ter<>.
.~tly. ~e .met1;r9~i th~.t .. is w.id1Y .U:tlliZed.

~nt~or-;.pi'e'iioi.ts:.ptegw.mcies. . . . 'i:n..t he :Philippiiie:ffi,tl;le:use ,

:. : , : '.. . of W,tra$ound to ide"Q.tifY .congenital ~kfec;ts; Its .
STATtts::~F-:;pREN~'f-,1\t,DJAGNOS.IS~.;m ::=im; . ~ ~c~e~ilit.Y .pt~$ from~~ ~U!.~ thiit ~- i,s:npn- ... .
PRJLIPP.INES::.; ... ' .. . : .. .... . ... .... .. mva.slye:and ..ea.sllY.: a,~J.,em,. oth~~ns,hnd
this. is bci::a:Qs .of the in.crease in =xn.ixnber of
Prenatai qiageosis using :g~~tic testing .and .obstetric and
i:Yn~logie .so:nb-l~gis~ ~to
il:J,~~~~:~~o.~~~Iee~ii.e'$]Ii '~~ f:'liJrij?'pm~s do -coii~eru,urr Sf!ln'ii'$.~:~
't

H.QINTS TO ~EMEMBER,

Prenatal~goosjs.isthe;S'~ pf iQehtif-J.ihg. ~trucbJra!.~odJun~na.l .aboorm~:ities. of.the developing

fetUs

The .goal pf scteeniog t~st 'is t0 defin e the fisk of disease in .an a~ymptom~tic .loW risk populat.io{),
whit~ diagno$:tle: testing .:is to cdiiftrrn or identify the lrid.i'lldl.tal Wit!:~ di~e.a.se c

Sensitivity is defir\e1 as th~ t>ercentage pf people with 'the disease .that was identified 'by .the test,
while specificity is the p-ercentageof p~tientS who do not have the disease that tested neg.ative f.ot
the \es~ . .:.. .. . . .. . . - ~ - - ....,. .

Positive Predictive. Value is pe rcenta gs qf pa?~ nts that ms. po:siti\;'e [Qr. th f; tesftlwt a.ct\l<?Jiy h av~ the
di~a$e,while.Negative Pre<Jietive Value is the perceritageof patients.that-has negative t~Htiat do a
l not.have the d.isease:
1
CongenH.qt.h~art d~fects ire the most. :Comrnon struc.tur;:~l, defects occurring .in approximately .8 in
1000 liv.e neonat~,s. . .

Snanned 8y: C
 CHAPTER 19: PRENATAL DIAGNOSIS AND INVASIVE TECHNIQUES TO MONITOR THEF:ETUS
----------....:...------_...---:------------~--~~ .. .. . 317

Prenatal diagnosis for congenital heart defects Is usually done using fetal eohocardiography at 20-
22 weeks age of gestation, because at this age.of gestation, most of tne cardiac structures are well-
developeQ.
Neural tube clsfects are the Sewnd most common major congenital anomaly oceurring in 1.4-:2 per
1000 pregnancies.
I.
Scte.enlng for NTO's has two main steps: first, Maternal Serum Alpha Protein in the 2 r.1 trimester of
pregnancy, and second , ear1y diagnosis bfultrasound
AFP Jev~l$ are maximal in the feta! plasma at 12 - 13 weeks age of gestation, while peak
concentration$ of amniOtiC flUld AFP are .reached at 12-14 weeks gestation and steadily decfine
parallel to the fetal serum concentration.
. AFP pea~s In in the matempl serum at 28-3~ weeks gestation. This Increase in maternal
cOnCeObation
serum AFP levels when amnlotic al'ld fetal s.erum.levels are decreasing ls helieved to be accOunted
for by the .increasing placental permeability to fetal piasma prote!ns.
For:~ntng pOrposes. matemal serum AFP levels ~~ maasu~~d between 14-22 weeks g~station
when the increase is lin-ear. . . .
-.
AMSAFP re$i.iliof~2-2.~Mo~.1 for singte~on or 4.5.MoM for twins is.Considered abnonnally elevated
and Indicates the need fOr further testing. ., . .
. ' . . ' . , .;..;:it~ :~ ~; r '.ll"" .

The.Ai'nerican Go)lege of ()bsteitics and Gynecology recommends MSAFP screening be.offer'ediio;;.:_; .

all ;pr.egnant women in the 2M trimester. . .. .. .
'
. ,.~: !.~:
. . .l!JI .. .
,., ,.
"f~j:-!\~ .~~-_I .....

The traditional diagnostic test offered to women with a positive MSAFP test is arr!!iiocentesls wittY
- - . ;eVa!uatiqn of ~rnfliOlk: .fluid AF.P .and .acetYl chonn.:sterase. These two combined tests appear:-to be
- ~ ......'-.tt1e:most :sen$itive and :spaclfiC determination .for: NTD. . :.. ..
. ~ - J~ :~ hands of the experienced operator. ultrasonography alone h~s up to 9Jo/o se~~;t~: ~,~d~:t~:': .
100% speCificity in the -dia.gnosis of .NTD..
. . ..In...-~99% . __ -ca~.
,.,. ___.of or>~>.rt $plnat lesions are asSQdated .........with
---....c.---------~-1:::::. ....~...._ - ........ .. ___ . .. __ ,.~ - -~---" ... --___
one or more---of
-~-'""- --- -~ -- ----.--..... - ~ - --~--- - ths
.. - fiVe
- . SnPl"Jfic
.r.::.::"' ... ... cranial
.. -- ..
~.A.Q!J1.3.J~~ !h~t grJ~S!~tecte~ I?Y_ !!!!l:~~-Q!!'l~~-~:L~!!!~!L!?!~_d.~~l. (ji_al"!leter, b.) Ventri~!9.t.n~<,ify,
.o.) lemon.sigri, d.) Banana sign, e.) Compression ofthe cistern magna.
Many centers offer specia!!zed ultrasound examination initially in all high risk patients and perform
amniocentesis in ~ly a subset ~f patients..
For.Jethatanomalies management is limited,:roufine prenatal eareis given but no prenatal intervention
.for fetal Indications because they Will not change.the prognosis.. . . . . .
Delivery.atterrn ifpossible unless deterioration of fetal status is present that may prompt immediate
~~~ .

For breech presentation with NTD, cesarean section is the standard.

Fpr \'.e nex presentation, rnode of delivery is controversial. Decis.ions about the timing and route of
delivery should be made individually and in consolation with personnel with expertise and knowledge
ot-soeti complications .
The most ~rnmon second trimester screening protocol used is the Quadruple Screening Test (hCG.
Estriol MSAFP plus lnhibin A) . __
. . . . .
Th:e first tnm~ster scre!:!nlng for Down ~y_ndrome consists of Pregnancy Associated Protem wh1ch is
.. . . . . . ~

decr~ased .and Jree0:- HCG whith.ls rncreased.in Down syndrome. ~

. '&.<

Scanned By: ~
.318 SECnON Ill: CUNIC~L-APPR0ACH TO PREGNANCY
--------------~----~--~--~----~~------------------------~~--~~,

The .detection r~te of ftrSt trimester and second trimester screening is simil?r.

Frrst trimesterscreening using il11Chal translucency combined withfree a. HCG, and PregnancyAssoc.iated
Plasma Protelr. A has comparable detection rates forOown syndrome as s;:;cond trimestenireening
using QuadNP.le Screening. . .

Based O'ft an NlCHO-sponsored trial the best results for detection of Down syndrome were obtained
When WOmen l)~~(nbined 1.Sl.and 2ild.trimester screening (fUlly integrated test) and then:undeiVIent
diag~ ~tins if result ~s positive.
The Cllffent rscom11,1en~.at1~ Of the American Coilege of Obstetric.s and GY.neGQlogy and the National
Institute for.ClfniGCI -excetlen~e js tt;latall pregnant w6men, regardless.of their age are offered screening
tor Dcwn 5yndrome.
Fully inJegrated:.1c.and -2ndtiitn.e5ter SGret;ning is tl)e most s.e nsiwe with lqwer false positive rates than
first :ti:trne~r $Cre4nlng alone. However; 'S:erut"1l integratad screening Is .a :u!?eful option: mpregnant
women when nu.ctial'translqcency me~suremerit~ .. .
floi .available or can'not be 'obtained.- .
~

The~optimargestatipnal ;~ile .o f rneasur.ement Df nuchal tr:ansh,Jcency is (110} to (131::6) week~ .v/hich

.correspqnd~ :.t o a :CRL of
45:"84mm.The 'loWer gesta.tlonal age limit all~ for sufficient embty9nic
develOpment
. . io d~t~t
.
mcst
..
rna)or a.natomical defects. .......

: fhe,val~~ :Of iion..:vJ~u~H:Zationo(the nasal bone as a screening teit in the.genera{ :population 'fer 00wn
si{n<irom~ has-remaine9"c6ntrovers'.aL . '
.~ifVe $econd m~.e.~et.sbff:~~-e~ that are:con~iaeredti.$etut ih.th~ ~valuation forJf~talanetiptooy
. done.at 1~20 weeki art:: mcreased :nuchal fuid; eehog~hic b;Owel, -m:na ventnculoinega JY, ecn()genic
ioenn.meh~art:and tioroid plexus cysts.. . .

::A~?r,~titm,ot~e:~.~;Gi,f2~'f~eru1tfci~~9.9~e~.ic:n1afk~rs~c;ts:~the;t~:ck:6t$~hdar9lzation
':. -m:measur:ement':and
. .. defiiiitionsof what' eonstiruteabncn:nal
. :finain
.
gs. . .

The ctirrent
reeommendation is'th~t ln.the event of multiple rnafkers (>2-malkeis) are idenlified. patients
shJd be .referred for. confimatkm, counselirfg and possible further investigation.
..... --- . ,1..,... ............_... .--
- .

~ -- . . ... .
~

' -.1' .

.. .. . . .

.. .... ..... .... .

# ...

. . .. . . ..

. ..

. ... . .... .. . ' . - ., .

..

Amo!{>.cente.sisJ s.. an .u.lt(aso_und :invasive .,pf.enafaLiiiagnostic . tJcocedum.. usually ..perfOCJT}ed. ,at .1:4::20 . ~

weeks.
Tte-two mostccr::mion -tests ..Mrf9mi.ed for amrii.opc fluid are fetal karyotypjng and: djrect.measurement
ofAFP. .
. . .
.The .feiai'karyotype uSJJi311y ta.kes '1 tq 3 weel<s. from the time of .amn~ntesis depeooiog :ph the
cyt~netiC.Jaborat0ry. The: major ~is;id~fUlt'?@.e o{amnl~~ntesis is that the' re.sults -Qfp,renatah:liagr.osis
Is n.o.t available until 17'.;20 we.eks. ges~tin~l .age.
. .
P'regn~ncy 'loss rate wlth amniocentesis is i % and the Fi'Sk of inlection is estimatea to be less than
0.1%.
EarfY. amniocentesis is done in the first trimester before 14 weeks {11+6 to 13+6 weeks)
. Meta~analy$is shows thatearly. a~niocentesis is assix:iated ~ith a greater' risk of spontaneous niiscarri<Jge
~d. neonatal talipes compared with cvs. .. . . . .. : . . . .. ,\ ...
Foot deformities associate.d with e.a.rly, all)nioceQte~is most ljl<ely r.esulted fmm damage to the vascular
supply of the developiil .limb rather than fr{)m eompression effect of oti~ohydramn1os.
ChofioDic Villus Sampling is an~ltrasound-guided -technique . that utilizes either.a catheter (t(?~'scervical.
or
method) spina\need\e {1Jansabdomi~al [\1etho<;f) to get 5<imples of CQOJionrc tissue from the developing.
placenf4. ftis usually perforrried 'ln the fir~tlrihiester..belween 10 t'o~(t~6)'~eeks ge~tati6n~,~., ....

Scanned 8y: ~
 . CHAPTER 19: PR-ENATAL DIAGNOStSANO 1NVASIVE lECHNIQUES TO MONITOR THE FETuS 319

.- Mid trimester amniocentesis was -~er than either transceryiCal CVS <>r ear1y -amniocen~esis.
'The major advantage of CVS tS ,that :results.are Obtained at an ear1ier age of gestation Qnd rapid results
mc;~y be obtained.

Percutan~~us Umbilical 5100<! Sanipfing .is an ultrasound-guided procedure that Is used to get samples
of fetal blood through the ulllbilica( c6rd.
Most ~mmon
.
~mpliciltio~
.
associated. with 'PUB.S is ..bleeding from.the :puncture,.
.
site..
'

Majority of serious cutaneous disorders require actual visualization of the skin and histology to make a
diagnosis;
. Skin biopsiescan be cbtained 'by US guidante or by direct visuali2aUon by a fetoscope. .
: Pr.~lmpiC~ntation Genetic Oiagr.csis.ldentlfies the genes responsible for certain severe 'hereditary diseases
ai'ld as a rest,:!t, oniy the healthy embryo.s are selected for implantation.
. .
Isolation of fhe fetal cells from the blood of. pr~oant women -is being used -for the detection of fetal
~~ -- ~neuptoidy, h~wevercertaln problems must be- resolved t>efore this can be used <;linically.
lf .

:
)$.
t::
fl: . . _,;c . .

1 .
. i..:. :_ .9. EiwoydJU, Lime J. ElwOQ<l JH. (~s); ..~_plde.z.i#o,ogy

,'
f~- . . . .. ~C<>ntrol :lf~eural Tube Def~cts. -~w~. EJi8l~d:
1. Cupningbam ,F G; :L!::veno K. Bloo~ s. et 8L- Prenatal OXford University Pr~. 1992; 96-145:,. ' t"-~:.
~osia..and feta,! therapy. In; CiU:.nlpgham. ro; et
~ :(ed~):;William:$ O~tiics. '~ ~.UsA: Mc()raw- . .10. M#1l.Y lif, Wl;i.!~a$ P~ .et al. Die~.fc)~ , .,_nd
.. . '~ HillCOn:i~y, .:200S ,
~ ;,:-- :
- -- r:.o
. . . p~enc otmD-.iA ~..'1\ritish :itd~~t1$~.1ia.St1:two
d~e$,. Br J Obiitt Gyn~ol ~OOOft:07i '88S!.ag9; .
2, Jez:ikina.'I',:Wapnet.R. .Pteila~ diagnoSis of.(:OngCJlital
r -disOJ11ers. "In: Creasy:R. R~' R (eds): :Nateinal&.nd
:. ::.~- . ..

-tr
.I(
3.
F-etarM~4icit:l~. l?I-~:iple3 .an.4 J>I.~tke ~.... ed.
....n~.:'t"'"'"el
..-~-J~..
rua: was ~d eo 2'004
_: ~~
E.;ioorn~"J;~ecat--~cai~g
l!f"8 . ' .

.In: EYJmsM, Johnson M~ Y;~riY, et' ai. fed~): ITenatal

ll. ~J1, OhnoK, Ohtani K. et aL Epid~l~:o(~phm
bijj.4ai,.~'f()ttQri Pte~. J.4pan 1976-199&:.P ediatr
li~.Jf.Qtl~S;, 1.2;.1~.20.3.... .. '

{: . D~osia. USA; }.dCQ'raw.:lUD Co~. 20()6. .
"~> 4. Silverm~N. squcidt K. Uitntsci~devalUJ!tion of the
fetal hes.rt. In: .C~e.n P {e.;l): tr,ltri;lspnogt&;phy in
Obst.:itics and Gynecology 411a .td Philadelphia; WB
: S~..mders Co., 2QOO
5, .AJlan :1.. Crawford-De. Familial I'eC\ltTJ"...JlOC ofcOt:lgenital
.:.: heart disease in a prospective series ofmo.t hers J"Cfen-ed
for-fet&.l e<:hocardie>giaphy. A:n J Ce.rdiol1986; 58: S34.
6. Gill, et:al, l'attems of reau:rence -of CHD: An analysis
of 6640- con~cutive evaluation-by fetal echo~ .JAm Coil
. Cardiol2003; 42: '9 23.
12. Brock J;)J, -"S utclne -RG. Alpha - feto prote~ in the
anteriat91 .d!agncais -of spina hifida and aneuploidy.
Lancet 1972; ll: 197.
13. Schell Di, Drug<ul A, Brindley BA, et al. Coq1bining
ultrasonography and .a mniocentesis .f or pregnant
. w~men witq elevt\ted MSAFf: Reviewing the risk
estimate. .J Reprod Me~ 1'990; :jS: 543-546.
14. ~..o;t AG,.Hogda)e E, Larrer. SO, et .al. A comparison of
amniotic fl~id .alph!lfeto protein and
acetylcht:illnestetase in the prena tal ~agnosis of open
NtD &."ld .abdo~ wall defects. Prenat Diagn 1993;
13:93-109.

7. Stoll C, Game E, et al. EvaluaUon o[pr.enatal ~osis
of anociated .CHD by r etal ultntllonographic
examination in' Europe; Prenatal Dlag. 2004; !21 (4):
243-252. .
~~.:.t\CQ~ITII:ctie,e.J:t~etin..J~f;ur;d.-ltR}~ <J:elects. Clinical .
. Managem ent Guidelines for Obstetricians and
Gynecolog:sts. No. 44, JuJy2003.. :
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ka.Iyotyping.for:pa:tients undergoing an1niocentesis for
elevated MSA:FP. Am J Obstet Gyfiec9l1 Q96; 17 4:436 .
l,6. Le.nnon CA. Gray PL. . Sen~itivity and specific_ity of
ult;ras9und f9r the detectio.n ofneu~ tube and ventral
wall defects In li high risk population: Obste{Gynec01
199; 9 4: 562~566. .

Scanned By: ~
 320 SECTION Ill: CUNI(:AL APPRQACH TO ~RE~NANCY .
.~~:..
17. Crane JP, Le LeFev,e.e ML, .et ..al. RCI' of prenatal
u1trasono.g r<tphy screening: Impact o n detection,
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1S. Watson WJ, et al. The role of ultrasc::10graphy in the
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~l,-.34. .
i' .. .4.1suP.P.lJ}:
-... :R ediatr-SUfg1994;
. .. . .
. .
~23t: Mtruf~.
, :'~t"til: trhe;o~:""""'1 -~ute-C:if.d;;.,;;......,.ror Je-W
, H""' .-' - . -~ . .. . ~~J.
<l'
:oe;ili:,l~yelocel'~~ ::Mn.iJ:<ol;>stet.:~ii:l.99~; 170: ,.
- - ~~40. . i . '
-~~:iu!}ur;DA.. ~t a4.:.~-~)pn.il#o~ ~~Set of
- ~r~~~~;::
:25. -~-~ ,Ctll}../.Ul, ~~-bclw-~~:m.v.~~p
-and ~m.Osom.ar.abnonntili~Am.J": QbstetGYP,ecol
"1W.i4~: ~~-g--~--- --;-- ~--. .--~_:-- . 41. Cicero-S, etal...A:J;,5eni:..T).a.sal..bohe.at.ll-14:wedcs. of
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ro~ Fetal ~euploidt N"o~m. Ju1y.2'oo4.
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trhoiiiies 2-1 -and l8;Trim:e.Ster M"titemal Serum
-Bi~ch~mistry and .'F~te,l 'Nuch'ai -T:ransluscency
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screening .for Do-~:! sjnd.~~e: .tile res~lh of the
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Seanned 8y:
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.. . 2003:
. .
34. Firth HV, et aL S:e vere l.i.mb anomalies after CVS
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aL. .me; Dllliticen~r-e :Pr9J"ect on
.. asse~~eni of .risk oftri:wmy 2lbym~ttrnal age and
. fetid nuchal tr;ai1slu:teney"thlcknts:t 'a t 10-14 weeb
. gestation,. La:b:cet "1998; 351~ 3 4:}-346.
. . ~
37. ;'.COQ COmmitt;Cf;.- '0PW:io1); .Firs.t Trifuester .Screeiling
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3.8. ZQppl. MA, d ~- Absence of feW nasal bone ar.d
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39. .~-Mea:~ement.o~.nasanx~neJ=gth ,atll-14
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. ~drow.erlSk~enMl:Jltr'asou:ndX:>bSt:ct:Gynecol
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40: . \?<mi'-E;'"e_~aLW~~~-.=aluafi?nqf{etal~ bone
at ll-14-weeks:in'a .coi\secufive .series <>f 1906 fetuses.
Piez1atPia#'-2oo~~-~3::7s~7k7. ..
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42. Senat MV, ct a l, Intr:a iunim ter opera,torvariability in
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. . ." I ' . ' '.
43. VBJ\ de Hof M, W.ils.o n R.q, in.;. T:he Society of
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44. Canadhm J;:arly ahd Mid trimester Alllni..ocentesis Trial
(CEMAT) Group. Rai:ldomi:icd trial to as~s safezy and
outcome of early and midtrimester amniocentesis.
Lancet 199.8 ; 3~1: 242. .
45. NICHD National Regi~try .for A,mniocentcsis Study
. OroU:p: Mid tiimester -amniocentesis for prenatal
diagnosis. JAMA 1976; 236! 1~i1.
46. Oordon, et al. Co!Dplicationa ofthird trimester
.... runniocentdis :4-sing~ltiaso~dguldance.. obs tc;t .
Gynecol2003; 99_: 2552.5~-
C
 l .

CHAPTER 19: PRENATAL DIAGNOSIS AND INVASIVE TECHNIQUES TO MONITOR THE FEllJS 321

47. Stark CM, et al. Need for urgent delivery after third
trimester amniocentesis. Obstet Gynecol 2000; 95: 48-
50.
48. Blackwell, et al. Role of amniocentesis for t..'"le diagnosis
of subciinical intr~niotic infection in preterm
premRture rupture of membranes. Curr Opin Obstet
Oynecoll999; 11 : 544-547.
49. Tabor, et al. RCT in genetic amniocentesis in 4606 high
risk women. Lancet 19!36; 7~ 287-293.
57. Nanal R. A classification of pregnancy lo_es after
invasive prenatal diagnostic procedures: an approach
to allow comparisOn of units with a differentmix. Prenat
Diagn 2003.; 23: 488-49 2.
53. Wald NJ . Antenatal screening for Down's syndrome.
Health Techno! Assess 1998; 2 : 1.
59 . Rudd N, Cox D. Prenatal diagnosis: chorionic villus
sampling (CV$) update. Bull Hared Dies Program
Alberta 1989; 8: .13-16.

1' 50. Eddel MonK, et al. FASTER Trial .Pregnancy loss rates 60. MRC Working Party on the Evaluation ofChcnoo Villus
,-;.
v
after midtrimester amniocentesis. Obstet Gynecol S~pling. Medical Research Council European Trial of
i, 2006;~y>B: 1067-107;2. .Chorion Villus Sampling. Lancet 1994; 337: .1491~1499.
').
't."
51. D 'Alton M. PrenaW diagnostic procedures . Semin 61. Bianchi OW, et al. Ozigin of extra em~ryonic mes.'l-!erm
Perinatoll994; 18: 140-162. in
experimental animals :Relevance to chorionic
. mosaicis m in humans. A.r.1 J Med Genet 1993; '%:
52. Wilson RD . The Society of Obstetricians and 4~ ; . .
Gynecologists of Canada .Clinical Practice Guideline s
ii. Amended Canadian Guideline. for Prenatal 62. Royal College or Obste.triciai>s and Gyneeokigisb
:i:., Piagnosi::(2005} Change ~ o 2005 -Techniques for Guidelines. Amniocen.t e sis and Chorionic Villus
. ~- Prenatal Diagncsis GQ!deline No.168, 2005. ~..... Sampling Guideline No.8 Janua_ry2005.

1
~:
53. Centirii G~ et al. A report of early (13_:t0 tc 14:t6 weeks! 63. Evans M, Macri J, Galen R, et at. Tiss:Qe biopSies. In:
. . and ~idtrUnester aJllrilocentesis: 10 years experience. Evans M, J ohnson M, Yaron Y; et.aL. (edsl!.i\~atal
.
JMateniFetal Neonatal Med 2003 ; 14: 113 . Diagnosis . USA: McGi::itw-Hill Co., 200Q. >. ': ,...
. : : .: ': ~::~~f:. ~- .
. f '.
54 .Philip, e t aL Late first trimester .invasive preoatal 64, Elia s S, et al. First trimester prenatal ~gnosis of
d iagilosis : Res ults -of s.n .intematicnal randomized trisomy 21 in fetal cellS from matemal blood. Uincet
.control~.
.
~
AliiJ Obstet Gynecol2()()4;
. . . . 103: 1164.
'
. 1992; 340: 1033:
; ..: :. : . . .. . .:~~!I
55. ~t'Eiu-ly amruocentesis versue ~sabdom.inal 65. BianChi DW. Detection offetal cells with 47~ -~~: .+2l
Chorion V:illus sampling for prena~ diagnosis (Coclrrane karyotype in ma ternal peripheral blOOd. lluuioenet
Review). In: The Cochrane Datab ase of Systema tic 1992; 90: 368-370.
Reviews , "T he Cochr!me Library, The Cochrane
Collaboration, 2003. - 6~. 01-Y!!lbirt.--:-Ahle.rt D..D~tection offetal. trisomies 21 and
1~ (r ol;ll I!lQ.t~rn!!l J:!l!i!.P<l u.s ing triple gradic:ni: and
56. J ati.iiliiilic E, et aL What invasive p rocedur e io use in ms.gnetic cell sorting. Am J Reprod Jin.munol1993; 30:
early pregnancy? ( ~eview) .Bes t Pract Res Clio Obs tet 194-201.
Gynecol2000; 14(4): 651-6 62 .
- ~:
67. de la Cruz F. Prenntal diagnosis by use of fetal cells
a. \solated from m aternal blood. Am J Obstet oy:pecol
-~
1995; 173:,1354-1355 .
~

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 20

OBSTETRIC ULTRASOUND

Physics of Ultrasound

Safety of Ultrasound

Conducting an Ultrasound Examination

Philosophy and Psychol09y of Ultrasound Examination

.Guidelin~s for Obstetrical Ultrasound Examination

First Trimester Ultrasound Examination

Second and Third Trimester Ultrasound Examination

Transv.agi_
n al Scans

Doppler Ultrasound in Obstetrics

3-.Dimensional and4-Dimensional Ultrasound

Ultrasound Guided inva~ive Fetal Assessment and Therapy in Utero

.;.:.
. . . . -
... . .
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 -N

'32'4 SECTION 111: CUNICAL APPROACH TO PREGNANCY

. Ultrasound has had a significant impact in the coupling medium or gel is applied between the
practice of Obstetrics. Sine~ its intr.~uction in surface .of the transducer :and the skin. 1
. the late 1950's, it has provided. valuable
U;Uornl.ation to the solution of common obstetrical A storage oscillo~cope. is used to create a
problems. It has giv~n vital infonnation with compounded ima-ge and produce -a tw<>-.
regards to the fetus and his ~nvironmenL 1t has dimensional pictu.r e. The standard tran~ucer
...lh--o~ght the hands of the obstetrician closer to used in these systems is 3.5 MI:Iz. The higher fu~
,.t'heret:u.s .as early as the da_ys of embryonic life. frequ.e ncy of the sound, the betfer ' the . ..
WP:3't was not seen and 'f-elt before is .n ow brought repr6d:uction and resolution but'the shanbwertbe "
. :out .in a "cinemascope. So t4at early int.e.r vention depth. of penetration. Jl."igu:tes 20.1A & ?.O.l:B) .
.. ,or c0n.ser.Vative management of th.e pregna:cy ~s
made. -ln the last five years, :Ne hav~ ..see~ tlie
. :4ev~l?J:-1~.eat of more. s~p~istieate4~ p_1gh.
~'Wtit;)n~c'hl~es.mat bave beeh ~-:gt~t help . SPECULAR REr 4 EGf 10N Of S~ND
.f urlnbse .doing SOifbgraphjr. New developments m
~"aginal ultrascund, Doppler ultrasdund, and
~ aii~nsiotial, 4- dimensional ultrasound, have
: :~ef eifuanced O\lr ability to evaluate ilie ftt'...lS.
~- -~-----
'.. T~J~lc:l OF ULTRASOUND
. ... .
:
. . ..... ...,.
. . .. :Ult:ras0und isa -wavef.orm :ofenerzy~that .causes ..
. ." . iinhlr'_partiCies'in a medium to pscillatei Tn~..
~

. . :
i:,.,____. '"""'.""'
:\

. .
. t~uency'ofoound..;r:efers .to~:t;h~num&rofipe;alts .
.:- M wtiv.es that !:(averse a"'gi.ven, ~int. per unit -of .
. . .
um~ and -i~ expressed irr hertz. S<rund with a ..
:~~ of. o~e . cyc;le or :~p.e ~:per.second,.
-:.W.0~4"hliv~ ro:fr:equency.oi;l-'Hi:l!Jlf.iasqund:are . :. ,'

: . - ~!&lr.it~en~sound;,Wa.vesexceedirig.2p~oOOrtiz?:;.
. ~stic Ulfui.s(?und' iristruments ope~te .in a .. Fi.gv.re 20.1A.. Ulaasoundt:hiu>logy.'
: -~--$IDge of fr~uencies varying from
. "'~:'1flre:-duty..fa-ctar6rttiagnosticu:Iuasoiliid,
1. to .tO -
... ..

.~-d~a:s-tlie:mo.a:oet'ween "the cemissio'n 'cf a

~d.~wave. ~nd the reeeption of th~ sound wave, UNEf'.R ARRAY
.-. {!('i}t~OOOorD.OO i. During.a 15 n::imufe diagnostic
. cValti~tioil.) the fetus is exposed to only 1 second
/>f ul.trase~nd energy.
,A:two-dim.ensional picture is cr:e1;l~e4 W}).etf L'le .
. :.f.e-~gU!trasound echoes are displayed O!l an
-pstflioscope scr:een. 1 The ultrasound s ignal
'retutnmg to the transducer is c.o nverted to an
t;l~~it;icai impl,llse, a nd the strength of that 1
:~P~ is directly proportional to the strength of 1 . 51~cm__.-
;--
the f.~hlrr>..ing echo. The den s ity of the medium /
.
iiito which the -sound wave h a s been transmitted Figure 20.1B~ Ultrasound technology. 1
'afi.~ "tl:itou.gh which it -is reflected will determine
.. th~.istrengfu o.f the signal. The velocity of the
. .renected. sound w ave will be .faster and its signal
. ~n.tli~ osciosoope brighter after reflection ofL.oone SAFETY OF ULTRASOuND .... .. ..
. . ~off t:i.s~ue th~t are less dense; sl,lch as.muscle,
fat1 'b rain, or: water. Air greatly :decreases th.e Studies.of clinical qutcomes of infants exposed .. , ..
' ' .. ~srnission of sound waves. For th1s reason, a t o ultrasound have failed t'a derrwnstrate' any. ~ .
.. ..

- - - - -
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 . CHAPtER 20: OBSTETRIC ULTRASOUND .. ' 325
--------------------~------------------~------------------------

significant effects. In 1993, the American Institute because of its inherent emo~iorHd and
of Ultrasound L"l MediCine Bioeffects Committee psychological implication. This is .s pecially
.concluded: There is no cnfirmed biological effects important during pregnancy, where, not only the
on patients or instrum~nt operators caused by rnother, but also the fetus are being examined,
eT-}>osure at intensities typical of the present and the father's interest must be considered. Wrile
diagnostic ultrasound in$truments have ever been ultrasound may increase bonding of the parents
reported. ~~ough the possibUity eJ9~t!J. thats uch to the unborn.child, it should be remembered that
biological effects maybe identified in the future, the examination should be aimed at reducing
cutr.en~ data indicate tlutt the benefits to patients ~tress for the patient especially .in the ~rly
'Of the prudent use of d iagnostic ultrasound diagnosis of fetal abnormality.
outweigh the risks, u any that m~y be p.resent.2
OBSTETRICAL . ~TRASOUND SCANNING
In considering the ~ety of any dia,griostic
procedure, one must also' consider the skill with GUIDEL~ ioR oBSTETRic.A.L
Which the examtnation is cono.u~ted .and the: way SONO.G RAPHY
in which.the res\Jlts are interpreted al'.d utilized.
False-positive and fC;l}se~negativ.e ctmgnoses apperu- Because of widespread use.of Soilography in
to be the greatest risk for the patient undergoing Obstetrics, and its pd~ent,ia! for ic:lentifT4lg fetal
an obs~tfic ult:ta:Sound $mlnation;~4 .abnonllalities an:d providing r,~~ce pffetal
. '- well ~g; .Jnany questions have c:ome Up like.:
CONDUCTlltG ULTAASQUND EXAMINATION . Should sonography be used routiniely .in -all
pregnancies? lf so, when should...it<he initiated?
Ultrasound is :unable to penel rate gas,. .. How. .vigo:r.o us ...should scannit;;g :;:b e .:raf)ietai
whereas...flu.id is ~n excellent mediUI;l fcr 'abnonn~lities? Who should.:;;P.~nfq~,w~~:'}the
transmission. Regu~arly, the int;erface Crc:atcil!:b y .examination? SOme .of these .qu~ns ba'\e been
gas is 59 intense. that the ultrasou.nd ~is : . .addresse4 an<:l.partially answered.
completely reflected. As ~Y .pelvic ~tr.uettue$ . . . . . .. . .::\.'.:.:.. ..:-- ;. , .
a,teloca~~bebindlooi>sof:bowel, -~tan: us-qal1y. . ;'T he .:.:.e.Y! dence ;available 'from .,;: se:vera;l
gas filled, the ultrasound eXamination.sh<Y\lld .rtcit ran.domiZed .COJ1trolled trials an~eta,<O~ses
be pedonned until the patient fills up ~etbladder. :showed eon.flicting results: Summaty repartsartd
The distended.. bledder displaces the~~~~~ ~Ql.~p~~~j_q~~ ~eties failed to ~_definite
cr~ates ari ac<;u$tic window to th'e::.fS~l\ticf - - re'i>blmcndatlons .for tl,l.e routit1e use of
structures-t(j"be-exa:mme'd'. Tne fuir'"6:1~acier . .'~uffijisoun!!_ .iil'1Q!!~i-Ii~ pr~@:iD.Ck~~-j'he~e!o~~
te-chntqu~f provides 'the Tol\oWili~( auvanta~e.$:'- . .O bstetriC. Ult,rasound should be performed for
First, a full bladder pushes the uterus.outof>Ule ..specific inditations on:ly (Grade B) . It is to be
pelvis, thus removing it from the acou~tic shad.ow recognized however, that ultrasound has a definite
caused by. the symphysis pubis. Second, a full group benefit for estimaticm of gestational age,
bladder provides an ~coustic window thro~gh growth monitoring an(\ detection of multiple
which the pelvic ~rgans cart .be visuelized~ ~d pregt"~cy and, coiige~W anonlaii$. lt is fair to
third, ~t displace_s.~the bowels .superi9tly, thus info~ out patie:i.l.ts. of itil . a~i.Ja\>iUty and . the
preventing the gas fn:lril s cattering ~e ultw,~O'lJ.Ild choice of a routine scanis left in the hands of the
beam. 5 patient and .her ob$tetrician.
. ..
If the vagmalrQute is used. ih~paUentisasked The Ph.i lippine Society <>f Ultrasound in
to empty the blacide,r:beforc the eXarilination, since Obstetrics i;Uld Gynecology (PSUOQ) in its clinical
even with on:ly.:a s~l amo'!lnt of .urine in .the pra ctiCe guide~ines (200Q} states that all
bladder; it can. push the uterus posterior out of pregnancie~ warrant. at least one ultrasound
the field of view gf:the.tnmsducer. ~tibn aU.bout 18 weeks gestation. All other
ultrasound eX.a.tilihanns .should.bc penormed for
P~QSOFHY Atfi>::P.SY<l:lJOI;tOQY :oF valid clinical indications. S~arining -; for fetal
ULT~OUNI> SCANNitfG abnormalities is done at least to pick ,up fetal
defects that are correctable ~ Ulti,asound
Ultrasound examination of the female pelvis examination must be .p erformed by a .<properly
differs from a ll other ultrasound examination tra ined obstetrician sonologist.

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 326 SECTION lit CLINICAL APPROACH T0 PREGNANCY

FIRST TRIMESTER ULTRASOUND SCi\NNING. Conv~ntional transabdominal scanning-allows

for the lqcation of the. gestational S?-C at about S
The guidelines for a routine sonographic weeks of .amenorrhea. If at this time a gestafioO:al
examinatiOn in the fitst trimester of pregnane; sac cannot be demonstra,too. inside -the uterus in .
include the fGllowing: . . a ~tient with an accu:ntte menstrual historY. on.e
should assume the .g estation i s extrauterine.
L .Estabij.shment of an - 'intraut:erin:~ pregnancy,. ~gio.al ~n~phy, on the-other.han<t, I!J.a.Y
partic~lady when ect-opic pregnancy is vi.suauze a ..gestationa.r sac .a~ early a~ A:s weeks
suspected. of .ameqox:rbea. One~ seen. the g~sta:tio.n.e.l -sac
2. Detection of embcyonicj-fe~ life. : grows a,t a .fairly constatit rate of lmm in mean
diamete:r~day.6 The yclk sac 1:$ vi~ when
3. Identification of. the nuttiber of fetu~s.
the sac djameter is 1Omm -ot larger at -~bout S
4. Evah1ation of eo~pliCS:t~d .e arly pr~attcy . w~4; Between .f ue seventh ap:(l the .t:hirt.eenth
such as rettoeho:rioil.i~. ll,el;I)orih.ag~, ~ mens~ wek.. .the yoik .s ac gradu!illy )ncrea:;es t.
embxy<:>nk p~cy .-fuq:rmpl~~:aQ<)tti.;~ or in diame~er from ab.out 3-6mm. The am.nipn
coinplet.ed abortion or ~ola:r ~ey. . develops:a?out th.e S3;til.~ time as the-yo1k -~c.. but
5. E!id.Y d.a ting of the. pl;'~am;y U,-f1itlg ;the ~uieit i~ ~ei-.. is :Inore difficult to~. .
.-gestationalsacdi.i:tmeter:{G-sl tlie-~hltil.F Tb.ea.m.trlb'n gx;(jw;na-p'ldly -cl~g ear1y;pregnal_lcy,
let;l&e.lela):an'd...t.'l h~v~e:~-;~j~~:mi:16) and .fqsjc;m With .(he eh~.riOfi is -usually 9mpkte
6; -F;vah:~ati()n. of tbe utetQ:s :und the ~-eJt.a~, . l?Y the Sin~~ntb: week. {Figure 2_0.2)
. ...'

.: .

,;,

...... .. .

Sagittal view .or 9.-w.eek IUP.stmwjng ..

yoli< sac and <;rowr.r-rurnp lerigth, , : ,:.
Figure 20.2. ~arly p regnancy sqmnip.g.1

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 CHAPTER.20: OBStETRIC ULTRASOUND . 327

lnlrautcrine gestatilmal
S<i c is rarclyvisualiwd
l
I. OQ ~onqgram before
25 days after LMP.
. Normal sac should he
visible if /}-HGC level
is :<: 6,000 miU/ml
100,000 ...--.,.,....,..,..,J
50,000 '~~
~5 . 000 . J-..---,---'""""
l 0.{)00 +.---...::....,....~.,.,:;
5;000 .........--~
2, 500 .J-.-~~-o;o
1.00()
suo
250 .

1 00 ~
--~
5 6
W~e~s sin'e last m~nstrual periOd (LMP)

-
To pto~rly evaluate a patient l~ whonr~opi~
. pregnancy is suspected; it is a:b~lli~ely imperativ~
to correlate sonographic fmUxlg~ With \)eta aca
.titer. A "discriminatocy hCG. z9n~ ha~i been
d crmed for diseerning normaJ, ~ble inttaqtenne
pregnancie~ from ectopic p~gnafi~es by ~earis
of tmns-abdonUnal and Jnm.$-vaikai UltraS<.tmd.
In the trans-abdominalUl.trasound;. this ZQne.lies
between 1,800 and 3;606 ttllU /ml of the SecOnd
International Standard or 3,600 and 6 ,S.Q.C IhiU/
m1 of the International Reference Preparation. The
absence of an intra uterine gestational sa.c ..in
conjunction with an HCG value above the
discriminatory level signifies the presence of
. ectopic pregnancy. Using transvaginal scanning,
a normal intrauterine gestational sac is .oft~n
Visualized wh~n serilm leve.ls-.ru:e..~b0ut,.8QQ~U/- :
m1 of the Second International Standard~ (Figures
20.3A & 20.3B). . . .

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328 . SECTlON lll; CLINICAL APPROACH iO PREGNf.NCY

Establishing the presence or absence .of fetal most pregnancies termina te ~pontaneousff within
heart activity, very early in gestation may be a few days. Presenc e of fetal hean motion. does
somewhat .complicated by a contusing electronic not nec~sarily assure that the pregllan.cy will
Picker. Using the M-IPbde, fetalheart n'l.otion can continue to term, paz+Jcularly wh~n fetal heart.
be detected. .(Figure 20.4-f Present of f:1:z,l h~ motion i.s pr.e sent.m ~'Ssociation w;ifu large areas
motion .ca:rt .UsuallY.-~ .established by 6 weeks' cf of subch.Ori9nic !lexp.orrhag~. (Figure 20.5) A
gestation. .:O.nce the e:mbrye> i;:: Sm.m, ca:fa;i~c -$ubch~ :~. With a volume .Of 60c:c or
activity ~.OO.Uld-~ ,pres~n.t; it;r:tibsen~ is -~t,i:v~ ~e.ater is .as~~ia.t~t('.With .frrst cr.early second
of .e arly 'd~~- At p. :w~ gesta~().n, w $0tne ~spOri~usabo:rtion. ~ly.p~ioss
~~ .P,1u~ns ::a fi#ng from ;fu 'embryo. ~ihi~ :is . . . .... . in' the Iisence
. :a~ . of ~.,...;~
~
nl bletdin.g
p.

is dd~~i. .:Op}?.9sed .to th:~.Y!?Jk -sa. ~'be':detectci.l 'SssoCiated ~th a. n~""via.ble pregnancy such rut
and ser-Ve as indicat,ion of.'fue p~ee:of'~e:ta:Hift bi~n+-ted:. vv-.lm-p~A~i"'V
~ - . .... ~~-':""J)
anem~'onlc.
_...,......,.
r-~J
-~
and viabilitY. ]n. tll:~ .al)~ru::e .of fetill 'h~art'l;notion;, and. .~.tnbhir pr~cy: (Figures 20.6A & 20.68)
. -~ . .. .' .. . . . :. . . . . . .. . . ~-.

i ' "r

.......... ..---- -...

~- - ......... ____ - -.....-........-- . ..._, ....... --.-.............._,______ ____ ..... .. ..
_

-~

.. : ..

. ..
...., ;

'I
Figure 20.5. ~:rtrachorionic hey;natom~ !l weelql:ge&tation. 6

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 : ' ____..;..-~~~~-:-:---:-----
~- CHAPTER 20: OBSTETRIC ULTRASOUND "329

,.;~ :...
lllighted Ovum

' '

.... ..
.
[;:
:
: .,... .
....
. . . .~ : ...
._ ) ..' .. :.:,

l :: ' f". --:- .

Figure ~O.I5B. Non-via,ble,pregnant-)'..6

'
. ;:.:.~

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.330 'SECTION Ill: CltNICAL APPROACH TO PREGNANCY

Identification of the number of gestations is
impomnt to asc~~-~~n.. to avoi~ ~e.if.ying ~~-e
diagnosis of m.ultipl~ pregnancy until the time :or
d.elivety'.(Figure~~P-:7) The~- are
times Vlhen oile'
of.the gestations ii1os.t as :th~_.pregTt.an9 .a4van~ ..
which is termed ~5i.the ~ ~ishipg." t}yiil.)tis at
this time aiso :t~ esta}>lis~ . ch6~opi<;ity-- .a~4.
p.innionicity. A mcr~pt:hbriol;tic, ..mop_:l)ii,mri:iO.tig .
p~etn~cy is ~s'SQCiateg'.~th a higll_ ~~tal
~~rtality and l::no-rbid~ty 'because: or $n~g of
~tionand a#ion'~y :$~-twms. ttte ~bda'"
sign as see n by 1ll~~;l:lAd .conf~~,..~;af~4~
<'
pr-e"gnanC'Jis dleho#o.nic... ... : .. '. . .-;' .;: _.;. ~:
... . ., . : ~ _:
Early c;lat;4lg of pregnancy ma]ce_S,. ,'3~ ~f.th.-c: . .. : P~!;:~SY.~:.. . . .
f9UoWing: .-..;; ....::,_, _.....
Gestational Sac Diameter (GS) - 4-6 weeks
Crown-'f<u'n'lp ~ngt_h (GRL)- .8-10 weeks tnost .
accura,te dati..>ig .' .. ..
Bi~etil Diar#~t~r-(8PDJ -: -~1-12 w.eeks
Evaluation cfUt~~s and Ad-ri.~:ii~
: .. -" ......_. . ,_... '... . :,.~;. :;, .: . :-. :: .
.-'The utem$ "and:adl;ie.ia $olild:be examined
.wlth~l#;_8:tt~nti~n~ci.th~.~pearanceqfthe
~rvi;i 1{IAc~rnP'eten1:.tervh:}. {Fig\ire,~0.8) Cervical
'i~ shoUld :be 3dm'.a:iid:-the'':iiiternal os.closed.
M....n~,.,~ss, approxtmitely~~ in si,ze, cystic
in.-~ppeai,anS~ ~~d.~~spg Iz:~mthe ovary is
p_hy~_io)bi:l~l.. r:~p~senfing coft;us luteum of
.:> _: _
=> ...:-:~;:<:.:,:_ .

. ::: t .

.-i

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 CHAPTER 20; OBSTETRIC ULTRASOUND
Fetal Anomalies
Although all major organ systems are fanned
by 10 weeks menstrual age and many congenital
malformations are already--established, the.
structures are mostly tpo small to Visualize with
current sonograms. Between the eighth and
twelfth weeks, there is a normal midgut herniation.
(Figure 20.9) This should not be -c onfused with an
omphalocele which can b.e diagnosed with
certainty after !hat time. The liver can. be seen at
9-10 weeks, the stomach at 10-12 weeks, .the
bladder at 1.1-l3 weeks. and th~ 4 clla;tllber.vjew
of the fetal heart at about 12 weeks.
Pjrst- trimester ulttasound should not .be used
as a s ubstitute for a second t:ri:Jnester evaluation
oHeta!- ~my. .
Flgu~e20.10A. Nuchal ~slucenc-.;_:6
Scanned By:
331
Recently, . several studies have t~j)orted
measuring the nuchal translucency at 10 to 13
weeks. Menstrual a ge niay used a.s a screening
test to detect chromosomally abnormal emhlyos. (
The nuchal translu cency is the maximum '
thickness of the subcutaneous translucent area
between the skin and the soft tissue overlying
the posterior .a s pect of the cervical spine as
measu1'ed in a sagittal . plane. A nuchal
translucency thickness of > 3.m m is associ&ted
with :significantly inc reased inc-jdence of
aneuploidy~ Chromosomal analysis should .b e
considered for. these embryo.s?
The nuch~l translucency is >3D1m in 90
percen~ of trisomies 18 and 13, 80 ~t of
trisomy 21 and 5 percent of nonna.ls. (Fjgures
20.1()4 & 20.10B) . . . : :
~&o~~~~~rt
1'he followirtg shouiq-):x~ dooum,ented in the second
and th~trimester obstetric son~grams:
1. Fetal viability, number and presentation.
2. Amount of amniotic fluid.
3. Placental loc~tion.
4. Establishment of'feta.l age and gro~ by fetal
biometry including biparietal diameter {BPD);
femur length (FL), and ap.J;Jominal
circumference (AC). , ;,.
5. Evalu atio~ of fe t a l anatomic s t~ ctures,
includin g the cereb ral la teral villtricles,.
spine(in bo t h long an d sho rt axis), four
~
~
 '
332 SI;CTION ill; 'Cl.,lNIOALAPPROACH TO PREGNANCY '< .
"

ch.arnber view of the heart, stomach, Ultrasound is invaluable in the ass~~sment of!etaJ
bowel, abdominal .wall at the area of the growth in twin and higher or~er im;gnanciea.
umbilical cord inse,rtion, bladder and kidneys, However, sonography may fail to reveal additional
limbs. (counted when po~sible) and 11ID.bil1ca1 fetuse ~, if the second fetus is in an uriusQal
cord. .' position. -Maneuvers . tha~ can -impn>Ye
:6. Evaluation of the cervix -and ad nexa.e. visu~tion of additiona l.fetuses ind ude haVing
the .Patient lie on her side -or in a knee-chest
The .pr-ese:q<;:e o'f feta\ viability can be posi~ion..
established by docum:en~g:tbe _presence of fe:tal
cardiac activity and
bodym ovement$. Fet?Jactivity The li~, presentation, and position of-the fetus
fonns. the ba,sis bf.the sqpogra~Jhic assyssm!!nt of _ should 'be determined since t he mode -of -delivery'
Jetal_condition, referred 'to a~- the b~t?pb.y$ical may be :affected. So:nographic esfunates of fetal
profile. In partku1<ii-; .one should_<>b~e f?r the weight ~sed 'JlPon the biparietal diameter {BPD),
presence ur absence of fetal ~~~thing movement; abdom1riaJ drcuinference {ACkand femur 1e:p.gth
'body J;llOVePlent, a:rid fe: ton-e, ,tui.d :a mn1otic :fluid '(FL). ar-e usually within 10 percent of the .actual
index. The~ par$neters acUr'fitcly pr-e.di~ fetal- birth w eight and may be. included in the decision
. well .being- and- are a direct ~easu.remen.t -pf'fetal process r~garding timing and mode o f deliv'!ry~
oxygenation.~ . caatinuo.u..s wav)': D cJ.tpl er
:sonography of the. uterine ,'!ind ~bilithl :arteries s onographic a-ssessment of the amniotic:f luid .
may afford. ~essmerit" &r '!J;tero::placen~ ~lqod is iiifpcrta,rlt. A 3 em v~cal pockei:: _ill. t}l~ ~nd

ae~A11it~EEe~e-:. .
in ::ili~ urobruari:F';~:irikY.>hw:icilte::a;,~ere~i. .~~J&i ,or:.nuid in the ..f()~uJ; quit dr.ant$.or i:he
..- .;~~~~~~~;~~~:~\->. ; ~.:.-;>;:: . }:~ ->-:.:~--:-~_E:::~}:~.:~:_ ~. -:~:~;;~J:tJ.~;~~,~~te.~J~~~~~: ,
. ., ,1'-he :~ nu"m
,. :' :1, ". '
:_~...,..:.,\.,;~~--e::..'J;o;;,.-., .,'l_.,i~'-.!i!:u;:;: .Q,.~.:t-..;~~t..,:.~;;,.J :on "xli'"'-"'""":;:;.;..,._;o
.,.,:.A' !fl.u"-d;~nd.~.,.:., or:;:r..;.,-.,.,._1-C...._.,~~ t"s ..
;,"'~: ... J.; ~_::"C'.\::Y:-"""'~<~:~.I...lf.l;P. .~;, ~ ' '~~ . ... _ ,. ~'!. c :J:~-~- .":!:. ' .. . "-". ~.- . L~~--,~~
a~.-c~fthln _ -
- '
~
}to'~aV:oid;;;o.'iit~:'
'' I': ~

a n ~'th'C
, ..
' <tfiS,onoSi~~'OJ-.
. ~:' . '
.- E>1iirr\fiuiii:alitilios-;arid
~~ - ~-. ' .
:;:.;2S-cm:.ii3
. ' i .,.
-:TV\~
-~.lt.:J~~~
..........-.ies. ..
_ .. ~e-. > . : ...
. v#
Ultir 1'' -: 'tati15' . ':$ ...m'til 'tlf'<:tr " ... l d ''lW'' : (F: ' ~. 20 11)'
m _... ~ ~(~e,$ . . : ~ \-. ;:!f:~,;c.~:.: e.~ 2.:~~~,: --~ ~ :~~_.- ,
, '

. .
. . . \ . !

. .
~gure 20.11 . Assessinent.of amniotic fluid volume.6 : . .

..

Snanned 8y: C
 CHAPtER 20: OBSTETRIC ULTR.ASOUNO '333

' .
Localization of th~ placenta ~nd its relation to the';p lacentaduring thecourse of~ Other
the it).tel'Jlal OS of the cefvi_x is' a verj .important abno nnali.t ieso{ the pliu:entii.shoU1ila1sQ 'be noted
factor to deteimme wl;len one 'is s~iming. The as in acoessortlobe <>r the placenuJ.$ad.pl8.cental
gradiitg :or the placenta may . add up to the ;ibruption. Piacttnta preViais. di~when the
infoi';tilation when scanning the placenta. This ph;tcetltal edge is-< 3cm from. the ;~ o.s of the
grading.showsthe normal cnanges .thatoccur in . c.. er:":i~: 1Figures
- . . .
20.12A
.
& 20. .12~
.

-
,~

::

~ . - .
' Figure 20.12A. Placenta previa.6

Scanned By: C
.334 CT~I7
------~--------~S~E= 0~N7.11~t~C~l~
JN~.JC~Al~A~PP=R=O~A~C~.H~T=O~.P~R~E=G~N~A~N~C~
Y--------------~~

. J
Figure 20.:}:.2 6. 'Ihelow-lyingand marginal.placcntaprevia.~

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~_.:~ ._ -~--"---
r CHAPTER zo:o.esrETRIC -ULTRASOUND

Even thoug h biologic variations in fetal growth

becomes most expres$ed in Ule .ird trimester of
i '335

reflection of fetal liver size, which in turW-m.iy be

adyersely affected by intrauterine grC)wth
pregnancy, the biparietal .d ianieter .(BPD), femur retardation. lts use should he l.iniited to
length .(FL) and abdominal ~ircumference (AC) . establishing the proportionality of the fetus and
remain ~t~e mos.t itnp()rtant p~rameters fer determ,~nh1g fetal, weight estimation.. By using a
dete~tion C)f g~stational age. Determination combination of (etal m.easuretrients and ratios, an
vf gesmtlonat:4ge ~hould :be petfotmed prior to 22 ana1y~is .of fetal _growi:.b . may be obtained which
weeks g~f;!ltio.n. Third tr:irile~t~r (ietetmhiation .o f may identify intrauterine growth .r estriction or
ges tational age . do~s . not accurately -renect macr.osomia. Fetafsoft tiSS\leS are $aid to be verv
gestationalage. .BiparieWd1ameterata ::;t.andard sensitive to
chang-e s in growth, so that -~
reference lev~ m.ea$urement should include the .mea~ureinent of fetal tl1ig.~ .thicknes~ {trr), iells
cavum $e;~>ti peUucidi_, the thalamus, ot .f.-he :UJe statUs offe~ growth and .riutrition.to-nu~rwill
cerebral J*luncles ;When. the Sha:J>C' is not oval. early discrim,inate fetuses tba~ :are severely :growth .
theBPD meal$tirement b not a~urate;AppliCa:tiorr-- ~ retarded. so that early .intervention may be made.
ofthe -cei>ha:Uc index may be more h~lpful ip L'1is {Figures 20.13/\, 26: q _B & 20.13cf
,situation~ by the use ofthe formula BPD X OFD I Selection of appropriate norm6gram:,; for
1.265 (where OFD is the outer-outer . estimation of gestational age and fetal size has
eccipitofrontal dimension). Abdominal . been made. In the Philippines, we ha;ve coJ1),e up
circumferenr-e is the least . accurate ,f.Qr the . with 9. ric>rmogram that suits the Filipi,no b:ullt. 11
assessment of gestational -age sin~ it may be a (Ta:b~e 20.1) . -...... ._., .

F igure 20,.134- Measurement ~f biparietal diameter.

Figur~ 20.13B. Measurement .o f abdomin;:U circumference:'

Scanned 8y:
~
~
336 SECTION 111: .CLIN.ICAL APPROACH TO PREGNANCY
-.

;.
SPO . FL
. ' ..

. . ..:~AL:. . .
. l ' '
.
,,'
-~~~L
..
' . .. .. . ." .. :...~~
/ .
. .~

.: .
. ....
~ . .. ,: .
..'

Survey.pff~:W ~~t~ro;y d~nrt~~e s~~bnd:and .visualized sipce norm:W. .kidneys $1. be dete2~ed
thi:rdt:r::i.qieste:rs Io't f~W . 4e(qts {s aJ:d.:iri.po~t -as early as .24 'tp 26: we eks: Yts1,ializ8.tion q(the
aspect'~ s-econd and . thi~d'Jritne~ter. sc;arirung,. 12 : -ventra] abdcnp.inal w:all ~~y.help to .dia:gnose
Targeted o!:gans .should:. irtclude the c~i.-ebr;al o mphalbcele o.i .gastroschisis~ (Figut:es ~0.14A &
-ve;ntrl~l.es,. tl:ie=s;pirie, .stomach; u rinary bladder, . 20.t4B}. . . . .
umbilical c~id insertioh.$ites .and Tcil'al:.te@.ons. . the cervix: ~a .adnexa shouid be scanned
The rlatJon ofthe fetal :Ventricles-to the.c~o(oid$ : specially for .the. presence ofincofupetent eer:vix.
plexti.s'.Sho'til~ - ~ established. 'The spill,~ should-. 'The .ce'rvical.;.length sho~.l<f at least:be..3cm. arid
be view'ed iil:oothcoronal.and. short fl.Xes to detect:' .t he internal oS..closed. Adiiexaf masses.are u su.c,lly
me~~g6_~~~~~1e: Th~ ~;;esence :of fluid in the Iot.at~d .$upepor to. t4e func;ius:d~n~i.:pregnaFCJ
.stGmaeli ~lioilld .be vi.sualized as well as~ uiine ih . . in contra~t fo the non-gravid s~te wh~r:~ they .are
.the bl?-claef. the. r~gicin .cifthe ki~eys sl).'ould' be .parauteriri~.

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 CHAPTER 20: OBSTETRIC ULTRASOUND ":; ' 337
--------~--------------------------------------------------~------------------------~
.~ ~

~t,

.. .
, .... ' : . . . ~

. ' .

'1~>t~ri:tn-:r~ntmhtmrrtl'ii.,:r...;c. : -....:~""". - ~---"--.......,_

iutu.-ttlll t 11mtil
. . .. . . ........ ' ,

C.

Fi~re 20.l4A. Survey of fetal a:natomy.6

Scanned By: ~
 - - - - - --- ... .. - -

338 SECTION Ill: CliNICAL APPROACH TO PREGNANCY

thosy _of-the fetal_ middle:cerebr:al.and thoracic

aorta. The qbsei:-va:tion of absent or rev~ end-
diastolic blood pow. in the umbilical artery is
cliniC:ally more usefu~_than the~ v.cujo.u"3 indices
which, indicate progre~sive _, fetal deterioration.
Indic:;es u sed. to m _easure . utr.bili~Lartery
resi~tance e .resistance .i_n~fex a..rld."~tility
in~~: 1 ~:(Figures 20.1.5 A .:&'20. 15B)"- :
. . .. ;. .: . .

~~:2o:T~a;:ff<;u:t .'CKii.IIi'B.eFVie w.cifilie 'tetiil'heari.~

- .-. . ~-. ,; :' ... . . : .: -.: ... .. - . .

~ : o ~ I

'l'RANs\r:Aarirn:.,sbumN~h ... ;..

. . . .:::_._. ;.~ . ~:};;_: ;~: .-: . -:--~ . / _,._. .. ~. ' .. ,. . \.. . .. . . . .
With'.:s#.<illx:,aeswe!f.::W..os;.t:u.J.t~ri.sm~d;.. ,
seannfu.i'can. & ~aorie -i~th.,tiie>:Piccibe;~jil3Ce(F in
: the .vagin~~~'f..-the :.tien~.::Thi~ .ni"bili~;usl.lcilly
.
pt:ovides:~l5ftti.,-.igliges'::,artcL
. ......, .-... .., ..;. "' ' . .m.~rer-U:UOnnatioii~
.. . . ... ,. . . .. .. . in-.
~

. pati~t~~w~O:~e~ o~se..~li/: or futhi:.early-;;tages .

~- .
.. ~

.or "P~cY.r:nlet!~.tter~~~-~~~:~e~re:st -of::..

the clo.sef:P.~t:f.,< cfFilie ;:p"i'Qb~~;~::~~~~e,rus
.a nd th~ ~~t;;~\?,~~-$.~1-~~g.;i:n,~h.!g\i.er
. :resoltitic~l<:WlL~pUisatiOii~ian:B-e;aeaf,ly
qbse.::ved~at-6 ...:wecks .gestaticijl-.u s i.ng.:.the :V;:.rginal
sCan.. The vaglnal scan is ").l.Se9, alio in 'the early
"diagnosis of ectopic pregnancy and caily fet al
abnormalities.
. . ...
~- .. . ..... . . . (

DO.PPLER VELOCi.MEt.RY .IN,Q~R!Cs

. .. :. .. . :. . : . . . : .

. Doppler uitra_~oung Bffers a non..,iriva~ive

method for:a~s~ssing.ljlooq flow-velocity -in Vessels
during ~e :cardiac
cyc.Ie..in tl}e f.etC?p1a~ental and
uteroplacen.t al circul~tions~The olc_oq..flow .yelocity
waveform can
"be analyzed. ta \;l,S:S~ss 'resis~ce
downstream.~n the
peti.p"heJ."al vessels.su qh ~s may
oc~r with prqgr;"essi\r.eYt?ssel opliterati~r.t:'m the
placenta. The umbilical. artery wav.efomis have
been fountf.to .~--better
. than the u tenne
. . "in the
~

prediction: of feful . 2ondition~ an~:l::}ri ..r:W1domized:

stud~es that'have :shown
to.:ilnproye a:-number of
obstetric outcomes. In fetal gro)Vili restriction, it Fjgure 20:1sB. Fetal blood .v essels depicted..by .color
a ppears that the umbilical artery-:chan_gesprecede dopplcr. 6 . .

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- - -- ---
 CHAPTER 20: OBSTETRIC ULTRASOUND
...&J..

l . The use of color flow mapping can clearly
~. depict the flow of blood in fe'tal blood v_essels in a
r!
real-time scan, the direction .of the. flow being
"' repre~nted by different colors. ColorOopplei is ..
particularly indispensable in the diagno~is of fetal
If. ,ear.dia.c and bloo<.l vessel defects, and in the
assessment of the hemodynamic respont>es to fetal
hypoxia and anemia. A more recent development
};. .. is the Power Doppler (Doppler angiogntphy). It
~! uses ~plitllde information !rom Doppler s ignals.
! rather th~ flow velocity information.to Visu~
~ slow flow in smaller blood vessels. A color
to have an important catalytic effect for mpthers
to bond to their babies before birth. What are
known as "reassurance scan or "entertainment
scans have quickly become popular.
Most experts do not consider that 3-D and
4-D. ultrasound will be a mandatory evolution of
the convention~! 2-D scans, r.1ther it is an
additionru piece of tool like Doppler ultrasound.
3-;0 ult.'":asoU.Tld appears to have great potential in
researt4 and ;i n the study: of fetal embryology.

i
Whether 3Q ultrasn~nd will provide unique
perfusion-like display of a particular organ such .i nformation Qr tnerely .supplem~tal informa.tiou.
, as th,e placenta overlapping on the..2-D fuiage can tq the c:Onventiorial2-.D scans retnams tc be ~
:b e v ery well depicted. Doppler exrunirtation can. (Figqre 20. 16).'
be perforined ~bdomina.lly and via the transvaginal
route, The power emitted by a Doppl~r Q.evice is
l .greater than that used in a conv.nUol)a12~P. scan.
Ia Its use in early pregnancy is thtrefore cautii:>ned. 14
js
I .. , ..Poppler sonognt.phy in Obstetrlts is a wiC\ely

I
aecepted functional method of examining ~e
ute.rofetopla.ce:n ~~ unit. :ExaJI1ina.tion pf .the
uteroplacental and ,i etomatemal circulation in the.
-early'.second trimester h~lps pr:edict pregnailey
cO.mp)icatic;ms like preeclampsia and IUGR .It is
. a.D~i~porlant .tool foi- ' qu.~llfyirig high-ri.sk
pn:gll'@cj~p .

a..D. ultraso.und can furnish us with a

3 ... dimenaional . ixna.ge .of .the ~fet us -and- hie
:enVironment. ' a-dimensional 'Ultrasound ' tak~s- a
~es or images; ui thiii sllces, 'as the cotilputer
processes these images in 3 diinensions. a.:.o
- ul~so.und 'i$ qulc!dy mQving out of the rese!U'Ch
and developmental stages and is. npw widely
employed in 't:he clinical Setting..The s cans require
special probes. and so.ftwa.:re to ac<;umulate ,arid
r ebder: the images, ~d the rendering time has
been reduced from minutes to fp;~.ctions of a
second. The usefulness of 3 -D scan is in the INVASlVE FETAL ASSESSMENT AND'THERAPY
diagaosis of congenital .anomalies. The. a bility to IN UTERO
obtain a go.o d 3-D image is. still very much
dependent on operator s~ill, tpe amount of Access to the fetus as a true patient is ilrecent
amniotic fluid, the position of the fetus, and development in maternal~ fetal .medicine.
maternal obesity .15 Ultrasound~guided amniocentesis, chorion biopsy~
. fetal 'b lood sampling and transfusion, .a nd fetal
4-D ultrasound .or dynamic 3-D scanners are shunts are .
~)ow being
.
don,e.
. .
These
.
prQc.edures
<~;i'
in the market and the attraction of being able to have markedly decreased ' adverse ~bnatal
look at the face and movements of the baby before outcome in selected group.' It is standardJpractice
.birth ..'was also enthusiastica,lly reported in to undertake a ll invasive procedures.. under'
p arenting and health magazine's . .This is thought ultrasonic guidance.

Scanned 8y: ~
 POINTS TO REMEMBER
. .
Ultrasound 'is a waveform oi-energy that causes small particle-s in a m ediu m to oscillate, .treating
a eompounded ima_ ge which resu!ts in .a N:o-dlmensicnal picture.

Sonograpqy has .not,been found to~use-~verse cliniql :~ffects in humans with the energy .Jeyels
.useG in diagno$tlc studies.

, . soundls unable to.:penetrat~ - .gas, Wherea:s fluld Is-atleXcellent medium for transmission;
Ultra_
. hence the full b\Zldder. technique-is.a 'requisit~ for trans;abdomitral scanning, aiK! tha .r-ev$5~ is
required -for ti<msv~ln:a1
.
scanning. . . . .. '

.;.-
ultr3so.ur.d .e~mltion~canieS ~tiorJ~ :and p~qloglcaf.impliCatioh, h~oce- searintog.should I.

-be aimed at redu~ng stressfot.thepatieht ' : . . . -

- Obst~tric .l)ltrasooi'ld should Qe .perfom'ied tor st?eCinc indicatipn;; ,only { Gra9e B), but :the choice
for:l .!QUtin.e $C3n-1s -left .in t.he,})andsof the-patlenta:rid her~obStetric~n.
ool' : ',_ ~.. o. : .: : , . , ,..._ ~:. ~ ' , '' '' , :I ;:, ' ' '' ,
:. - ,_,. :~P~.i-=~J.il~::itf~~--fYS!, ~M-:~nd thirdArlme$ters of pregn<;~ncieS correic::J.~ w.!fu_ the
-: '. ~us,O'f!tM J?(;~o~r.ncy,~uy1$tarid'~nvirontnental staws-ir:r-ut~w. .

~:.:~~~--: N~~~ey,~Jt~~~~1~~ne~r~suh~sitrao~~~ifl~:\lltr;3~~ui'l'd,t~pp-ter!U1ttaSOand''; '' .

- _.) : :__ ~ ..
:-; . : ,. _:;iif.l4~.1'inen~~ :~<i,h.a,y,~~ impact,i n the;tl1aml_9eme"ritof ob$tetrtc-patiefits,Spedslly;.
-_:: >'~ -~- -~ hjgtJ :~~':~~~~:~~eh:t{~~.(;StaMdin.~ ut~t?: _. -:
.. .. ..::: . ... , . ::::~ -. ~ . - .;' .. ' ~ - :, ...... .
.. \:~:,... .. .
., ..:-. ....... -:::- -~ . - ~-... ~.......;-
. :- " ' ', ;:_ :~'_:: ..:. .. . ... ~
-.. , ''. '' ,\

;:...."';: .~- . .
....
. ... ' :: . -
, _. __ '" - - -~~:' . . : . 9. v~T.A,ntcp~fetal evalu~ti.otiby'~-~iop~~
: ,. tmlfile id:Jrink: -A:l~ e xperience. UE~P J -Med
' : . : _.: :.. ' - : ' :_ 19&9t.:l-2('tr.--_m..:f3,- .. .. - .. --- -

:_~;- ~_91.
_-_:_:._
_ ____. :_3 9 ::_1_r_4_L
._._J_
:_ .~
- --~.. _~-=- -:_~.. . ~j~~=~:';;=;::=.,~ _kru
_= _,_: _.. 10.
O~!rtet- ~ot1 Q93; 17(2).
; --
.' .. . . '~ . ; . . . .
... . .
H . vera.-t; -6kai:1', Mizuno M . "Ultrasohlc-:~inent of
j D 'iAg;ItC~tiC .:....' d ...... ~,.;~- -in ~-R~
. - -: rn:;;....-
'"'~"'~~- -~~g.
ke rt
~ -.-~1 ..... p<l ,feta;t .t hi_gh .tl:U~ds and - m~ex o(intrauterihe .-fetal
Con~ensu.~ CQnfer.enC.~~ Wa:sl}ington, US ~pt~ Pf uo-wthand nutn:~on."J'ap~'J '~.M~- t9M.
H~th-and:Hu,in?-n.Setvice3; i984.
12. 'v~ T., PB:~~lina c,, B;tt~sa.P. Ul~mc es~~~on
4. O'Brien WD ,Jr_ Assessing the~ for modem diagpo~tic of gdtatior1ai a ge ai:tlo~g:filipino:,;-..9.Cii. Phil-J Ob~tct
ul~cu.nd imaging. ;,Tpn J .\p:pl P.hysics 1-9"98,: Gyn:ei:olt9M; 10(4): 23 v 2sa.
.. . . . .

13~ TWinning P, Mc:;Hugo J M ,-PilingDW; TextPo<>k o! Fei.al

s: Smith R.. Neltet'
. . a. Oh-'.Gyn Women's Health 2003.
. . .. Abnormalities. U>nd()n: Gh urcbill Livin~tone. ,
'{
~6. Saue.t:brci. E, Nguym ~. Nolan. A. PracticaHiuide To
.Ul~$0~d io. Oh~t~t.tj.cs -a ,nd Gynecolo_g .Sec~>nd
14 _- Smith N , Sinith P. Obs tetric Ultrasouti.d Made ~asy .
L9ndon : Churchill LivW"gstone.
. Editi~n, 1998.
15. Dewberry KC, Marie HE~ , Co sgrove DO, Frur~t f.......
7. Fleischer :.!4 Manning F, JeantY. P .Scmqgraphy in Clinical .u ltrasound. Ulp:asound in Ob.s tetnc3 and
Obst~ti:ks:and :G~eeoiogy~ $j.xtli:i:A,fitiod ~~1. Gy.n-e~olo-gy. -.Vo l 3, 2~ ed.: Lo ndon~ Ch.~rchill
.Livingstone.
8. 'S.l ierer -o:,' Manni p.g 'F. -F'irs.t trimester n'u -ch a l
'.. . tran31ucency sci-.ee~~in-g "lor -feGl-1 ane).tploidy . 16. Baba K;-Ju rRoVic D : Three-Dimen s ional mtra.souna in
Sonography in Obs t'!tnCs antfGyn ecology .200 1. Obstetn~s and CJ!lecology, 1997.

Saanned &y: ~
 21

DRUGS, MEDICATIONS AND . .

IMMUNIZATIONS DlJRING PREGNANCY

MARIA STEPHANIE
. . FAYS. CAGAYAN,
. MD

Pharmacokinetics in Pregnancy

Fete-placental Pha.rmacokfnetics

Principles of Teratogenesis

. Mechanism~ of Teratogenesis

. FDA Pregnancy Categories

Representative Human Developmental Toxicants

Guldelines for Prescribing and Counseling in Pregnancy

Immunization During Pregna.n cy

Scanned By: ~
 ,.,~')(jig,
-~?3~

342 . ------------------~~~~~~~~~~~~~==~~~~~----------------~~~ft~
SECTION Ill: CLINICAL APPROACH TO PREGNAt~CY -~ _.J:;."ii
.
----------~----~------~------------~--~----------~~----------------~--

4. Volume change's -dramatic i_ncreases ' i~:-~;~.

maternal aqueot1s a nd -fatty tissue ~pacea: ::
. 'Pharmacotherapeutic d~isione in pregnancy (greatest at 10-30 weekS) and the 'increase k ..
. U!ke into. cqnsideration numerous factors . The total body water (mostly extracellular. 40%.
ideal drugior treatment in pregnancy. is -e fficacious materca:l, 60% feto-:placental].
. for-the maternal indication, Iilmimally transported
thf(l'.lgh the placenta and, in the event of 5. Metabolic changes- relative decrease in ~.nim
tr:linsPiacental passage, exerts minimal effect on albumin concentrat ion (25%) and e1evatec1
;tl).e 1~tu-s.. Often neglected but .of -~imilar levels o f steroid hormones compei:in:g :for
ii;rpQit$e are drugchaiactet.isUcsfu~ ~Iifluencl! _protein binding sites, elevated levels cfserwn ..
_t9l~~ty and - tj_dher~~e to ~~ ~g .~sin,.&. .. pro.g~st:eror~e, e l:e v.ated levels Q.f.'~enim
. schedrile-. ~()fe !>t? . when the dr.ug tlier:apy . in .. . estr-o=gen. . .. -
.questl9n= e:iacerl>at~~ con:ditlon~ c ox nmon i:o . . '
-
~--

pregnat;;ey s~c;h . a:~ .~!nest$,. g~s.ti-o'hitesti.hal "6 . .,R~:q.<~l ~har.ges ~ -illcre3.:$ed ~nai bl~ .flQw
~~~_ges ..eith,~r iil 't he fi:rt.tn -of .diarrhea o.r ,('50%} and the consequent h:i:crea!re in
~ol;lstipation, gl~co$e intolerance an~ glomerular fiitration (50%) 1
. h~rtension.
The ne,t effect of these :cb.a:nges lead. to an.
_-':r~eoimtETiCS IN-PREGNANCY expected decre ased s.tee.d.y slate ~ ru.j~
.. < concentration in .p r(!gnailcy it: ,a normal do$:e .i~
'Pl),ysiolpgic cl'langes in pr~gnancy $ignificantly admiriisteied, Le~ ?.. hlgber\iose wn1 ~ neede:ii -ti;i
. abct. p~apnacokineti.cs ih the pregn_artt patient .achic-,;e therapeutic levels, ait..l-J.ough drug-specific- ..
..,"'':(Ri~1~1-.1}-.i.,These~.changesin.Clude::~
. :
..~. . - . .. . . . ' .... .- . -exceptionS"'
. '
:will-oecur-;
. . .1.. . : . ... . . ; .._ . . ...

. i... Car,dioyascular changes,.-. increased .tar.ci.iac Although the change's . in phanliacokil;l.etis':iri' : .

.. .. . . output (4q_%) 9il.d ~creased ~lasma,. volume, th:!. pr~gnant;patie,nt '~.P~~ t6 .)Je very impott;ant . .
. ..
..'.cs:Q!'
.
/0) and total.bloOd velU:m,e {40%).
. . it-1 .theol)") the~-..~iuitrge$ :ate-.~~~err..no~ :siguifi:~t',- .
. :. ....:.~ .. .... . -..... . . . . .. .. .... . clini,cally: .. Notable:. exceptions-are :dr-ugs that-Jaie,l! :.... .:
. .2: =aastrofut~stinal , cP,a'ng~s - dec-t eased gut . exclusively el.i.tr\itlated via the rena1 route, ~sucil..
. . . . ~o~ty.. :in.crea~ gastric-pH and nausea and as ~itbium a.IJ.d digoxin. The inGrea~ iri r~nal
.. !9#ung. acretion leads to a significant decr-ease in Setll.ID. .
. ..
. . . --- .
, ~Q~s:~m~t!on... -~~; .. ~9-P..!ll~.r.i!lg~!h_~!r .!i@I.Qi_.. :
:3~.:-.:.R:e.S,p.itatory change:s - .hyperventilation, . therap.e.u.tic .ra:nge,,. m ay ne.ce s.sit~te . s~e.tu:m.;_ .
..:ir-c:r-e-ased tidal volume, a n d inc reased concentration monitoring. .'Also n oteworthy -are :
. p~on'ary blood volume . . anti-ep'ileptios (carbrunazepine, va1proic add.''ai:l~

.
'
. ..
Expanded int rav.a.scular
-: . voltune
.. :frfu'i-eased reill\J ~Oj)(}. flow ~nd
GFR
Decreas~ gastrointes tinal motility
." lncre;tSed prc>gesterone .ae.tivate d
. h~{ntic m etabolism
Increas ed thin ning_offetomaternai .
ba~rier \Yith advancing gestation
'Incr-eased minute ven tila tion ~ :.

... .... : ."

'!B
. ,. : .
Fi~re 21.1. Phy~io~ogic changes in pregnancy.

Scanned 8y: C
____c_HAP_TE~_R_21_:_D_R_UG_s.....,~
M_E_D_IC_AT_I_ONS_
....AN_
._D_I_
M_M_O_NI_ZA_J-=-IO_N_S_D_U-'R_IN...:..G_
_PR....,E_G_NA_
_N_CY
:._- - - - - :.. i;. 343
'
Table .2 1.1. P:l1ysiol9gic changes in pregnancy and their impact on pharmacokinetics of ~~ted agents.'

PHYSIOLOGIC CHANGES IN PREGNANCY EFFECTS OR P.HAIU4ACOKINETICS

DCcreued gut motility, increased gastric Variable bioavailability ofor&l Most oral preparations
pH and nausea and vomiting prepa.rations

Hyperventilation, increased .t idal V()lume, Increased alveol!U" uptake of Inhale~ anesthetics

and incrCa.sed pulmonar:y blood volume inhaled drugs

tncr.eased dUdiac output, and increased Increased volume of distribution

plasma volume and total bl?O<i volume

Increases in matemal11.queous and fatty Further irn::rease in the volume

tissue sp9CeS _(greatest t 10-30 weeks} ohlistribution . .. .
an.d theincrease in tQ~ 1xxiY Wa.ter

Relative decrea!Se in . Senun -a lbumin Increased free drug.fractions .or" DiauplliJ1, phenytO.in.
concentration and elevated levels of protein-bound drugs SOdium vatproa:te
steroid hormones compc;ting for protein (especially lri th~ 3,.
binding sites tril:nestet)

Increa~ cytochrome Pberiytoin.

metal;olis'in of.somedrugs carbamaupine,
sodiu.tli-valproate . .
. ,. , .;.;. -. "(:~~ ,.,.. .
Elevated:le"Yels of'sei"Ut!l estrogen Pec,n::a~ cytochrome oxidase Theophylline and:l@ffdhe
netabOlism of some drugs
... . -. :. :.'~~-:, . .
Increaaed"ret\al bl~ now and the lnttea.Sed renal eXcretion and Lithium, Digoldtt ~
conkqu~t itt<=:lse in ifumeiular cri::atinine cleax:ance Ampi~ .(doubleri) ~ .
~~:;; . . ... '.': : . .~::."'.:::. .: ! :_:.:

phenytoin) which experience a decrease in
effectiveseroJn.::eoil~~tltrtrfions seco'iidary lo
incr:el!"S-e1l' ..h:epauc. me:taoolfsiri . an-are:nii
.elimination. increase in plasma volume, and
dec.reased protein binding. 3~ These .drugs,
. howevet", are more the. eXception than the rule,
because the changes mentioned above are often
offset in most conditions.
Thus, very:often the effects on the developing . pass from mother to fetus, howev.er, solutes must
fetus are taken into greater consideration in
therapeutic decisions in pregnancy rather than
maternal factors.
Ft'ro.P.L ACENTJ\.L PHARMACOKINETICS
Drugs that eventually reach the fetus are
(almost) always. administered to :the tnother: For.
... --
the fe~~l :s.~x:um'" Q.ryg~.. ;g~ . !.h~n :.t ransferred
~.~~~e.t:lt.<U!Y. W. fu~.m.o.th.er ijlld .are eventually .
excreted .
Raised areas on . the basal surface of the .
placenta, termed as maternal lobes or cotyledons, .
are intimately related with several fetalcOtyledons,
allowing maternal circulation to be virtually
superimposed onto the fetus. For materials to
pass through the syncytiotrophoblast, either
directly through its cytoplasm, or lesfi commonly,
via a network of specific tra nsporters. 'I'he
transport of molecules from maternal to fetal
circulation thus involves the passage between 3
function al compartments: maternal blood, the
trophoblas tic cytoplasm, and finally fetal
circulation (Fi~re 21.2).
.~

a drug . to exert its effects on the fetus, A grea.t majority of substances den.e~d on
transplacental transport must take .Place. . After simple diffusion to pass throtigh!J these
maternal administration, 9rugs firSt pass through compartments. The rat~ of transpo rt';~etween
the placenta before reaching the fetal serum. From mother and fetus, then, is dictated by the

Scanned 8y: ~

344 SECTION _Ill: CLINICAL APPROACH TO PREGNANCY
~:n.2. Major pathways !h,d Interrelations of
pb,ailnaeokinetiC$ in maternal, placeiltal and fetal units.
2_ The protein binding capacity of fetal plasma is
,, .;.;... . _.size Ot llJTOWS indicates relative ~porta."lce of effect. . (Re-
~~.:~, d.'"1iwn from an originB! by.O arland M .Phannaco.logy of d.r..1gsignificantly lower thap that of maternal
~~(~~-- ~~" arysa _'tlle p~centa. Ob_s tet Gyn~col Clin -~Am
f~\~Z;~ - ~~s~. ~stu..;~~2~
;~l :~~ ~t; ' .
..'!f .. . mol~lat. weight; -dtgl:ee oLionization; 'proi:ein.,:
~Jll)c;i, finally rela~ve concentrations .across
th~ :eompartinen ts.:z,3,1
~. - r . .drugs. with poor-affmity.to fetal proteins such
~ ~. ~~rs involved in drug tra.nsfer across : ..
the piacentaare:
1. Th~p~ysicochetmcal- propcrties of drugs, i.e.
-lipid solubijit}-, degree:of.ionization, 1IlOl-etulat
size and prot'!in binding characteristics.
Drugs that are highly lipid soluble, non-
io~d; oflowmolecularweight (<200 daltorts)
and ~ally :protein.:bound eas_ ily cross the
pla.eenW .t,_anier.
2. Th~ tra,nsfer of t1ow-limited,drugs a re af{ected
by placental blood 'flow .apd .maternal serurn
drug .c oncentrations {gre.a,ter maternal serum
concentrations _create a greater concentration
gradient causing 'increased placental
transport).
3, Compo~nds that alter blood flow also alter
maternal drug dispo~ition and consequently
affect placental transfer.
4. Placental metabplism (i.e. dea lkylation,
hydroxylation and demeth,ylation) . .also
. mfluence drug transport through _the placenta,-
' although these effects a re relatively minor
Seanned 8y:
I,.
. ..,:.
compared to metabolism via the Platemal and
fetal liver.
5. Fetal metabolism may also play a part, but
these effects may change during pregnancy.s
Fetal pharmacokinetics a lso play a role in
dete rmining the net e ffect of drugs on the fetus
(i.e. teratogenicity):
1. Maternal blood flow throQgh the placenta
gradually increases during gestation (from
50tnLfminat 10 weeks ofpregnan~ to a Peak
of 600mL/min at 38 weeks AOG), thereby
irtcreas ing the fetal drug expos ure as
pregnancy progresses.
cir~ul:atjon {1> tal plasma albumin
concentration m;ly be 15% greater than
maternal, but this is offset by the lower level~
(37%)of.alphatacid:-gl)rcoproteinand the:lower .,
affm.i ty for binding of fetal plasma proteins)
leading to a greater free fraction for drugs that
enter .the fetal circ:ulatiqn {especially basic
drugs su.ch.as propranol9loand .lidocaine arid
as ampiciliin and benzyJpenicillin): and
consequ~ntly, a greater risk for: toxicity.
..
3. The fetal-pla'$Illaahd amniotic fluid areslightly
more acidic-.thanmaterna:tblOOd, favoiihg the
ioniZation and subsequent ion~trapping of
b~sic drugs in th'! f(;tal .compartment after
transplacental .pass~ge. This apparent
acc::uinulation in the fetal plasma further
. predisposes to toXicity.
4. The fetal liver. also e,xpresses drug-
metaboliZing .e nzymes such as cytochrome
oxidases, but the metabolizing capacity is
much less than th_a t of.the mother. Dr...1gs that
pass throu gh the placenta may thereby
unde rgo first- pass metabolism through the
fetal liver before reaching systemic ciraulation,
though this eff~ct. is Il)~dp.lated--by the ductus
venosus shunt and may vary by 30~70 percent.
5. The fe~al: kidney is immature and glomeiular
futration is. markedly. reduced. . Glomerular
futration. rate -increases .w1th ge&tational age, ..
but peaks to .only 2-~4m Lfmin at term ,
prima rily because
.
the fetal kidney recdves
'
~
J,
!
.\

CHAPTER 21 : ORUGS, MEOtCArtONS ANO IMMUNIZATIONS DURING PREGNANCY .... 345

------------~------~----~--~~~~------------------~---------------- .-~

only 3 percent of cardiac output, compared to that mimic the human malformation at cl.inically
.2 5 percent in the .adult. . Cation secretion {e.g. c<;>mparable exposures and that the meChanisms
cinietidine, is efficient, but the renal excretion of teratogenesis are understood and/ or results are
of anionic drugs (e.g. penicillin) is very low. biologically plausible. 1 .J,6 7

6. Fetal urine er.ters amriiotic fluid, which m ay The timing of exposure to a suspected
be subsequently swallowed by the fetus, and teratogen play~ a crucial role in its effect on fetal
renally excreted drugs 3.i""ld metabolites may development {Figure 21.3) , Periods of
subsequently be reabsorbed. 2 "'.s su~eptibility in emb~genesis are characterized
by rapid cell :d ivision and differentiation.
In general, drugs that exist as large, highly .
protein bound and/ or ionized molecules in During the preimplantation or the so called
matem.al plasma a.'l.d are poorly absorbed into the "all or none= period (<15 days from fertilization to
maternal bloodstream rarely .. cros~ the placental inlplan.tation), the zygote underg~ tapid cleavage
membrane and are usually confmed to the and_org~pon into an outer and i,nner cell mass
maternal circulation in therapeutic doses, thus (blastocyst fonnation). Development during this
.exhibiting minimal e ffects to the fetus. stage can be consi<iered "~l or none. that is.
injurious stimuli are either sufficient enough to
Due to decreased protein binding, ion-ttappLg cause the death of :t he embryo, or compensation
and poor metabolism and excretion, drugs .that by the uninjured "cells ~e enough to conljnue
do pass tO' Lhe fetal circulation exhibit a greater norm.a l deve!opment :(Figure 2 L4) ..
PQi:eritial.J or:to:rl.dty than .they do for the mother.

PRlNClPLES OF T'ERATOGENESiS

.:.,ay-far''the greatest concern fer both patient

and -j)hysiciail"in d..-u:g therapy d~g-pregnancy ,; . .: ."')j..: ;
rue:-the possible -teratogenic effeCts of. d rugs -on
~ tfiet: ietus. 1~erat9gens (from the Greek teratos
meamng-<monster"}referto agents t:hat act during (67 doy>l_

tha embryonic or fetal period and produce a

. alteration
pel'IiUihent . . fut6nn or function. 'rhbe
~.

.. . . .
att~auons1nctmre '15trt1i -aerec-rs; or:vrsil>'h~
aexotinttieS.liii:it a.re~congenmu-in ongm; bu1.mli:Y
occur as- tiletaboli~ derangem~nts .that may be
more subtle .a t birth.

Envlrt>nmenta] fa.c tors (e.-g . mat-ernal

conditions, ii).fectious ag_e nts; mechanical
problem~. che.m-icals, drugs, radi~tion,
hyperthermia, etc.) account for about 10 per:cent
of all abnormal outcomes in pregnancy.
Evaluation of the teratogenic effect of a gents
d.e pends-on the ,following c riteria: 1) proven
exposure to agent at critical times in prenatal
development, 2-) consistent epidemiologic
evidence,'3) clearly characterized clinical -effects
(i.e. .syndromes), 4) ,frequency ofclinical syndromes
reflecting actual frequency of exposure in the
population, and5) "the abilitY' of the agent toerol?s
the placenta-or sufficiently a lter r_naternal or fetal
t W..on ing ..
:::::'"" .
metabolism .to cause ~ignificant effects. Other 'J
useful but non-essential criteria for evaluating Figure 21.:3. -Sequenceofevents in normal embrtogenes is.
teratogeniCity are experimental ariirrial -models to
(From Human Pharmacology: Molecular .Clinical, 2"" ed.).

Scanned 8y: ~
 346 SECTION Ill: CUNICAL APPROACH TO PREGNANCY

:,~ ...

gametes ~ blastooyst ~embryo ----+fetus - + newborn

! .., .I I l (normal)

. sierillty '
death
deafu
!
1
death
1
Functional ancmalies
Strootural anomalies

~ 1
Newbom (ananalies)
t;'i~ 21A. O.Qteomes associ~ted with exposUTe-at clifferent stages Qf~pUction.

', . The embty(>nic period :{from the 2 "" to the e.xam.-ple, ..agents m~ d~tl,ipt th~ meta..bblism of
su. weeks AOG): is the .iil<>st CPJCiAl stage . in folic llCid~ Folic ~-cid. :pl'i!-Y$ :aJl i mpott:ant role in
. tel"at4;lgert~s.is; . F.e ta.l- $usceptib.ility- to . the .synthesis of,t >NA-apd::RtA l;>a~s. :nrugsthat
. tetatottns" is':greatttst<- attid:s'stage; andf.-is1 e ither.p:re>tent tbe~-absorp"tion- ~f~folate.:cr act ~as
centr$1: totll,e p~h'ogenesisor lnost,.st..rucNra;F .- --a..ltagonists (e.g. :sati-:-s'~lzUt-em~.atioJls: -va,lproic:
m.atfortna:tib*s~ :acid~ phenobarbital, carl;>ama~ep.ine .and .
. . . pb~&:>)'tQ.~J J>teW~pq~- ~ ;a :Wl'iety. pf. CQngen:ital
: ''T:hfdttal :peti:ld<(froni:9~w~s,up.- to :term) is- .. -~C>nnations{th~ ~mpst., r;c>ntmQn :of- which . are .
-ch.arit,eteti,Zedi.l)y~ tlj.e;.--rp'atutation' offe~. 'or:g~s:~ neuralto.ibe detects/!;;;
iiliporta.n~ -t(l-' :turt.~tiomUd~loptnent: . Thefetus '
reriuwis:wmef:iit>I~i:Ji)-~,l_liwl~ . and :~sl,lr~: to . Oth-er drugs e~ert th~ir #fects by the.
~tog~s may still re$';llt t() d.efeets in function ptGducttcsn of ox,yg~n. Jnr~ tadi~~!l t:(nd ~ther
and-,jninor anomalies; -AJ:t -~xaU~-ple -is tbe oXidati-\te'-intenliediate$; ..:~--mdicrus-- are often
p'Qlmotnny:hypopia~-~\J~ by any a gent that rendered inno:ctiou-a--by --;c ytoplasmic ~poxide .
cause:J 11. red~Ctlon .Ui am.tiicfic "11\.l.id volfune from bydro~lase. Thi.s ~e $_Y$te'm, however, Js
2()...25 weeks. immature in th~:f~tt.:l;:t_.l~ to the accumulation
.of these free radicals .in t e(al t:issues, and. .
'MECHANIS~S OF TEAA't'OGltNEsiS subsequent carcin~genic .a nd mutagenic effects.
Spe.c ific ..examples indu&e phenobarbital,
Some pr~posed ine~$m$ .-o f teratogenicity pheny.toi~ ap.d car))'a.ma~e_-pln:e, which are
irielude: me~Qt)ljzed: by.--}lepati.c tnierosamesinto .e!)<d~s
and are.ne oXide:s.:&
1.) ~n-death beyond recupet'iltive capacity of the
-~ffibi-yojfetus - rhe inaternal condition itselt may play a role
~-l Mitotic' delay (increase itt the length of the cell in fetal 'malformations, ~P prQvide a synergistic
cycle) effect with th~ drug in -q uestion. Alcoholism i.ri
3.) -~etarded differentiatio~ pregnant women, fo r instance~ is more likely
4.). Pbysic.aJ, constraint and v~scular insufficiency associat:ed with . com;:omi:t-a~t 1,1se of other
5_) lnterf~rence with hist~gene-sis P.Y cell recr~ational drug:s and . sxno'king. , as '?J~ll as
depletion, necrosis, cal~ification, etc nutritional.deficiencies. Fet1,t~e,11 born to alcoholic
6.) .Inhibited cell mjgr.ation and cell mothers, thtts~, eXhibit:greater. ten<;lencies fQr.
comtrtunicatlon6 congenital -d.e fect$ than would ~otherwise be
explained byexpo:s ure -t9 alcohol alone. .Likewise,
Other agents have more established epileptic mothers , everi without therapy, carry a .
physiologic and g~netlc m echa_nisms. For. gteater risk for congenital malformations. .
/
I
'
Scanned 8y: C
 CHAPTER 21: DRUGS, MEDICATIONS AND iMMUNIZATIONS DURING PREGNANCY .

Genetic factors of the fetus also contribute to
the teratogenic mechanism of toxins. Previous
mutations that alter the functions of certain
enzymes, especially those crucial to the removal
of toxic agents, may increase the susceptibility of
lit particular teratogen (e.g. risk of-.malfonnation . 1. Normal development is an extremely complex
after exposure to phenytoin is increased in fetuses
with lcv.r activities of epoxide hydroxylase). This
.interplay of both environmental and geneticfactors
, probably account for most anomalies that are .
"mul~c.t~rlal illorigin. .!l . 16
Oth~agents act bythe direct alteration of key
geiietic sequences hi embryogenesis. A key
tXample is a group of genetic sequences $at direct
the future position of numerous structures 1. L'1e
body, These homeobox genes are arranged in a
-futed order along the length -of the .c hromosome. .
. This -position, in tum correspo.nds .to .a particular
body region: .the 3' end correspon4s to :-he caudal FDA PREGNANCY CATEGORIEs
'regio.n,. aqd---t...~e 5'. end directs thede\telopment of
the caud8:d' region. Agents that pred.ispose to a
partieulaf<'homeobox gene (e_.g.. valproic acid
exhib~ts a predilection to the 5' end) thus
,pref~rentiilly cause II}alfor.mations to the
.correspon~g body region {caudally in the case
.o f -valp.roic::-Ei'cid). .6.8.9
.. ,..
.:.,,
Finally;pa.ternal factors can also exert effects
on ~ormations on the fetUs. Agents that cause
genl'llfu.e mutations. ancl genetic m~development malform~tions in huma,ns. T he -x. ~~tion
.of $ perm cells can destine the fetus to become
i------even
riiilforiiied rm lantatiOii takes
&tore
. ... - .. . . . . . ... P -- . -- ..... . -- p .
Drugs or agents .taken by the paternal spouse can
gain acc.ess to the developing fetus duri..g sexuai
interc6Urse in pregnancy."67 8.9 .
The. great majority of agents, however;'ibave
poorly understood mecha,nisms of teratOgenesis.
The difficulties in analyzing the mechanisms of
ter.:ttogenicity include the following:
process that is not completely understood.
2 . .Environmental toxicantsinclude a wide range
of chemical, physical and biological agents that
initiate a wide variety of .m echanisms, and
exposure . to specific toxicants are rar.ely
encountered alone in the clinical setting.
a
3. Some toxicants may affect on:ly .fraction of
individuals in the population, while "sparing
qthers from their ter:atogerJc effects.
4. A mechanistic understanding !>f de.relop-
mental toxicity involves understanding .a t
several-levels of biologic organizatio:::l'. u.u
As a guide to physicians; the .F~an.,d;.pr_ug
Administration utilizes a lettered .C,\assif!~tion
system .with regards to their sruew~~r.J:\~-1in
pregnancy. The FDA recommendations are based
on the bestavaihble clinical evidence. anc:lasSign
lettered:ca,tegories to drug~ from A:t;;,9R~:~t
have ,be~n cat~gorically -demonstra~(l.:.;~ -.~~.no,
teratogenic effects inhumans, to q7,-~,P;Ild:~W,;.; ?r
drugs that have been dir~tly linked.to con~tal
is used for drugs that are absolutely
iace.
cqJ:!~dicated i~ pr~gn~g; v{hli~.-jf!j~_u$1i@y
applied to drugs that are positively teratogenic,
but for which no other useful alternatives .a re
pr-esently available.

'h.ble 21.2. Drug FDA categories:

FDA Ct\tegory Interpretation Examples

A. Controlled studies in humans show no risk. Adequate, well-controlled Multivi~ins or
.studies in pregnant women h ave failed to-demonstrate risk to the fetus. prenatal s upplements .
B No evidence of ris k in .humans. Either animal findings s~ow risk, but Penicillins;
human findings do not;.or,' if no adequ a te human studies have been done, Macr:olides,
animal fmdings ar:e negative. Betalactams
c .Risk c~not-be ruledoUL Human studies are Jacking, and animal studies . "
Metronida.Ulle
are either positive for fetal risk, or lacking as well. However, potential
peneflts m ay justify.the potentiai risk
D Positive evidence of risk. Inves tigational or pos t-marketing data show risk Carbamazepine,
to the fetus: Nevertheless, potential benefits may outweigh the potential risk. Phenytoin
. ~ ~-
X Contraindicated in pregrtancy. Studies in animals or humans, investigational lsotretinoin;""
or post-marketing reports have shown fetal risk which clearly ou tweighs any Thalidomide;.. : .
possibte be~e fit t o the patient. Cytoloxic agents
Diethylsilbestrol

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 ,._
SECtiON Ill: CLtNICALAPPROACH TO PREGNANCY

The next table (Table .21.3) lists .d rugs that .are
pr<>ven human tel1ltQgens. Most d..ru:gs in this list
are dther Ca~gory .o or X, but ~me are listed as
Category C. When viewing this Ust, it is i iilPQrtant
t9 note that some medications me.y com.mcni.y
:ca.use maiformations, while others rarely cause
them, even when.a positive relationshipdpes -exist.
Moreover, since .dfll:gs are O'nty used when a
disease ~ready -exists,it .is often hard to show .
whether the birth defects are caused by the agent
itself and not the -clinical condition. Careful
clirJcal judgment is then necessary to weigh the
possible risk and benefits from the \'se of a
par-..ieular a~nt. .

ACE :~biti>rB ~~g. ~p>pril; efi~ill) t> Acetobydrox$1riicacid.{AHA)- X

Amincn.aproic ac;id - D .Androgens (e:;. Dena~) ~X

Angiotensin l1 r~toi' antaconist$ (~g.l6$~ va!sartan) ~ D /.ntitle<?plaatiCa alkylatil\g agertWJ - D

Antineoplastiea lantime~~li.tes) ~X 0 ~Flu<>ro~cil
o Meth<itrexate 0 Meili.Y.la!nin9.Pte$
o ~me o ~~~ ..
o CblQ~bu.cil 0 ~l:lUOprim
~e~oieibBIP1ne
o . Cyel9~o::ph~ide
0 Cisplatin
,, -(>
()
Bieoxnydri

Aspirin-P

. ..1-te.noiot:.,.,D_ - . . Ben%od~azepine:s .,. :D ,a nd .x .

. - ~am(X}:. o 1'-eixa~patn'PQ

. ,0 Tr:~~(X) Bro_ttll4es - D
. .. ~ . '-1:: : .

-.: ~~iite-D Colebieirie - D

.Co~co!lt~id.s;. C . ))~1-X

DiethylstilQe_s trol- Not o*' market- X :f;rgo.U;Unih~ - X

Finasttrlde X Flucona%ole,. C

Folic a~ anta,g<;lllist~ o . Phenytoin - .D

o Methotrexate - X Lithium.- D

Methim!iZOle - D . Methylene blue C

Mifepristone, RU-486 D Mino~dil- C

Mi!loprpstol- X Misoline- P

PenicUlamlne - P Phet1obarhital ot methylphenobarbital- D

-Potassium,.i odine and m-edications lhat effect Progestins -X {ex~pt megestroland

iodine lev~ls {diat:rizoate) - D norethindrone .~ D)

Raloxifene (Evista} -X Retinoic ac.id,lsotretinoin (Accutane), acitretin

(Sori!l.t!Ule), etretiriatc, t,o pical tazarotene - X

StatiJls (3-hydroxy-3methylglutaxyl ,c oenzyme A (HMG-CoAJ Tamoxifen- D

reductase inhibitors) X .

Tetracyclitle -.D Thalidomide -X

Valptotc acid - 'D

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----~-~...,...... ______________ _________ ___________ ....
.._IMMUNIZATIONS DURING
CHAPTER 21: DRUGS; MEOICATlONS AND --'- PREGNANCY ,,, ,. 349

~~~ENTATIVE HUMAN DEVELOPMENTAL result from mutations in certain HOX genes or

TOXICANTS . exposure. to retinoids .in cases of treatment of
The deleterious effects of ~editations Ya.ry
depencii:1g on the crlti~ periods ofdevelopment
when eXpc>sed to said agents: Different organs
have diifer~nt critical periods, although the period
from gestation day 15 to day 60 is crlticalformany
organs. The b.r.ain and ske~eton are . always
sensitive, ftoin the beginning of the third week to
theendo fpregnancy and thenonatal'ri.Od. tb.e
heart is most sensit;ive durlrtg the third ltild foUrth
Weeks of gestation'while the exterrtal Wtital.ii! 'a:re
moat sensitive .during the eighth and ninth
weeks.1.2.3ool,6;8,to
. One must also consider that genetic mutation-s
an.d .tnedicatloils may cause mnillar abnorn:lalities
and synQrt>~es. Axial mtill'ormations ill nnee can
dermatologic disorders in unsuspected pregnant
women. :Matenuil ingestion of warfa_Ti.n can r esult
in defecti:v:e bone mineralization, telc:br'achy-
dactyly., and facial dysmorphism with fia.s al
hyp.o:p lasia. Human X~ linked dominant
chondrody's.plas'ia punctata .(C.OPX2), ot Happle
$yndrome, i$ associated with mntations.-in the
human en'lopa.nlil-biriding protein, a delta-delta-
ste.r ol is~merase involved in choles terol
biosyrith:e sis. Happle syndrome is a genetic
disease ()f bone and cartilage whose phenotype is
quite similar to the dysmorphism caused by
warfann ingestion.lo
Table 21.4 lists .some representa.tive human
developmental teratogens and theit associs:ted
clinical sy'11dromes,

Agent Vse Adverse Effects

... ' . :' ~ . '

l3ci~ rctinoic acid ~entofcy~~e . Crani?facial, CV.S and menta! deficits

:.. ~: (

Folate anta;,..Onist Abortion, CNS, craniofacial, growt:ll d efectll .. ,

: -'
ACE inhibitors Antih,rilertensive Skull defects and kidney hemorrhage

Cigarette smoke Stimulant Growth re.tatdation, facial de!~

D~. . Repr.ridUctiv.etmct~defects
. ..
and vaginal
. . . cancer .

Diphenylhydantoin Anticonv:ulS&nt Craniofacial, mental rlefects, fetalloss, grQwth.

retardation

Etretinate Psoriasis Limb, ear, cardiac, th)"!llic defects

Lead . Environmental Abortion, .g rowth retardation, CNS defects

contamituutt

Penicillamine Chelator Connective tissue defects

Polychlorinated biphenyls Environmental Growth retardation, hyperpigmentation ,

contaminB.J;lt n eurobehaviorn def!cits

Thalidomide Antiemetic Reduction defects in limb and ears

Vali>roic.acid Anticonvulsant Neural tube closure d efects

Lithium Bipolar disorders Cardiac defects

"!.[;;

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3;5D SEcnoNfll:
.
' .. . CLINICAL
. -
APPROACH
. . . .
io PREGNANCY
. . ~

GUIDELIN:ES F,{)R .P.RES:CRlBING AND midwives and .nurses are. frequently asked by
~comcsELrnG.m :P~N...W:CY concerned pregnant women about the risk ()f drug
. . . . intake, .other mecU.cinal products and exposure to
. As a rule:ofthu:mb, drug intake in .the pr~ant pther :substa,nces -for the :up.bor~ child. In
patient i~ gen<;;rall.Y ~v9ided, -e.$.peciliny i.."l the 'f!.r~t providing such ctrtl.p~l to _papepts. tb.epqySician
trimester;-when thefetus-~"bitstb.e greatest risk must . always m~ke sur.e that he . h~~ the most
.for t<ingenital ,maltQin1a~on~. It is importar.,t to .current, .~st evienc~ -a.b:o~t the d,rug ip..que.s tion.
.con~idet, tile:O~ wb,.~~4,:.r i:w;n:- :phatnit?:ologic It In-Ust -always be emphasized -Qr.at.a ba.~line 3%
tre;atment$ are..av$ble ~d ~\l~.Y as ~~e~tive risk for copgenital ~a:tfo~<~:~ions .~sts for all
fqr tJl.e condition :tLe.. P~. ~agmi).~). pre~andes -even with~ut an.y knoWn expos.Jre to
.. . ;:m:y -~ept. u .u_.g,ro
~en. ':drugtherapy ,is abSol\ltely ne.G.e,ss"aiy,
:Pref~nc~ must ~ ~~ -~ .Atugs ~at have l;l . It should a!~o .i?e en').pl).as~d :that - ~ for
.prove~ safety -pt.Qf~e {:Ca;t~_gotie.s :A _,a..""l.~ E):. :~fi s9me i_m portarit ~~~eptions, most .commonly
opposed to newer :ag~t~"fo:r whl~l?. .~t;a;is l~ckip.'g prescribed and over:-the-coU.nter medl<:a:tiO:q.s a re
.o r eq~.t~-v~"a.l. Monoth.eraJ,>,Y .is prefened ~d in relatively safe in p~gnapcy, and ~ven for those
Instances Wh~r.e dru;g. eompinati.qns i.s . fhe witt>.. pr~ven ter:atggenic :pj;>ten~~ .the iissue of
' trea:ttnent of:chcii~~. ,~p._t$ .~\l~;J:~e ..~~~c re}a~~e ::risk (a~{mprease ln pz:oba:l?ility versus an
at
o n:e a "tfule. Expio$yi;-e :Q f t;h.e :{e"f:~JS t~ fue. agent al!-or;-:n one . plt~n.()m.:~~UO"tl) s_l~oy.ld.: always be
must Pe k~pt to -a mJ.p:D:n.u.nt: 1~west wssible d6se exphiin"e d. :e~uai emphasis .shqulC!. -~so be put on
a:Ild ~ho~t.possi~l:e efh~ciiyetr~"b':Ii.eJlt.duration. tbe.po:ssiole ris~s for -~ru;fo_rn:i.ations asSociated
: when oth~t routes are -avaiJabJe., sy.steJUjc with the ~ndi:t;iop. ~orwhj.c}?:the dril.g"theraj:>y was
adlninist:ration 'S.A Qultt:li~.:B.vo-id~:-:(~orlcl mdtcated:~{~.:g~.:epileptics :have ;a.;~b~~selm."e 5% 'risk ..
-~d pi~ ~Tsl+S oral a;n9-.futtaV,e~QU$"),: ~ost . :ror .":na;ifqrmatiqns. as opposed to 3% in
iniPQrtantly,):g e ~~e:_t;i~ o.f}:P.~-~ of .-a.,ny :drt.:?-g ~"Q.r;:p~p1ic;;tt~d pregn!mde:,;-).2 ..31 11 12 . L<l.:stly, the
~hoilld cl~y oq:~gh -ar.,y rislts..posed. to both dilemma :of weighing_:rislc yersl,"ls ben~fit should
the "fetus. ~d:motb.el'. . . also ,Q e -to\i~l:ted;. "f >Wause. some conditioi;l.s (e~g:;
fever) c~-r-ry a. .:g:r eater .. risk of" producing
. sin~ "ihqst eXpo-sur~ -t~ cif.\lgi) iil ptegn~t . malforrnitj.ons than. !lllY theoretical: risk a.ssQci:it~
wo.meno<;cW.~ev.en befor.e:fu.~pt;gri.a:Ucy:i;s.)4lown, with :the. d),'ug thera py in que~tiop.. {e.. g.
th~ phys1d.anwiri <>ften.:find.hiili~lffu.fhe..position pai-a.cet~ri:l..Ol) .
:of: .CQll.il.~ling~the.:pati.ent-4f~,tli~"'teratogenic- -risk
o.f.ter, "~~-po Mue . . -Gb:ste:tf.ioi~ns-,.. genera-1 T-able21 .-5 lists rome comm-on conditions fu
practitioners, pediatricians "an~.ge.heticists as well pregnancy ani the L.-nportant agents to ~nsider
as o~~rhealth"prqfe$~0nals s\ic!i as, ph.q.r.ffiacists, for each.

T:11llte:r.n.~. qomp1on con~tions in ,p regnancy_and a~rociated ~gs a,nd:interv.e ntions. Letters in par.e nthesesmdicate
FD:A.ca;t~ories.77 -~ 011 ~ 12 ~ . . . . .. .

<::,ondition Drug/Int.erventiol;l

Bacterial Wections f'e_rj:~cuis {B.) -:preferred agents and proba,"Qly tne safest antimicrobial in pregnancy
ErYthromycin {B) .- for pentcillin allergic patients
Use with ca~tion: Cephalosporins (B), Ch\oram:phenicol [B),
Metronidazole (C)

Tub:erculosis Rifampicin, Is oniaZid, Ethambutol- h ave shown no i.ncrcase.d risk for congenital
malformation; use wit~ caution

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 ..... CHAPTER 21: .DRUGS, MEDICATIONS AND IMMUNIZATIONS DURrNG PREGNAN~Y 351
----~----------..,.---------.....;_.....,----'--_,....:_...:.....,.._~

Colds, Coughs AlWays aim for sympwm!ltic relief with "fluids rest.Antihicstamines with relatiV~':;dety:
aria
Chlorpbeniramlne {B), Ttiprolidine (C), and Diphenhydramine iC) (more rapi4 ot)set of
rebound congestion in pregnancy; use for no lonF than 2-4 days) Paeudoqmedrine
(C) generally ~ns.idered -aafe in pregnancy. Cough Suppte~ts: (htaifenetiin (C) o-r
Dextromethorphan (c) {avoid prepar.ations With alcohol .and iodine) .

Nausea and Vomiting Should always be treated conservative!; when effective (rest, -m:nall, .frequent
meals, and acupi'e~sure)
~doJP.pe Vit D6 "(A); P'flidoxine in eombination With t)oxylal.nin~ (S); or
Emettol- fi111t~line
Ust with caution: Pr<>mtthazine (C), Metaclopramide (C)

Paracetamol {B) - p ain reliever and antiP.Yfetlc of cliei~~ !bu~~~ r.;;.

Naproxen '{B), Aapl"i!J (D) -use with caution
..For Severe Pain.: Narcotica {Codeine, i:>einerol, Morphl,n~).ma.y be Odnsider:e:d,
but .adtU"ctiv.e potential for both mother and fetus should be re-cogtili:ed (risk
for respinltory depression)
LOcal Ane$etiea {Xyl.Qqrine) may be used safel;,, but combinaQoos with .
' ~pmephrine are genCJ'Il]ly ._voided
r'
f Diarrhea
'
:Kaolin ap.d PectiQ (13)- a.nti.,qiarrheal ofcllQi~, not absorl>ed :syatemi~y . '
Lop~de (B) - most probably $8fe . . ~- :.-.. .. . .. ~ ,.

Tr.ea~ent istbe saml: -~with the nonpregr!IUlt p atient. iheophylUil~ (B)...~~ ~

Salbutamol Via aerpsol (13). Stel'Pid~\B) and Leu:kotrienea 03) are ,all ~e
in pregnar.cy '

~ ' .,

Alway!J e~pha$ize ~ill~ in r.aK for1nalf~n~tS% in:~ileptk,3 ;,If;:. -5;;:;;. \.~ .

3%.inother&)iti.ifhorwithout therapy. Avoid dnig.corn1)lnatioli8 whenevet ;- .~, .. :. .. ~,-~
po~siblc ~d u,seth~peutic ~~ mQnjtoring whenn~" --
11i~r.@J?tli.d.~ :D'I~~jm4~.~~~ ,;nd :OJlC mqcondder elowty
witli~.g:t!ietaPt..it~~nt baa,~ ~re free for "2-3 yeara. -
Tite~:in11$olut!:ty~cr:JIDttlf!a"'ti()tt".fljf"~~-ftQnn\~gWitli te?at()gepic
risk:(e;g;emh~e)w-orre-'abbut-wliiclreveTba~i:s'lafo'Mi.
PheMbarhital (D)- J;lQ inc':*aaed frc<iuency in minor or major birth defects
Carba:m~itie (Pl ~ "tradition,ally .~ .drug of clloke in pregnancy. but .presep.t
data on ita teratOgenic potentialia. \ltl.cl('..lir
Phenytoin (D} teratogenic potentia!lnfluenced by genetics (epoxide
~ydr.9xylase .levels) .
Va,li>roic Acid"-(1}) 1-2% risk 6hpiria biiida, also as~ated with minor cra,iiio-
faci;a.l a.bnp$alities .

Hypertension Methyldopa (C) -most wi~ely used, \.Ulparjilleled safety record in pregnancy
Beta-blockers ((except Ater.olol (D)) - not teratogenic, but may .c ause growth
restriction
Hydrala.zi.ne - no adverse:fetal effec;ts, used for the 2~-3rcl trimesters
Sodium Nitropru$side- readily crosse3 placenta and in theory, may cause
accumulation of cyanide in the fetus; no adequate clinical data

Hyperthyroidism Propylthiour'acil- used .m ore often than carbamazepine. Is less lipid-soluble

and more protein-bound, thus transported le ~s well to the fetus and
breastmilk.

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3S2 . SECT~ON (It CUNICAL AP?ROACH TO PREGNANCY

IMMUNlZATIONIN p.l U;GNANcY
Vaccinati.oil :in pre~cy. s.irriU.ar to drug use,
is a special scen.a.rlo ~fnat bOth the effects .on
th~ mother and fetus must be )nsi~ .together
in its admini~tration.. Vaccines that gener.ate an
immune response in the. mat.rill!l serum ma.y also
become protective to 't he fetus .wh~n maternal
antibodies pass thrcn~g~ ~e plE!.ce~ta. Tl).is
;phenomenon, however, 'lni;l.y ~-detrime.ntal when
a sufficient amount of matetn:al tmubodie$ are
tr3.nsmitted as to interfe~ With the devel~pment
of natural antibodtes in the fetus. .Maternal
reaction~ to vacc~rtation, s~ch .as -fever :and
hypersensiti~ty ttiay so .adversely affect fetal
s~pjx>rt and devel~pme~L . effeets .on the fetus i~ indicated. Regardless .of
These tisks; however, .:ar~:P.~Y.theereticaJ.~
At p~e.--ht, there isrto av8.i1:.8:ble ..($pica!. evidence
tl1~t ilaccination ,elth.er With l.na'tivated baCteria
or..:viruses ortt.~ds ~'es e.p.y .tisk t~t:he :fe~s.
. Uv.~ v~ccines, hcweve-r l cany ..a .greater theci:etidli conim.on ~lacdne..S 1n pr~anc,r.
.risk of cau sing fetal disease a :nd are :geneia.Uy
av.oided. i,n p regnancy. Altogether, the benefits of
vaccination in p:LCeg:n.aney generally OUtWeigh the
risks of .fetal dis~se; especially when the risk of
developing the disea:se is relatively high (post-
exposure prophylaxis) and when the vaq:ine is
'unlikely to cause any hmm.
Liv~viruses (measles, mutnps., rubella) are
genetally "eontialll;dicate:d in pregn~cy ~use
of the probable risk ofy-ertical trailsmissi.on. When
a live-Virus vaccine f.$ 'inadvertently given to .a
pregnant woman, or when a vacci.nall:d woman.
subsequ~ntl.Y becomes pregnant wit:bfu4 v.-~lq1
of.the vaccine, COUl:l~eling about the po:sci.bl~'
Whe,Uler .a. live attenuated or kirled vaccine is
adinir~:stered. risk v~S\ls benefit a~ is
stilNhe nile Of .t:hum:h~t;u.i4
. :Taq~e 21.6 . ~~'izes the re~tive safeg of

Coinnu:::nta

1'etamta4>iphthe~ (fdl .:,:.~. .. Y~~.:-, :- :. ,~;Pt;~t::.J:i~Uen~.:ahquid.~e:te~ toxoid .as ~ ~a iftbde

':liWS~llQ pnorAd!Jlipi~tn~;tioJl:wmunthe-last lOyeara. ~sly
u;n:v~k\ patiep:ta,$hm;u.d ~~J(e ~ .cQ.~plete"~ o3 . ..
~tion~. The iprcfCried-sehi!Uie ~ifter the~ trimea:tcr
.. ~e~dd~ gi.V.Cit4 w.eel5'~apan.. iiui ~..ilie oti.IY vaccmuOii.tin~
Tn~Ette'."d<tor 1ill.Bi:is:eep$1~;p~gnax~rpatiffits
. - . . .. . ..
- Hepatiti~ A . B~u.:;;~ v~~ i's :~ kmed ~~,Q.~. thei:rretic;llrnkhlow. btrt,safety
. 1n pi@~o/ has t;~-.ot'been .de~e<L liay be indicated IOC)lWl.
rlskpatiep_ts,

Yes .P.regn_!;l.Il.qj.snot.a-c6n~diq.Jioh.~apatiehts:!J.t.~rislc.{e..g. >l

m
sex partner the 1!1-St 9 ~nUt,; ~~~t STD .IV~ u~ or&n
.BBs.Ag~positive p~~l ahouidhe'it~ted. CJ.u;rent ~are.
non-infectious a.Ild no data ha:s:$owru3.etrim~~ effects to ~fetus.
(HPV) Human Papillomav:inls Not req:>mmended Vaccine has been relat ed t o some !J..dver-ie outcomes in -prcgn.ancy,
but data~~ limite!f.

ln!luenza (Inactivate..i) Recommended du ring ~ue~.s~~n. aspregnantpatirnbwbo

be~pme infected are atinrea.s.ediiskfor :~-evere complications.. No
.adver-Se fetal outcomes :r:ep<lrted.
. .
M~asles, Mumps and No risk to fetus of live vaccines cahnot be cxchided and shoUld not
Rubella . be.administered in pregn.arit patler~h. Vaccinated wom~a.OOuld 'be
advi~ed'not to beg>me pregnant for:2:a days after- a~
rubclla.containing vaccines a.te Cq'n~9l~ted because Qfthui3k of
developing congeni~ rubdla s~drome (CRS) i inbe !~ttu. But to
date; n o documented. case;~ 0fpost--\ract;fuationCR:;l have been
reported. ..

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 CHAPTER 21: DRUGS, MEDICATIONS AND IMMUNIZAi10NS D.URING PREGNANCY 353

Pneumococcal Not established Safety in pregnancy has not been evaluated, although DD adverse
effects have been report~d .

Polio (1PV) Yes, but avoided No advecse.effects reported, but generally avoided due to theoretical
risks. High riSk: pe.tients, however, may be CO.f\sidered ~vaccination

Tetanus-Diphtheria- Yes Pregnancy is not a con!rrundication t!l OPT. Matem&! pertussis

Pertussis .(OPT) antibodies.may be protecti'!e to the infant in early life, a nd so m~y
practitioners v~rer this vaccine 6ve'r tetanus toxoid alcme.

Varicella No Because effects on the ietus are unlmown, Varicella shouJd be avoided
entjiely .in pregnancy. But because of its lower viru!e..'lee, the risk of
transmission (if any) should even bc'lcwer than, the wild type. VZlG
should be strongly considered, however, for pregnant patients exwsed
to varicella. . . !;

.BCG Not recoxpjnended No harmful effects repcrted

l)pboid Not established 'No available data

Yes, .as post- B~ause the consequences of rabies -far outweigh the t'Qic of
expasure vaccina~o~; p.-egntl.P.cy i s not a contramdication for J>(W~sure
prophylaxis . prophylaxis .

. 1.
... . ..

. ,.,..,.,.POINTS 10 REMEMeER

P~Pir:t9 pregna:11cyor;~u~ng
in ~~alwa.ys a~iss~eofco~rn. Aithough th.eH)~\~~t~~~~+ ~
lactation .. - ..
.: :.
pregnancy and lactation gutdehnes for drugs, the classifications typically do not answer theqoesudr)~-:.t -
. .,~f Whether.to treat or not to tre,at. or which drug to use.

.For !he .prescfiber:rhelp~ln- making-deeisions about presGiibing in pregnallcy c:i'r1d.lactau6ii can be

gained. from .standard prescribing practices and -guldelit\es.
The -FDA classifies drugs inone of five categories based on their teratogenic potential:
Category A: Controlled ~tudles in pregnant women demonstrate no fetal risk (eg, foic .acid,
levothyroxine); .
Category B: Controlled animal studies have not shown a fetaJ .risk but t'1ere are no 5tudies done
. on women OR controlled studies in animals have shown a fetal risk that was notreprodUced in
controlled human studies {eg, amoxicillin, ceftriaxone);
Category C: Controlled animal studies have demonstrated adverse fetal effects and there are no
human studies or there are no cont(olled studies in humans or animals (eg, nifedipine, omeprazole);
Category D: Controlled studies in humans demonstrate adverse fetal effects but the benefits of
using the drug are greater than the risks (eg, propylthiouracil); and
Category X: Controlled studies in ~nimals and humans have demonstrated adverse fetal effects
or there. is evid.ence of fetal risk based on human experience. The risk of using these drugs
outweighs any, P.P!:!Sible benefit. The drug is absolutely contraindicated in pregnancy (eg,
misoprostol, warfarin, isotretinoin).

Most drugs prescribed for pregnant women are Category A, B or C. Category A drugs are uncommon
because controlled studies In pregnant women. are rare.

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354 S EctiON. Ill: CLINICALAPPROACH TO..PRGNANC

When it is necessary to presccibe drugs in pregnancy or_lactation, clinicians should fotlowthese g~nerat
rul~
Avoid mediCations during the first tiimester When. ~ fetus .is at greatest risk fr.om teratbgens.'
D6 not u~ combinatiOns of drugs. Use one <.lgent at a tim~.
L}s~ the lowest EFFECTIVE dose p6s-sible for the shortest amount of time.

1 Use topical.tr~tments wtlen avaiiable as yo.u g~t.r~ss systemic absoiptkm.

Use.the f!led~tlon only if jhe benefits outweigh the risks.

8. Lo W'Y, .F ritdman J 'M. Ter$;togenicity ot recent ly

intri>duc z;n.edi_catio'us in h\U'Il.8ll pregnancy. Ob:,tef
1. ~f:P, Le-~o'KJ, BloomS, HauthJ, Gilsti:iw G~ecol2002; 1P0(:3}: 465-47~l.
.LC, w~ J{ (eds). :WilliamsO.b$tetrlc:i . McG_iaw-
H:jh. 1ne. md~ ~s. 9 . ~chtle A, lilSoh H. ,Birth .d,dect cla ssification by
o~ ~tem: ..a:10'!Cl ap~ t o h~t= teratogenic
~- .R~ Jl,., Rubin Viwter. MR. -~e -.Notes ;fu
:P6, . si~a!ling in a p:~~cyre.tMtzy~ Pharmacoepidemiol
Clliiical PhapnaQ'logy :~4 The-rapeutics: p e.?~S6. DiUK'$ af12002; U{6): -46:s-47S:
M~usefu::.~l>ub~gl.td, 7th'ed., .2000.
10. Schlei:lfd~'NS. l'era.t!;llogy;~p.rug .use.il,l pttgnancy.
-3; .Kore-n: o; -s~~peeb"O(~~ate.P~d~tric .. Gob.tritill>.:U.ni.~~ity;:2b~i:~ :: ,. ;,:-. .
phan;liaeo~ogy. tn~gs,~di: .~r~ t;,r..d. c l.in.idd .. . . .
?harroacolag;y;: p9Tl~72. 'Mc6ra.w~H.ill Iilc, lOth.td., ll. 'El?-k RA. Hill'DA. Ov~-11;t~ilnkrimediatio?-3 in
2001:. : =p~cy. Airi~can'l"ll.lnW=P.by-&cian~3; 67 (12):
. . 25t7-'2524"~ . .. . . . .
4. Q.cdeOri: c, -Ko~.:-<;:-.. .~ :p1'egilancy cex:it~e.d
.. . .medkation4: J::miga~:~O n6t ~ ..t,h.e hUman .. 1~: Cen;t~Vf~$: ;i)rug1' AI)-,Pl;:OVM .~Y the. FDA {2004): :.
... pla.<:;en~-~centa~00$-;:2;.;;}. ; . . . A!.~ble,at:J;J.ttm(l _wW9.; $Q!t~t$-Wi!l/ ~t/-
. . 'drU~f~.ht:UH. 8.~ t-4~,1'homp36:n.; 2004'
5. H~t~pg .G. 1'$8.~ ':r~ ;M, $il,pir 0., .J:i~efu1 M.
Meior M~ !kti ZV'i Z. Nc;w- ~ in p~tal il...~g 'rlng ~g:W.;cy. clin 'ObsU:t
1a. Fa.ix-R. Imm.lmi.iation.. dU;..
i:ran--arer:P.IaC.~~g'.tran~2oo:J;:s:.at3et: - -6yn@l'ZOti2;4S~t~':J:'4Z=58-;
.. .. .. .. .... :
. -...... . .
. . ... - . . .
. . .
. ~ -. . . . - -. :
- .. -- . ., . . . 't
6. Bret~;tRL. Terati:>k>gyln the 20th century: environmental 14."-C DC. G~dclines for Va~ating :~t Wom~:
- ca.use11 ofcongenitat~orinati6n;.3 in li':.linan~ -&n"d h ow .R ecomm:e n daiions of the Mvi~ry .Commit tee on
they were estap~ Neill'Q~w5ctll~e;a~l2004;:2,6(~}: . .lnim~tioA;Pi'a~ (AC.IP).2.007,
:r-p. . . . 1 .
7 . Briggs ao.Fre~ RK;YaffeSJ. I?.rugs in Prcwi;mcy
and .l:atfil.tion. 't?tli etl.' Phila'delpl4a. : Pa; Lippmcott
I W~.il.'&W'~$;.;200;1.

', j

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 IV

,.rGiinkai.Approach to .
. Labo~/Oelivery
,',"; ' ~ . ~ :~ :- .. ..

22 P arturition: Biomolecular and

~ .. ~ '~ .~ ..
. ,. ""! : ... ;:: ~

. .. .
. . 4_. . ~:l' ,..... . : .. . .. .. .: ~

:r~:n:,.,.,.;n~~\~*'~~i~-
:ft!i;~~~'{;~!t:":'!"' : . .:.:~\_:: ;,_~:
. :.:: .:. . .;,.
~-stiien
'. .
':.
t!f~~~-,-;_,:;" . ..:, ; .....

Ariestfuesia
. '.;_ .::~ -~'"':.

29 The Normal Newborn

._ :;

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 22

PARTURITION: BIOMOLECULAR
AND PHYSIOLOGIC PROCESSES

Phase 0: Uterine Quiescence

: '._f I i i'

Ph asa 1: Prepar~tion fer Labor ...

_

. Myometrial Changes
Lightening
C~rvical Changes

Phase 2: The Process of Labor

Myometrial ceu Ancrtomy and Physiology .
Regulation of Myctnetrlal Contniction and Reh:ixation
Three Stages of Labor
Cervical Dilatation and Effacement
Placental Delivery

Phase -3: The Puerperium

Regulation of Parturition

"Faii-sate System to Promote Uterine Quiescence

"Fail-sate System to Promote Uterine Contraction
Fetal Contributions to Parturition
Oxytocin
Prostaglandins
Intrauterine Tissues (Amnion, Chorion, Decidua)

Scanned By: C
 . ... -:~~>:m

35t1
---~--~-:se==c=TJ:::ON:-:-
:-:
. 1::-:V_-.-=c:-:U-:-:N:-:ICAL:-7"
. :-_ -:-"AJ>::-:P:-::R:-::0:-:A-:C-:-:H-::T:=O-:-LA-:-::-BO::-RID=" =:R:-:-Y~--~---,.......___.~ -1~K
. =E:-:LIVE:-::
=.

the delivery of the fetus and plac~nta. Parturition

ends when the nQJ! ~Ef~.~t anatomic and : ;. .
.. . 'Parturition is fue-~on :of giving birth to an functi(:mal .Part-5 of the -q.t.e rus a.n'd ceiVix ar~ .
. op:~g or a prQ9eSs -o f bir..hin~ that s~ from reg~~ . :~
:th~trea.t from p~pancy mmnt.enan~e to ~~ .
. .. ;... dellvei}' of the fetus,:e~Sion :ofthe placenta and PHASES OF PARTURITION
i Psu~uent retum to the non..:pre:gn.ant stat~. It . .
' .is al~ synonymous with bildbirth. It covers all The parturition process iS divided into: 4
.)he:-,physi6logi:c an.d _n;rot:phologiccb~et ~the 'fun~tio~ 'Sts.tes: ph~-se$ c. 1. 2, and 3. ~ The
: .uterua .. ~d~- -M d th~ biomo~ ~n.ts d.iftere~t .phases.h:ave been -~efined ba~e<;l on the :
. .ru1d pi"oee.stea t hat ~te these Chan~ major .\!terine and ~~- ~~- th.a:t oc~ur.
;.:f;;~ :.: :_.: ::.. ._
.. .>
fM::'8;i:>: . The term'~~r~ve.b:een U8ed .t-9~4~~-'the
:.:..~ . '. ,.:~. .. . .. .fnetH~h:'ph2<se. Tli~ morpl;l:o~ s;na;tU,nqonai
.
4"ataitioti&. .progtess in .~: ordetly .~d iliD.C;;iy
-:::~:~+ '
1
.cf'~e d~;- W.\l$C.'or&~-4i~ . -m anner f..--o.rn .one -pha-se-to Ur~ :fl.~t. {Figure
diffict.lltV This."reflecta 'the energy an4 Paitl 22.1). . . .
.e::Q;)er:ienbed by 'wo~ during 4:be time -tha.t the '
.eet:vJ.lX is dilating afid the ute~~ c()ntractiilg. Pha.se 0 .
.. myomettUd :contractions are painful tliU:s
;~~k~t'lllt:l as labor ~s. This is. the prelude to :pat:tU.z:itioP, the tiiti:e of
contractile tr.anq11~.tity e;nd tep7lcal r.i.glci.~Jy
.~.fu:irt 36. t~L$8 ~~ of g~~n, obServed 'from biid!;e :hnPfiffitaiioO.";Qiitif'~t~- in .
~.~r.o~letr.lUil1:1.~~ ~unr~@e ..to .'~.number ..uf gestation at a)x>ut 3S - 38 w~'3_..
but 'aft:er.tlift:J ~>-prolqn'ghi: :per.iod.:of . .
;J,i\l~~ice,a.~i~p~.i1'!-..~.wh~re Phase 1.
~~ fo_i and :the"~:is .. !aoor .
~~~]~~~~~~;;~ All~t whl~l;.l~ : f~~fta .This, phase.ie .;v.her~:.the functlonal chiuige's ~ih
9: 9~.:-the m~c;>-~~1Wl..:~<;l ~~~fttual:-.- ;.p:~.yo~~t:P.~ ~~~~~ r;>eiur..in .p reparation ,foi . . :.
r~~1~~~:,:~: Of!.the i.ftra~$lbdomit;taFpo/...sure 'force':. : labor~. .'Clin:icru!y;~~e.clistindive'~.igns:which -~..' :

:- . I
...'' - . .. .... .,....,_ _....__..""1
_..'/ - ...,._ _ _ _ _ _ _ _ _ _ _ _ _ _ _'"':'.""tf......._;~~
..,_[ .. ..;;:..
..;_
" .;....'--r
;,;;.; ..._..~
........ -- ;,.;;
-;.;;;
-;.;.;
";;;.;,.
" ....,

Phase o Phase i i PhaS 2 Phasaj

. ~ . ..~ ~~- ~f--~~---~~-
~'__ ~--+-k_~-~tioo-+_s~~~~~_.. -1~~:,~~-~~-~
.. ! ; ' ' t
_._r. n :for Proc
JPrep_aL. .ra_.botio _Leasbos__.rsof
e :Parturient
~. . . : . ,J .Ptefudeto -Pa'fhlrftion cc 3. . .. .
R~covery
.. If. 1
l

.... .
. ...' ,

. . ... . . .. ~ ~
eomradije Unrespoosr~eness. 1 wm .j AdrfS.~ -~:li/~;~~ ~
1

Preparodness . (Three Stages . :Brwst:Fieailg

fx Labor of ~abOr)
.: ' .:'CONCEPIDN
. :.
IN!nAT10N.OF ONSET OF OLNERY OF FERTilJJY
PARTURITION LABOR CONCEPTUS RESTORED
... =:.. .:. \ ------- ~-
--~----------------~
.
Figure !22.1.. Ph<;r.sc of parturition.
. .

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 CHAPTER 22: PARTURITH)N: 8IOMOlECULAR AND PHYSIOLOGIC PROCESSES ' 359

' I

during the ~st days o( pregnancy _are: '-ripening of
the cervL'c.,~ii}creesed frequency of painless
contractionsKd.ev~lop~ent of lower uterine
segtnent and~creased responsiven ess of
myometrium to stimuli.
Phase 2.
This is the period ofactive uterine contractions
which bring abo~t cervical effacement and
dilatatipn, fetal-descent and ultimately delivery of
tbe conoeptu$.. C ustomarily, this is divided .'into
3 ~tages of active labor.
Phase 3.
This is the :recovery:.period which terminates
..in Uterine.involut;ion and restor~ ferti.iity.: Uterine
irtl'Olution takes about 4..6 weeks but the duration
. of phase 3 is d~p~rtdent on the. dUration of
as
. h-l'e~~tf~!lln-g for long as breastfeed.ing is
i:ontin.~ed:ferti.lity will not be restored completely.
(j (~!: 1./ .:. \._
Specific modifications in the uterus evolve
during this phase:
1. A striking increase in myometrial o.xytocin
receptor$: A delay in the increaseofreceptors
is associated with prolof1ged gestation. .
2. An increase in gap junction (n'Qinber and
.surface area) between the myometrial cells
before the onset ot :labor w hich -ont,inues 'to
increase during labcr, and decrease quiCkly
after delivery, .
3. .Uter:ine :i trltability
4. Increa,sed ~penSiveness to uterotoriins .like
oxytocin~ '
5. Transition from a contractile state
charactetiz~d predominantly by dCCa~io~al
paii:lless con~etions to ~ne in which moS:e
frequent -cQnt:iqetlo'l.~s develop.
6. Formation. of the lD'Wer uterine segment'

Pl:!tse 0: Uterine Quiescence -~

, .. .-c- .. P~/:r~:~;-..
:_ ..

A few w-eeks -pr!Oi" to actiVe labOr, th~ :fuiidic

-: ,, .... i::J>hase,O. is described as myometrial $moo.t h lieigl !t decreases . to $6ine de:gree . at)d tl;lis
-ml,l,.Sele un;responsiVen~ss .to .na~aJ ~~uli and :expenertce is descil:'bedb jr :t lie mo~.e.,s .ffit~ba;~ ~ .
-~~~ '0iltractile : patalysis a .g$sta .host .of dropped": Th~ event iS :caned "mgh~g-~V:t'bis
nu:cha,tUcal an4 cijemkai challenges while the resulU; from~ formation of the -~
.cerviX-remains unyieldingand fum . .This begins _se~ allowing the fetal head to descent and
even before l.nlplantation and is maint:a,ine<J. for ~) rduction in the _amount of am.nioije_: .!!~.
. aboutlh~ 'first 9'5%.ofnormal preg nancy. Crvial voltiine. . .
.. anaf6Pl"ca:Ftilid '"sti"Ucffiril' mfe'' -~ ~h()uid -~be .
:!IVJ lH/\
n ' . . . . . . . .
1
. ~ ---- ~~"-- --~--,~--- ..- -- -- .... .. . . ...... .
ciafntamed t.niougnouf:-.Phase '0. Otherwise, CerviCal Chaitges GUy; > '
pr~mature cervlcal dilataUon, cervical
incompetence or s hortening of the cervix ls With. the initiation of parturition, the cervix
indicative of increased risk of preterm labor. must. soften and become -yie.ldjng to effect
cUlatation. The -cervical modific<1Jion~r of _phasel
Phase
.
1: Preparation lQt Labor
. or parturition involve changes in the principal d
.s tnic;tural components of the cervix. '_:collagen~
After the uterine tranquility of phase 0 of ~mooth musc1e anakonriective tissue or grg~<i
parturition is suspended, the uterus undergoes --.SUbstance: 'Thcn;mootllii:msc1in;ontenf of the
~aw~jpg' or "ac.tiYMiQ.D" to prepare the uter:u ~ cervix is much less than that of the furidus and
and cervi,x.for labor. MoJ:Phol~gicaland futif:tional varies anatoniica!ly from 25 to only 6 percent. The
~hangel! irt the myo~e-ttium apd cervix occur ground substance is made of glycosaminoglycaris,
whiCh. include restoration of the capacity of the hyaluronic acid and dermatan sulfate. Dennatan
. myometrium to regulate the concentration of su!f2-.t~ is necessary for ~q_llag~ru~z:q..s.Jiii.i@g~s~
cytoplasmic Ca++, reinstitution of myometrial cell Cervical softening is associated with 2
responsiveness , development of uterotonin . complementary changes:
sensHivity, establishment of intercellular :i,.
communicability and ripening of the cervix. As 1.) Collagen breakdo.1Y!l and rearrange~nt of the
. these functional changes in the myometrium and collagen fibers. . ,i&,. .
cervixoccur, phase l of parturition merges into 2.)..Alter.atio.ns.Jn_the-:re1a.tive amount-; of the
phase'_ 2 of active labor: various glycosa.minoglycans: hyaluronic acid

Scanned 8y: ~
 360
. (whlch retains watei') i s strikingly increased
while det;J:natan s uJfate is decreased.
~~dins. ~~ ~~ applied directly
to ilie :cdvix or intrav~t -suppositories have
beep_ uscii, cJ.inica;lly to etfect cexyical softenmg and
. f9.cilitate. -indl,H;;tion of l~l;>or. -R~axi,n m ay also
contrib~te to--~~cal -fteJUn_g while mc;dntaining
the-ut:.erv"S in qtl;i..escent iUtte.
- P ,h u-e. 2 -of-Parl\lrt1Q"I1! :T:he Process -of Labor
Phase 2 is .sytiol:!-ymous wi~ activ.e
characterized py uterine i:;On~P.ons ~~t: .~ring
_-a.ut .progresswe. ce.r-Vj-~~t$on an4-d~overy -
of'the coticepttt.s. This i~ customarily -ai~d~d mto
~- -s~g~~L14-br.::.. The -_o nset of.l~po-r . is the
"tranaitlon !ro:a>.- ut~e ..ph~ l 'to -ph,a'S,e .- 2 of
._parturi~n. At1-:Urui~l'~~niii,J;t.g.of;$~.~yomet.flal
:cen anato~y an4~~lpgy:.;:a?:9 ~- regruation
~~fni?ai-~ t:l).e ;m~~.t ~t-la~r.. .
:M;yq~;:etrial:Ce;li:A~niy~and:P.hySi.Qw[ry.,._..,, .. .. -.
_. .
. -_. rP-i lit~e s:qiooth J'n:qsle$ ,-~aye ..unjq_l,le
_-- ~9~iAAl_f~~;S-- -~- ~ p._~~~geP~~;in-~~h'e
,-~~~f;-~~~-i~~-~ ~-:4~li~:o/. -. :pho ;.ph.ata~~a~~Voi-tt ~~~:.'~e ,-Jfj!l_-a$g,- :Q:n :tf-e
-Qf:_~~fc;~,;\f~t.~,tl;I,e.-~.-~ ~.~Q~({-~.
',~:-.}i~.~ ~:~.p:~cpo~..~--~-~ /91;1-e ~:mi~r:.~of
.-~~- ~~r :th~-.that:atGUne4 by &~~letal
-~u:Sclc;:S.Wseco~a; -ro;~ ~- ~-eX.~~ iii ,~;IP..y
dL~on~whereasthe-q)ntra:cti:on -{o=o:;egenemt'e'd
hy-skeletalinu~le~~'always..:~~-:-Witli:axii <?f
the muse).e fibers.{,:)rbW!-, the- smooth n;i:~e1scl~ is
-ReQ~tation - ofimyo'rnet~-cell -corllraction
.r _.: a: .; .ii c:. ::.;
ll~h r,; \:'~.
A c.t u ' MI. C
( c c r1tr'a cti c n )
. . ~~ ph:~~:~Sif--~ .~"::
~1 LC
.f$oyl:!!hQn of ro:;ta><atiQ!'J. _ (retax.3 ti o n)
- "'~'Re-move .agonl:>-t'from r e _c eptor
:2:~;.... eytoD:h~-~'k: .carcrum
5 .. o.;~?e MLC
-:4:~..~.<:~-!~h.t~~oiy . - Fl~r~ .2 2,'2. :P hysiology of
.l<f P.,!hway-1{/.e~ c-.,>.l...., P.-o-r cGMP.) .-
Snanned &y:
..i
-not -organized -a nd this .facilitates the gteater
~horte~g and force--:generating ~pacity of smooth
------ 0 0
muscles.;::,Fourth, this-ll!W~~~~Hg in force
gene~tion permits .Y~Tat~~:itr_:.~ -~~~-::Il!ection
irrespective of the lie cr pre~..n:tati.on of the fetus.
Regulation of MY DJJ1-.Ef!.tri.al _Cpn-tracticw. cui:d
R elo"-w.tio n
The.)p_t:e_ra-etion ,of :lllyD-s i!.Land-actin i s
. essen~ial-"to inu ~le cpptractions~ Myosin is
.comprised ofmultlpie-U&ht- ap.d h~vy -chains and
labOr laid down in thiCk myotllaments. Calcium
releat~~d from L"ltracdlular stor"s bip.d t o
cad~od,ulin which then a c tivates mybsin light
chain kinase. This myosin light chain lqnase
catalyze..s tbe enzy'nw,a p)l.os_photylati-on 'l;)f-20-
~-P~ l-ight _.chsi'l:t- -oi'- .q).ycr~i:n.. ,Th-en the
- ph~YspAd.cylate"d -tn,yo#n JJ;~t c~a.in :l,uteracts
with ac.$ 1 ~~sing a~tiY~tic>n :Of.. ~.'l'f,a.st. leading
to _ATP .-hy.d:r:a}y.~is ..a nd .-for.c~ .:-g-~n-e'r:a..t+o~.
T:_l)~-t:~foJ:e ...:agen.ts:and~.n<liP.PnS:~.hi~4;Lcrease
in tr,acell uiar -ca:k:lum.,:.-~.~myo~etci:~ ;-~moo"th
muscles pr-omote = .contm.cti-on... :1'he:- 'inc:'~ase:in
caldu xn i s- ofte-n tt~si~ti~~ .b:u-t c~n be
, pr;pla:n'g~.d -:by:.' JnP,iti-j,tih n ~-;o'f ~ .tl):e :my~sin .
..
.ollier.-ha; .~oP,9i~o~.'WP4:h id~ -ca1etum.. :
. favor.-ne_4uql.tioJ:l... l~ ~~tio_I4 .,agents .il;l~t caus e .
aJ:l- _in;cr~s~ _.:i;fi . Jn~~111~.r -~t>_ppentr;a~o?- ._of
.cyclic ad~_nosi:g~~nl>.P.'~Phate {cAME) .:or
_q d_i:_c- "@f@..<fi.}E;'~~-w:.q'!.ffiPb?.S'Ph"a;t~-Tc~~-P.)' ~so
prorp,O.re-:-~~i-llf~~'!~~Q~~~.P~u-gl:itlie-. _e . xact
meq~arusm ~s p.ot- ,d~ ..{F'igv.te 2~L2).
t ~}\f-~ .- "(QJ+_ ~ ut'~('_
0
b.1 Ut-M'\
f;J.J.y_M..;.,_ --(AM(
c&I.Af .
-- I
.:. :. :;...
'\-
.
0 .:.t _,r:~r::>
:::..:4:.,.
{a~"tt v v) '. '-"'" ;,, n ,
my.omc~ con t+action .
~
 lt ,
!J
.~
CHAPTER 22: PARTURITION: BIOMOLECULARAND.PHYSiOLOGIC PROCESSES '361
--------~~--------------~----------------------~----~------~~. ,

-i.. The signal that controls the myometrial
contraction and ieluation is transferred front one
cell to the other cell through myometrial g!U!
r
i
junction:?.. These myometrial gap junctions t:Ons!st
or ~.rote!ut he~-chanrtels. termed ~-m~s.~
'E ach connexon h composed of proteins Called
conn~s which s:-e arrangedh~~gj_eally.
.....------:---: . .
Estrogen, progesterone and other ccll s'litface
receptors djretly rego-Uate the contractile state.
/ These are':.:.o-linked/ ion-.c hanne.l. linked ~nd
- en%yme.,.fuiked. Most :of these are he:ptahelj.cal
recepto~ and are associated witlu~depy}ylCYcla~
Other heptahellcal recepto.~ are assoCia~ With
O..protein mediated activation of .PhQ~pbOli~
C., which Willlea~Ho in~ ca.+ and myometrial
eontractio~.
in o_xytQGIDJ.e,v~ls in the plasma''but pros~'ghmdin
levels ~r~$~ in the amniotic fiuid~d maternal
blocd._,tU'ter the first stage of labo~e ~nd
stage of labor. begins with full cervical dilatatio.n
JU'ld ends with f~tal expulsion. .Outing this stage
of labor, matern'21 plasma oxytocin lev~ls are
increased. ,.The third .s tage of labor begins with .
. delivery of the fetus and ends with the gtage of
plaeental sepa.ration tmd expulsion. (Figure 22.3)
Jf"' l"" pt ~~ Af' /WI~ 01 IXf~fJI~ q ~Ulff~
.$arly Si!/nS of Labor
show.

The th.ree Stages of Labor

' . . (r
Theremes stages oflabor. The-firstcstage .of
labor cc;m1m~nces with uterine contractions that
are of stiffio ent f~quency, ;!riten.s1ty~ a nd duration
to bring ~ut demonstrable cemcal etfia::men~
an.ddilatation up to' full ccrvicaldilata:t:ion ,{a bout
10 cms): t~~g this stage, there is .no ipg_~

f I'

-E ~
..
~.
.. - ... - ....
.., ~)1111 ~-~(R IIi
-
.~

,..c:
to
.:- 8
k.
!'W 6\h thl-1
'()
.!~
. ;C'O
''"""
'~
~. -
8
'
.. 6
j-

0
~ 6
0
~ .
Cl), .:-
l> 4 .. 2

M1~: ft " Pithl~ 0 t--~--.----..=--""-----.-----+---.---JI----+--~-I----,.--t-- --1 o

.
. . ~. 4 .' 6 8 10 1'2 14 '.16. .~~~-- .

~11_. -lf0tl~ . Ti~e (h) .

=~~:
-~~.. l
/ lfml - 11..ttv-(tw . ft~Vt, ,~~~ / dJt.~W:.: iJ .qc,M
. Figure 22.3. Stages of Labor
"~~fbN'IM-J '7 N/lr-c(.J tvyM.,. , tf l'f\V't';~tvvi \ 1
'i
- ''"'"'' A ~~u ~....n.. .. m t'l111 ,,HAl'\ rl10M ttW1vtt M itvi !
j

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362 SECllO.Ntv: CllNICAL APPROACH TO LABORIOELivtRY

False Labor 3,) The uterine contractions are ip.vol!!!!_taryand

independent -of any extrauterine
. - -.. . . . . . .
~ ~
control
.
For a variable .t ime prior to the onset of active
la~r, w omen may ~tience the so-called false If .gu~. 9T epidural anrug~ is given early
labor. The utmne conuactions of fal$e labor are in labor, contractions may decrease in frequency
characterized by irregular interval, sbort~r and intensity. Neural bloc kade from epidural
dUration .a nd the discomfort is -confined to the analgesia <!.~~_.not_ diinipjsJ:t the frequency and
!9-ier abdomen and: . gro~n. ln .~ontrast,
~ntntctipntJ of true labor e.re :r.egu;bn-J<L~gc:_r iQ.
..
intensity of uterine contractions of active labor.

dutation Md .t1,1c ~...~mf'ot;_~9m!~l.:Pte.~.J~"1. ~ 4.) Uterine.activity is enhanced by mechanical

fun~~<!!! and then f adiate$ over the _u terus
and the l~wer baek. False Ja;bor is commonly
observed-in Ia~ ,p regnancy a.n.4 bl _J>atl;>us women.
It often :stops spo.ntantously but niay proceed
rapidly to tlie effective contri;lctions of true labor.
'th~fote,$DytepOrt ~:$liort4ive~ and'infrequent
uterine .>n~ctions shoUld .n 9t be di$mi~ to.
avoitf~.'~ :Qf-dtiveey .$11 tbe$.}:)sence of
tmlfesSionA! ..~M~l. :~d 'n~sazy
~ . . facilities.
Ghq.r~Jct<::ri.<itfc$. of Uterjn~ .($prc1r:actirm.s J).urin,g
LaiJor
stretching .of the cervix
Mech~cal : dijatapon of the cervix .e ither in
the fom,i.-of ma..nipulation,- stripping.' of the feW
m~m.brap.es. or cerVical dilatation r~sulting from
labor enhances myometrial 'Ontracti:lity. This
phenomenon "is. referred to ,the Fergq_S9~ -refl~ as
Release of oxyt6ein was suggested .a s the.passible
cause b.u t manipulation. . ot.;tervi<t a nd s-tripping"
th~ fetal membranes a re assod~ted with increaSe
in the levels o[:_p.ro.$t_;;~.gJ~:ti1.:;~. F2 .. metabolite
(PGFM). in .blood, . ;... . . . --: .
-..:. ~_; i l }' ! .) . ~ :-; ..~~

Uterine:ChaJ't,g.eS .-During:.taJyor .

:The ~ <:au$(: -~(!pain i$. ~till u$own but (f~ ~u:t~iu,s d.iffetentia~s 'into .2 :distin~t parts
there:~..~~:theO~~, ~et~::~)~~a_. duripgthe :phase 2 :or partutition (Figure. 22.4).
of..1il? ~~trate~:I;~J'Qn1~tii~~;Q~p~Jijion of . Th-e,L\J.ilf-p.e r, segihent .:whjeh ;is: t -he ,'a ctively
.the P.~e~eP.ffi~in~~e~,~~.~dt.lP:W.~~ut~rils-' c~.v.tt~.th)g ' P-orti_'Ql1C.:bec~me~h;ic~e.r:-as~
.. by .tl}~ ~tli iP~~~g .mu.~e l;)~dles . and . advance~he 1ower _poqion whil;l.is tnade up of
3.}.at~tclll'U.Li:if.lll~ P?ntoneu;Iri ovet:JYfhg tb,e the lower uterine s:egment and the .cer-vix is
~~.'l!;~::~f~~xX~fpipt.e~si\:>I~~ if t11c:.tie_~ _;~J~~Y.:.:J.>3-~.!y~a::~-~J~-~ _ii:__tlifri.-~~~
gan~ ia very ~cti\1'~ 'b ea)1Se of ,pataeervi~ ___passag~6r...the.ietus. The l~wer Ut-erine segJnent
i~tiO.tt with local ~ne:sthetlc produ ces w}l.ich is..J!.n ~lpgQJ!~-~~9_:the isthrini.s ~.Ql'l-
~Ppte~ble j>41"1 Tciief. p...f.~~~t !J.t~IJ!.~.:. graduaUy develop:!3 as pregnancy
adva,nc~s and beco~~s remarkably thinned out
2.) The nttactions beoott!.e Iilpre freq-uent arid gre.a tly expan<:ied during labor. Clinically,
thes~ 2 segments can be id~ntified during a
The inte.rvat~ .~tween coil;tt?tions. d..ilrj_rlish contraction by ab<;lott1inal paJ,patio~. The actively
grac;lual}y f.n>m ,~bout l~!":~*.!~c~~at.t!l~__ cn:~~-~t. :to contracting upper segment is quite fmn and .hard
abOut l ffiU:lu~ Qr lss d~g--. tl)e -s eeond ~tage. while the passive lower uterine segment is less
LikeWise, the duration of c.o~traction ihcre~se~ f1I1Il.
froni abb.ut-30 seconds to abOut go :seconds with
a.."l ave01-ge ,oU.minu~ However,lh~ intensity ()f This differentia tion of the uterus is necessary
uterine :contraetions may vary even during an to effect direc tion of the force of the contracting
apparently nor-allabor. Amniotic filii<;! pre;ssu re upper s egment and allows the lower segment and
~CQ.rdedduring spontaneous labor average -aoout ce.rvix .to dilate and form a thl:nned-out
40 :t nm }:Ig with' a range o_f 20-:-60 mm Hg. In fibromuscular tube through which the fetus can
between contractions are ,peri<!!ds o(r -elaxation be extruded. If the entire l,lterine mu$Culatui:e
which ar~ very es~ntial for t he-welfare .b fthdetu$ were to cohtfact. imultaneou~ly --~ - d. With equal.
be-cause if the contra.ctions are unremitting, the intensity, the net expulsive force w.oulcf be
_ uteroplacen.W blOQd flQ..wJOay be compromised . .decrea seq markecilyand will not result in effective .
-and u1timate1y the fetus will suffer from hypoxia.
- . labor and fetal expulsion.
---- - ........--- ..... ~- ----

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 CHAPTER -22: PARTURIT>lON: BlO~OLECULAR ANO PHYSIOLOGIC "PROC.ESSES

eXpulsion of t}le fetus and to maintain th~'ilterine

muscu.latu.r e in the firm contact wit~ the
intrauterine contents. As a consequence of this
retraction, _fu.e ..'UP~L~. ~~f th ~~~
~come~ .s lightly smaller with each successive
-~6~:traction and the upper s~gment becomes
'pioiressiveiy-thickened throughout the first and
secpnd...stages of labor and tremendously
thickened immediately after the delivery ct the
fem.s.

The relaxation of fue lower uterine s~ent is

.not a complete ~12,xation but rather the.-opposite
of ~trac~io~. The fi~ts of the low~ uterine
segntent become .Stfetched with .each cOJ}ttactiO!\
and do not return to th~ previous .length but the
t~!l~-~2-n..r~~!!ns .es~entially as before. The
suc::ces~ivc lengili~ of the m"USC\llju' f ibers -of
~e lower. ~teri..ne . $1"'.-gme.nt .a~
labor progresses !s
accomparif.ed by tb.i,rtttJng tc:cnty a few iniliimeters
in th~ thinneSt-pt\rt. .

As a r.esU.:lt of the t:hinriing of the lower li~rine

-seginent-w.i1;h coiu:o~tant tbickenlng:otiheJtippet .
. ~gmen~ .the bpunW:u;Y between the.2 is :r;narked
by .a dd_g~, .Oll ,ijie _iriner Uterine SJ'ttfAce. fue
: Mettaeh -eontractioll,:fue xnyornemum'Ofthe _i)by.siolQ&i~ n;!rn,ction ring. . wh6litb.~
~u.P:Pet'se&tn~mtd<>es n.pt re~ tQ its ()rigina!le~ . o(the iower. utl!ririe -eegment is ~fu.e~ti:s'' Ui
'but :rather beComes ::t$tiv--a-y_&:ed 'S.t a sliorter obstructed labor, ring becoine~!her.Y.~~ent the
Jep:glli.. 'HoweVer,the tension remains tht='~me is called the wtholo&ical re~cfipri'tllig : af
3..ild
as before the epntraction. Thi~ effect "is n~ Ba.JadLwhi::;h may bring about uterine rupture.
to .maip.tain the advanta~e .gained With respect to .:{Fi~. 22.:5) . . . .. . . .

.. . :o.: ... ~ ~ --~

'
"I

; :! :o~>
. . .Jo~Jtv.c

..
: StatittWT. "
. .)
I
"'
. ...

'
t
.

'
.~
I I
,.
' . .,
.1 I
I
~'<" R.~f!: - . .. h.tv
I SUII(Wf
Purv< I
SitliltWt
~(Ef---llortlMl\, 0$
~t 'I
'
I

~--'-..:_,.-.,...._E~t.t~M. Ot ""-----.J~O- l(T"(I<U\. 0

~muNt IITERifS' . PREGNANT. UTEFilis VTDlU$..<1N .LAlOR Ul'EIIU$ IN U80R
UT1\1$ '" \,A&OR.
AT TEitlol . ; NOJ\MM. ,.OII~Al . :AQNOll~ .. ..
E.ARI.Y 'fli~Sl. STAG. SECOt!D STAGE SCCOND."\TAGE- OY.~TOCiA

Fl~re 22.5, Sequence of develop~ent or the s~gl!lents and rings ill the ut~rus in pregnant women at t~ and in
l'abor. Note co~parison bet"fe\n '. the uterus ?fa .non~pregn~t woman, tl_te uterus at term. and.the - ute~ du~n.&
labor. 'T he pass!ve lower .se~~ent -of ~e utenne bo~ns ,de nvcd,f:om the ~sth~us; the pb?'siol~ogJ.cal retr.rg tJon nng
d evelops at the;unction.ofthe. upper .a nd lower utenne segments. the pathologJ.cal retract1on nng develop:!.from the
physiological rit\g. lAna t._lnt. Os. anatomical internal os; E;.O ... external os; Hi~t.lnt. Os .. histologicaHritemQ.l os;
Ph.R.R. .; physiological retraction ring) .. .

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 ... ;

-t-
-364 SECTION N: CLINICAL APPROACH TO LABOR/DELIVERY

The existence of a ,~dient of diminishing Ceroical Effacement and Dilatation .

physiological ac~vity from fundus to cervix was
established from measurements of differences Before the onset of labor during the phase
in l;>ehaviour .of the upper and lower parts of the of uterine awakening and preparedness, t.'le
uterus .during 11o_rmai labor. cervix is softened thu.s facilitating cervical
dilatation -o nce forceful Jnyometrial contraqions
Each contract-io11. prQduces an elongation of of labor begin.
uterus with a .concumitant-decrease in horb:ontal
dis..meter and thus pro~ucing the following Puring a contraction, tll.e ~gions. of lesser
effects: - resistance (lower uterine segmentand celvix) are
su~jected tQ dis-tention a _ n .<l thus exert a
cen'tt:itugal pull on the cervbt. ' As 11terine
contractioqs "occur. the ~.Y~:r9~tJ~-~QD of
1.) The decreasJ:. -i n horizontal -di~ter -produces amfiiotio ...s~c Of ctn~b~e$ ~ ~~~) or tiie
a ~tenittg of-'t he fetal vertcb.~ co~_!J~ pl):S~U.re of ,th-e pre~~ pax;t -{in-the lll>sence of
pressing its up~r pole finn!y Q:gB;inst lhe
uterine fundus,_-w hereas the lower pole i-s
intact metnbranes) agam-st the cerviX lower -and
uterine :s egtnent dilate~ the ~cal canal like a
thrust farther downward an:d mt()_tPe pe1v:is. wedge~ As a result of_t hese .fOttt$~00\~ent and
'Thus, ~e 'lengtbcniiJ,g of ~e febi} _ovoid !s ..dila.tati91! take place Jr..t)le alr~<ly softened
he tween 5 to t{) ~ aili.d-:the pressure exerted cervix.
is kriown as fetiil ~ pressw.e. -
The cervix is _said-w -~ C1?.mPJ~~lY ~Lf.!!Y
,2 ~} .with len:gth~~ing: ~-, c;)f:_ .:tl):c' ~U:ter~s; . t he ~teQ:owhencUJe,cer.t:ic:~lcanalatt.Q.4lsadi:ametcr _
lortgitud!nal fiberslll'C Ara-wn.: tau~-~ ~use .- of lO:cms... At this,~eter, ~-e :a~ fetal-head
the lower. segmeut :apd_-c:;e~ $.re~the o~ parts at ter;:n ~ pass.L'u:'Qtlgh :_fue .oan'i:X-aiid proceed'
. of.t)l.e:l:ltet\is-ih.atW'e~bie,: t:heSem paned to dQscent~ D'ttring ,cer-Vical :effJlcement, the
.upwitrtl:over:th~:tQW~:J?$1l~ofi(~tl1~<1J:iis~~Jtt ~.n$&- J?~rt. d~~nci,3 .tQ-;~Jn~ :d..~ ~ the
.oo , Jllil~:Ulte:ofth.~~
. .th<r. . sem-t.eritand
~ . .....;;..,. a
_ ce.Y._. - Ua ,e$
.... t. - .. . qunn~
"" - >Y
. s-c.c .Q.C.,_.bo
..;;.-.....,.... .--'
"li ..
. r,
........ -

on:th.e .~I'"iiX is an Uni>Q~t fa~tor ~ ~Wi6U, . d~tOf.thefeuil p~titmPsrt~ occurs

~taUoii. . . . ' . xath~ stOwly\])t. sfhatHb! jfi.jU)JnPata' b~t may
1,>e ~pi~!' ifi 'tft-ulti~!J. .
A:l a result ')f the $.Y.Ilthronous my.o niettial
contmctions;l:lie increase.ui'.intta.Utel'ihe :pre-ssure -FJftrr~.nlent-is..Synon~O'it~:to-j'lhJit,.-atk>ri or
.a nd the caudal direction forces the presenting part ~.ilp~o.ftll~__pe~ (Fi_gute :2-2;6) It means
to dilate the cervix. - shorte:ni.n~ of the cen-ical cti'~ frQm a le:ngth of
_$Qut-4 ~m.,~_by a vaginal examlnation ~~ ~lMar
A_fter f.:\111 cervical dilatatiGn, the most ..orifice--with.- pap.er.;-thin _dges. This can be
i tnP9!1ant 'force t}:lat . will o~ptl the -Jetus is' _ th~ compared to a fut):neling Pl'Qce~S 'in which the
increased.JntrJUabdommal pre.s sure e.xert(!d by whole length of a nattow cyli:J).deri~ con~~red into
-..:.eontracti.OiLotlJJ~_____:abd-o.nifnaLmus:;les w:fth a verr, ootuse flaring (un-nef.with 'only a stnall
simultaneous Jor~ed r.:espitatocy eff6rts with the circular orifice for an .o utlet. This :process takes
glotti~ closed. In Qbstetrical jatgon; this is place by .llpWard piill:i.ng of the. muscular..fibers.Jn
ten:ne9 as "pushing". 'fhe natur-e of :the tor~e the vici nity of the internal :o s whitb beco01es
exerted is simllart() defecation although :the functionally 9:.Tld an~tomicaily ~ J$rt of the lower
intensity .is much gr-eater. Although iMrea sed uterine.segment while the:c<>ndition.ofth~ .~tnal
intra-abdominal pressure is necessary .for os ren_:1ains tempgr~tily . UJ!.~;hatlged. Such
~9mpletion of labor, this 1s useless if the cerVix effac~rtrent usually fapilita.tes expul~i:On of ~ucgs
. is not f~Uy dilated. Duriitg the ~econd stage of plug..from the cervical canal as it is shortened.
labor, lhis is a necessary auxilia-ty- to uterine
contractions.. -ln. the-"tbil'd~~ge""'oJ~bot.; 'intra.- .- .. The .process.: .of. ce-rv-ical e ffacement ,and
abd~minal press1tr~e is noc.e ssary for -the . diiatation causes formation of. the forebag._of th~.
~pp'ntaneou~ ex_ p ulsion of the placenta . atnn~9!~C- fluid_ 'which will -later :~-:descrlbed .in
especially if th~ . parturient ls unattended . . . detaiL '

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 CHAPTER 22: .PARtURITION: BIOMOLECUlAR AND PHYSIOLOGIC PROCESSES ., 365

. .~

-.,

Figure 22.!). Cervical effaceme~t.

Patte111 of Cetilical Dilatation progression." Hence, only cerYi.caLdi~ and

k!_al de~_<;_ent are considered indicators of the
In his treatise .on labor in 1979, Friedman progress of labor.
stated that "The clinical features of uterine
contractions namely, __fre_quency..._ffi.tensity apd The pattern of cervical dilatation that takes
duration cannot be relied upon as measures of place during normal labor takes on th~. shape of
p~gres;ion iU labor not as indices of normality. sigmoid
---~-
curve as depicted in Figl;lt'e 2~;-3.
..:---. ,
Except fou~nrical.-dila4J.tion an_d fetal c\esc.~_!!,t, ..:.;
p.one_of..Jhe..clini~ featu~.s-oi the parturient The main phases of cervical dilatation are the
appears to be use!ul _in a~sessing labor -l_atent...phase- and th~~~ is further

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. 366 SECTION lV: CUNtCALAPPROACH TO LA\30f:UOI2UVERY
subdivided iJ1J.Q~~Ge.le':ta.t~9~.Ph;;tse, . pha~
-~-Slope..and..the. d~~J.~r.ti~~plias~ .. The
duration of the.:l,atenLpha~ is more variable and
e:an be affected by a lot of~epus factors su~h
as sedation {prolongation of latent phase} and
myometrial stjmulation tshortehing of latent
phase~. The ~uraqon .of lat~nt phase has.little
. pear'ilig on the ~ubseq1,1ent cour~ of laPor. 1'he
\ l <lccel~ration pf+a$e ~s "!;lSualiy P.~edictive of _!h-e
'~\ltc9W~..9.f..par.ticul:ar.:.:lab0r:-.;xnl;m:axi:m:lim slope
is considered a good +fie'as\ire of the overall
3fficiency of the. macbiri.e whereas thJ~n~'tut:c of
the ~~ele:r.ation phase . is more :r.C?.~~S.l~. . of
fet<>.Pdna:telatioii~p. - After complete c-erVical
.dilatation. the ~nd stage of ~wr.commences.
Therciftet. ortly progress ive :dt;.sc'ent of presenting
part WilHndi:cat.! progression oflabor. .
Ep.ga_g~ent .of the fetaJ h ead o ccurs prior to
.t he onSet ~i:ta1;or. in:many .ro_upipara.s ~:ut further.
..de~i.ttdQes':not OG.u,t; :.untfuclate:.in:.liJ.po:x;. The
patt~-hs of ;Jescent k.t normal la~qr:. follo~s a .
hy.petboti~: ~ whi!ili is .formed ~}+en the .fetal
. p:erul: :stii.~n:j~ p1c:>tted against Ui.bor.:C!ur~tian.
{Figure: :22:1) ..
... : . . . .. ..
.i~Y~~A~~~t iiJ..~~?.:;~e.~:..P.,\a~e_.w:hen"'th~ ..:... of...sli@tlj rur:-~a' .Soip.e~~i ~e~~tnbranes
<::eni!;:ar:d:ilatatio~ has a.iftiicty .aP.van4d .but the
. .~urn ~t:.f!!d~7sbent st<1rt:Uo~ds~r thiS'"iu:.ppet!s; the ~re.~ Is Mm 'S\Uroui):d~ ..by
. ~~tr~pe:-~or:ce~car-ru~~uofi in
n'ill1i~s. m:lq:-:f fiis .rp_'(e:jSm:auuaui'eduiil;il.lhe
presep,fu:!.g .P.att .reaches the .perinealJloqr.
. 0' 2 .4 6 . 8 12
.Tlme:(hl
. Fl~re 22~7- Functional division:
.~
Functiortal Divisions ofLabor
Friedman sought to .s eleet criteria that would
d~limit normal labor and th'!reby e~able
identification of signifipfu}tabnorm~Jities in labor.
He developed the co~Geptcf3 functional divisions
of labor which a.re _p r,par:atory. dilatational &nd
. pelVic divisions .as depi~ted
. !D. Figilre 22.7. -
Dui)I;lg the1pr~paratory diVi~ioh, only little
cerVical d:ilatatipn oc:<:urs w hile :;;~taat 'changes
take pla:~e ..in the groWld substa+rce {collagen and
other c;.onneetiv~ tissue components) ofthe cervix.
'This division can be aff:eted by sed:!ition and
conduction analgesia. The diiatatio11al p}:lase is
the time v;;hen dilatation.occu..-:.s its niost rapip rate
and this ..is principally :~ccted by sedation or
conduction analges.ia. The :p.e lvic. division
cornmences with..dece}~t,ion wse of cervical .
. dilatati'O.n and ':.his is Wh:e re the 'Cardinal
moven:ients of the.'fef:u..s prii:iQ.phlly take place;
Ruptureqptfv~ .Metnbmi:r~ < -.--
Sj:rp n tineous: 'rU-pture ~f :mitn branes
cortll;ncilly~W's:du.,r:ing~thc. o~:ofactlve labor.
Clini~y. tl4s ~ ~e~ted t;y ,a:snQ.!!~ ~s~..2.t
.
va1,l;)le :9;~titYJ)f.fiyjd. ~bicli:.rnaybe .ciotltss
relnaili ihtactu;ntifd.dive:r:y :o!.~:C:.infmitandwhen
'tne-m: an-cr-grej:'&&~~~-ffie~dJ'!CtP.-!<
..
newoonCi~ tel;!!.l:~a.;.as..:.~~% ~~~e 6f the
me:branes before the 9Ji~Qf ~l?Yrat ~y stage
ofges.tatiou~refetred:to as tirenlli:ture.Ey>Jure.of
___ .........
membra,tls-
~-
.
Vaginal and Pel14c ~Ftf?l)r~ :burin! .l.-abor
-x The, birth~ is.slit?,p6rtedand madeup Of a
number ofl<;!.yers oftisstles that t()getherform the
pelVic floor. From wi~~utv;:ard, the tissues of
the pdvic floor- are the followitl,g: 1) perit!>fieum,
2) ~ubpe.ritoneal connectiv~ tissue, ~) internal
pelvic fascia, 4)1evator ani and coccygeus muscles,
5} external pelvic fascia, 6J ~uperficial muscles and
fascia 1) subtutalleous tissue, anti .B) skin.
The m ost importai).t of
these pelvic .floor
structu:tes.isthe levator ani mustle.s.!and::.tlle~
coverihg the ..upper -arid low.~;. ~su.rf~~~: .this
; 14 16
muscle-.gi-ci.ip "C:fo~tne.}oweren~rot fP.e :pelvic
tavitj as the diaphragm'.P.ence this 'i~ Ca:l!ed the . \
pelVic cli~~W!: Th~!2g~~t:!~!_9-~P~W is
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 CHAPTER 22:PARTURITION: . BIOMOLECULAR.AND PHYSIOLOGIC PROCESSES . 367
~

~ea!,
made up .of 3 layers of .fascia: the deep the most__~dherent .portion, separatioa ~begins
~iddle, - and-Supemcial..perineaUascia. This elsewhere. ---
occupies the triangular space between the pubic
arch .a nd a line J?h!ing..the.Js~.
-The .su~rficial perineal muscles. are comprised of
the bulbocavernosus, ischioca.v ernosu.s and
su~rfi~ial g:_@~VJ.:S_e perin~ muscles but these
are no obstetrical i mportance except that the
superficial <transverse perU:leal1llu$Cles ar~:~~~s
t()~ !4.ease pf, perl.n:~ ~a~e.mtions. .
. . C,'~ . .
1
During the first stage of labor, the-:tne~br~es
antl'j)resenting part of tbe fetus sexve as the dilator
of the up~r portion Of the vagina but after the
. membranes have mpture(i, th~ pres sll!e is entirely
exerted . by . ~. ~.senfuig p~tt:t&~. Ui.~etus. .1'he
'-! inost rna.rked cllange during labor.!$ the .stretc.b.b:!&
ofthefibe~ oi the Js.u~tor am.m~scj~ en.d~~g
of the ~tra.l "PPrtion .of...the ..perineum which
becomes t;tansfonned:fr'Qm a wedg~ Jiias.s
of -tisS'lO.
. 5 dn in thic.lme.
. ._.....s s tQ a.
;,.--; . thin alril.ost
. .

trJtns~elit membranous structure . that i s less

then 1 cnlthlck. "\\Then the perineum is ~rucimally
distended, the anus becomes tn,arkedly d!:ia:ted
about ~&-~and t:hrough which . : ... ~

the-anteriOr recW wail bwges.

. .. _; .
_:the-~llase:Pf Placmtl;il Bep,~n
..... ..:
. .. . . . . . . . ._-,:::";L-
J'ip..ooe ~_ 2.8. Dimmu_tion i.n size of the pla;cen~_
. .,~it~ a[ter ..
birth or the infant. A-. Spatial retations:l>e!or.:'?b'~!!- B.
As the fetus is extruded out. the uterus Plae1:iital spatial re4\tionsafter birth. . ' ~ J~e
spontaneously contract~ntovi.n on its. di'rninisbiilg. . . -~!

conten~ . After the infa.p.t ls'deliveted; theuterus

is conv.erted.into. an-atmost- soll47~s:of:mu$Cles
with-wa:Jl..meas~g4~to.,-5-:'cms:in:thickness-a;nd
the uterine cavity is ncady obliterated. . 'This
sudden diminution in uterine .s ize is accompanied
by a decrease in the .aJ"ea ofplacental implantation
site '(Figure 22.8-) . For the pla.c enta to
accommodate itself to this reduced area. it has to
. ~crease in.J.hic.J:s.nes.~..J:t\,1 t ..bec~;tuse .o f J.iffiii~ct increase the thickness of the layer from less than
elasti.c jty. the P.~~enta is forced to buc~. The
resulting tension causes the weakest layer of the
~ecidua which is the dezidua . sEon~osa tQ_gjye
way_ and a cleavage takes place at that site.
Therefore, separation of the placenta results
. primarily from a disproportion <;:reated between the _.IWtcenta. which is either .i n the lower uterine
U;..unchanged size of the placenta artd.the reduced
i~ize of the underlying implantation site. As
s.eparation.proceeds between the placenta and the
dedduas. a hematoma_fortns-be.tween..them..axtd
this.Ju.tlb.~r :.acc~tera~~-J~!:..~~-ss oL.c:;:l~~yp,g_e.
Pl~cen~ separation occurs within a few minutes
after delivery. Investigators have found t.hat
beca.\,lse the periphety..of .t he_placentaJs probably
The great decrease in the surface area ::>f the
uterine cavity simultaneously causes the .(eta~
tne.mbr~nts_{am.niQJ.<h.Qrion} and the decidua
pariet.~~ to be thrown into several folds that
l rom to..J::.4....m.t:n. The membranes usually remain
in situ until the separation of the placenta i~ nearly
completed. These are then peeled off the uterine'
wall partly by further myometrial contraction and
partly by traction-e-xer-ted by the separated
segmen.t or vagina.
The Phpse of Placental Extrusion
~
After the placenta has separatecl~rom its
implantation site, the con.t racting myometrial wall
cause it to slide downward to the lo'wer uterine
segment or. the vagina. In some instances,

Scanned By: ~
 368 SECTION IV: CLINICAL APPROACH
. TO t.ABORIDELIVERY
.

"''It-
increased intra-al?do~m~..pres.sm:e is ~ee4ed to Phase 3 of
"Parlurltion! The Pllerpetium
~-i:1leplacenta. Women in recumbent position
frequently cannot expel the placenta Phase 3 ...encompasses
r
the events of the
spontaneously and h~nce an artificial means of r.puerperium: .:..maternal ~covery from cb:ildbirth,
completing th.~ third-stage is necessary: The usual ; maternal contrib~tions to infant s urviv-al and
oanegy~r:- employ~d is .~Jer~wJely corru>r~_ssi~ .~ restoration of 'fertility in the _parturient.' A:n bour
and elevating the fund~ -while ~ertirig mfuimal or so :after delivery, the myometrium :q:tust'.9e.held
~t:io:1 on the umbilical cord. in a ~tate of rigJd ar:td .persistent contraction and
retraction to effect cotnpressiort of tb.darge:u'i:enne
Manu~ removal of the placenta also be may
ves ;eis and thrombosis of their lumina to J)re'lent
done '.if the placenta is abno.nnally adherent. pos_tpart.um hemorthag~.

Mechanisms:Of-Plaiental.Extr..tsion
.
f .; During ~ly puerperium, maternal--infant.
boncting ~gfu.s \\ith "the onset of lact6genesis ~
...
. The .usual' type o~ .p).<:,tcental separation is the mille let-down~ In th~ next 4-6 ~~ks~ 'ihi uterus
one t.."lat OCCUrS initially ,a;t the Central portion of undergoe; restoration to its non~pregnant state .
k'l~ :place#~ and the.E~~9placeriW he!I!-'atomC!, known as . "'-i!J.Y.qh.}.tiori~.. Duration.of phase 3 is
formed pti~es the pll;\centit toward .the u~e~e dependent~h ~dUiatfon. of bre.a stfee_cllng beca.use
.1 cavitv and th.e~rest.of thep !aeenta,fbllows. 'Since for a:s longas;br~$tfeedirlgis cohtin:ue<I,-!actation~
f : . the ;urro\):ncfi.ngIJ1e~t4il~s -a:t~ .still-attached to . induceq .. anoV:).llation artd a.!P4~g_rrh~a persist
~\. t;he decidUa.s. the p~enf,a.;.de_~ ends ~bY- dra:ggiqg nence'."feriili,t:J.'.r esto'ration' i~-not accomplished.. .
i~~).'f.:~~~;-~~.-:-~-~~-~u__ ,~r:~Y~':w~a.~y-Pr.ese~t$ at:r. ,.
~}.:{::,the vulv.a 1s the, ghstemn:g am.mon ;-ov~- REGti!J.h'l'!.O:NOF 'PA'RTURlTIOii"'
lttP.iaCenta.L:sunacez:.while}f.be:;:,he:rm,ltoiil.ao; i'q~z6thin: . . . .
":;;,:~~~;:~e : inverted sa_E, o.r . !!:Scape~-~~er:_pl,:?.~I.!.!~l _:?.~t:uti~9nis_~~;;~ous. wi~<;~ It
[~!'~~ .This i~.:k.n;9wn as ~h~.chu!tze em'br.aces -~ .tlle .bioehen;:i~ :'ant\-'.phy~io,logkal:
l~:~ ;~_:!Zutc~,-:o!~ plac~tal:-~ul~ion:: . .. T~~-:. 6th~r-~... : . !'rocesse:,;. if.:'"~l'(~d .~~ . ~C;.~r :~d :d~ive_z:y1wpich
:~}S:~~'i~>P~ial,,..,ro~slon-ls.:no'Wn ~~s~~tJ?.<:;,. mclude:the-p_relUde, the:ilireparatiprv$e~
: : .Dunca.n;znechan~iam;1iri:~hich::~paiatiqn1'6ccurs...: of.labor,aswellas the parturient's~recovery fq>m
: ~.-at~~phery 'hence .th ;blo0d' -coJjit~d chlldbiTt:h. The regu4ltion o f these processes is
.;henveen theme'))b_tanes and.ut.i"$~ :w~-~s.a~S not q>fi:!,pleteiY dePn,~. Re~ches. froiil .a'.nli:nal
in:to-thc'o.va~. :Jn--thhmechanism, theplacent;a mcxtelstiave=-providedsom:e of~the;missmg'links
deseendatothe~-:aginasideways-~dth~m<3-tn!al to-me h\lfuah--parturitidn:pi:lZZle. B:U:t:gre-:P.~!~
~ ia the fll'st to appear a t.t.he vulva. ~llico.mplet~. '(Fig\.l,re 22.9) --

...
'
. ~ \
s ' .1.
. n .
. . . . <t:
BIRTH

~
c
c .
l
....:J
~
.

PhaseQ Phaso 1 Phase 2 1 Phase 3

_jQuiescence) (Activation) {St:mula!.l9&__j $~~::_~1\:!tio~.-
,pro:;taglandins j 0-,:ytcct:)
Oxytocin
? CRH
I
.
.:; Il . Figure 2 2. 9 .'key 'Factor~ in Parturition
j

i Research.

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Jl _ _ _ _C_HAP_
_TE_ ' :N_:_B_JO_M_O_LEC_
RT_U_R_IT_IO.-'-
_R_22_:_P_A...... U_LAR_
__AN_o. . .._PH..:...Y_:.S_IO_:.L_O. . :. GI:. .: .C. .:.:. J~;. ;,.R:.:.O. :.CE:. .S:....:S:.:E..:.S~--.
: .,.,_:'.:... 369
I
'i Contemporary. human parturi~on re.s earch is progesterone attenuates f._ contractive
I
influenced by two .o bservations: li) .b.lU~l~D - -r~sponslveness,~"'filiSi;-~st likely over -;m
pregn~cy is a hyperestrogenic_sU~-te and 2} the sitnplification or incorrect interpretation of the role
~.is virtuany llie
io~e ti'ssue sit~.<i,e~troge.n -of these 2 hormones. The true scenario is ~"lat
..fo,rm~:t.!I>ii." ... The' P,Unian p_l~centa col,lld not the plasma levels of both estroge~~_and
synthniZ~ estroge~W~ from aceta~ . or pro~esterone ~ ~2~a1 h\lm_an-pre-gna:icy a~~
cholester(;>l but ~he pla.centa is
ca.pable oJ enormous .a nd they act ii1 conce;rt to effec.t:W_ely
conyerting..:Cl9- .ste.r..Qi4 to ~~~~ens. ti_tal -~~tahl phase 0.
adrenal gla.nds..p~~S~- prodigious ~~rum.Dts of
C19 steroigs which are 'theri-traJ'!.spt>rtedin fetal .Estrogendoes 1,1ot .dire!Dr cause-myotiletrial
blo9d to the p4l.centa.and meta,boliz.cd with great contractions.but it PJ'.QIQQte;~ :Q.~r.ine a~.pacy~ to
efficiency to estrogens by ~e- s~t;i.9.1fop~ob~sts. generate coor.di.rtated and forceful contractions. In
The human pla~ta. therefore, is an incomplete aninnil models, estrogen promotes myometriel gap
end9c,rin~..o.rgru:1 at least in the caS:e of dttogen juncti;>rt ~oflllation by increasfug connc;Jdn:,4.3
bio~)'n~~si~. synthesis while p-rogesterone can inhibit it .
... : .
nowever., estrogen acts in part by- pii)motlng
Presently. there app~ar~ to be 2 general prog.e sterone responsiven!!ss by i~ducing the
thC1?ri~ of p arturition: Sxetre,:a!Jr.o~ pre~~ s ynthesis of. more... .p.r<;>ge$tetone ~ptor:s. .
. ;

~n~ ~ypot}lesls and the.._'9!!etQtOD!..il

induction of p~tiqn theory. ' . - ~n_Ilexj;n "43 is. the pri,pcip.~ .g ap jUn~tion
proteinin the tnyometrium. Gap jundions are
'JicijJ2SD.j~:~stem t,q .udititain uterine QJdescence QJ .trar.scellUlar memimme .c hannels comprised of . _; ,

J?.lylse 9:-._ . .connexins-joined with another.. ccnrtexihtiJ.h' the

:plasma membrane ofanadjacentt:~it' ,tilfi~~pairs
. The mypm~trial -...smo~th mus.ete ~s ,a n of connexins esUJ.blisb' a ; ecndUit to::f~~f'the
paS$<ig~ .Qf current (etectrical or ionic. coup!L~gj .
!I}'pe~e.nUy coll.tractil~ t~ss:ue with rhythmic
Optimal n:umber.s fai'ear Qf _fanctipri'a i' gap
' '
~. ~ ..
;~ptracf;lPns _e vea.jn. ~e ~~~nee of.any stimulus.
)~..is ~'dc;>re ~-~ll'_. difficult-to oomprehenii how jup:ctions. aJloWs es_ta;bli~hmerd:"'-ri.ii''~f.~tQc~l
,, t4e :u~~- qm ~ .expanQ.ed to aolilinogl.lte .a synchrony !n . the: myometriuril:(t't&J?er.re.Ct
:}500 stJAA fe~a, llikr pf,f,mmiotic fl_uid~ .md ,BOQ coorctinat. e d and forceful contradiott~\()f:l.abor.
m s of placenta and fe~ p:ie~branes witb9ut }cProgesterone . on the other hand~ tiegates the
~p#,Ag.-.ip,Uk.p.ow~ii!;:CQjj_ttacY,9~-~ 'l'lle -s~).l~. t <>.!l: eU:ect of estrogen .on gap- junction
fo~~_!i.$l. ~Jill~~ Ef.Qg_~~!~.I9JlC ~g9nista.le!,id. to
m.:r~~~~-.9~~~~9- :~:w.,fu!~~O..:l:i.$'U:D:iadtable
th_~ __.!L!.~. _p,tQPl\b.lY. Jndl,lc,.e.d ....hy ... m'ulti-p le
preJ.P._a_!'!![~ J_p_IJ~)J;\funl..O(gap"jUO:Ctio~s~reslilt:ing in
indep.e ndent .a-Q..d ~.ooperative bioniolecular p~tenn labor an? delivery.
processe~..:t.M!!ral,_ _:~~.~~~_ririe, paP:tcri!!_e, arul :~ most.aplmal studies, 1e~tradiol -i'7b causes
autocrixlej . . Moreover. a conipiemeiitaiy .fail-safe
~ increase in my.ometrial oxytocin receptors 'but
system th!lt prote~ts . the ut~rus ~gain~t- agents . this action ,i s prevented with simuhanecus
th~.t ~andistutb the tranquil state of phase :c) must
treatment .with .'progesteron.e by incr~asing
alsc;> be in plae~. Tbis 'w ould.include;
oxy.t.<>cin receptor >degradation. lil...h:4inans,
__!!?-g;ease .in oxytocin.receptors in myometrium is
. 1. . Actions -of estrogen and progesterone via
intracellular receptors. _ 3ttrFt?.u_t~~J~ .. -~o !n~r~_ased ~~Y~tocin _g(i.ne
tT~_nsg_r:tptrpn .and nPt_Jo es~rogens. Oxytocin
2. -YQmetl-ial .cell .plasma membrape receptcr- receptcl-s are also 'fo-und in human endometrium
i:nediate<t in~ases in cAMP. and decid\,las at terlJ1 (arid. these stimulate
3. The genenition of cOMP.
pr.o stagtandin production) and in the amnion and
4. Oth~r systems, :including modifications m chotion-(iecid ual tissues.
., myometrial ~ell iP11 c hannels.
. Progesterone; on the -other hand, .dit;~ctly or
Estrogen and Progesterone (;ontrib.utionto Phase 0 . indi~ectly -impOse (probably in concert ~Ul other
of 0~ritidn. systems) contractile unre$J)onsivenes~~ . .
' .~5t.~
There is a corp.nionly held belief that estrogen In animal studies, progesterone' (which
cause myometrial contractions and : th a t _maintains phase 0) levels decrease before labor.

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 . .
' .
370 . SECTION IV: CliNICAl APPROACH toLABORIOELIVERY

However, in hum~s no~ucb decline ptinr t0 labor Heptar.elital Receptors T.hcit Promote Myometrial
is deroon$trable but e!asnia ievels d~line only R~laxation
. after place.l l.tal -c!eliv.e~--suC:rnsfurhuitia'n
pregna..11cy .has al'So been docuJfiented ev.e n in :A riuihber of peptahelical receptors are
cases. of Vt!ry low level~ of .p iPgesterone irt earl}; associated with B:~tivation o{:~~~~y~yl.cyclase
or
pregnancy a.s in .t he case abetalipoprot~inern.ja. which increaSes level$ of.c.-'\.M~ andsubsequently
:... Abeu~l_i_P..~prot.ein.:~mia is form Clf famili.a:l .igactiyate~ the myosin li~ht chain ki~ase resulting
hypereholester.oleniia caused by a ~erect-in low- to non col!pling of the actin to 'the mrosin MLC,
dem>ity lip:Oproteil). {LDLJ -~!)9protein _synthesis. preventing myo~et:Jial c~ntractions. . . .
Sinc:e progestetone syntbesis in the co.rp~ellnl
and ptacepta ls rl~pendent on EI.asma ~DJ.r, this Studies have s:bown _L"lat _the beta-adrenergic
wo;nan with abet:a.lipoproteinem'iil h a3 . n? recept,o rs mediate . 9.~~;$J;i:m~~ incr~ases in
dettetable. F.Oge~tetone ,in her b!CM>d but ..in~pite ~denylyl <:~ee, .i ncreasing levels of cA.\t:P and
of thi~. tbe J~itient C9ncer-1e'd and het pre'gn!Ulcy :.tnyoinetrihl relaxation. The numberorp ~~o~s
progr.es~ to tei'm~. . e xpressed and level of adenylyl cylase eXpression
are the rate ii.'llith~g fa<::tgrs.
The'J.~rgge.mtQ.Il.er~!Qr..:..~!:a.&o.Jli~t !<0~486
or 'Jtii(eprj~tolle, induces pr.ertU~:tU'te tneri'$e$ -if y/hen chOnOnic .g'ortadotl'Qphin atta,che.S .o n the
S:d#Wtiateted during the !&.~ ~base of O'V~an heptaheli~ receptor; aderi:ylyf cycle:~ . is clso
cYcle .lt t$ ~$u..:effectiv~ in indncbl. ~bottion .actiY..lted by wayofa plasin4 membrane receptor
dur..;ig,the;fat'(ew wek$ of p.regn~cy:.o Jio~.ever) o<i$ - liriJc,ed system, oonu-action frequency .a nd
.:it;J~fr.~i~in~~~~.t~Q!""-~~P.I;!l_C!_s, foree. and th nl,imber of myometria1 cell gap
!eq'eff~v~ tl1 "PJ!~~1idVa'hees::- :'lf. ~ve~J fit JunC.:t;iQns.dectease'.-..The nl.Unber.:of.t hese:LlhHC<t .
tenn-::togetber ~with'-oxytQcin~: it; can).;$\l~~sfUlly~- . recep:tOP$ .~e greater 'b efore labQ.r than. during
in,(iuce ,ta~r but it -.i~h :mec;tiVe .if.:giv~n . . 'l~b,or. Thu$, .- thf! higb :titer3 of::H()G_ -~urlng the
. jDdq;cn$f.~tly.~ ;:B!i:~bnofrrl$.fUi4iQ$..:~d~~ : CO\:J~t;~ :Of .p:r:egn~ny -' tt,>.a)' ..be one of the
.;tq;~; pt~'g~i.~er~ne4cv~l;IJi:-nP~'tli.e .~g~y;.l'~ct~m.. :.. meelitulisni$ :c:au:~,:u~#ne.:.qt!Uts<ie~~ .
.re~s~Je7f'or4alX>t au.erm.-. , : - : ,. ..
' . '. -f!epta}le~te.cept()fs:foq:d~also!lll~te
. . ~i:.oJ~~~t~(()n ' aqm:mt~itation-- to. ptt;~rt~t)J::. . the . a~ti~atiQn ..of :adenyl -cy-l(i~e . pi'Qmodng
w{in;um ao.es not delay the timely pn'Se't .-or ~..;;..<tilte:triil r.~l-a*~Ji-ci~..:..@.~.:~~.~-nt~~l.:rll*itirig.
p~oniiiT~ifor~~veni Rieieffii;laUr~.--tb'e:se R~l~Jn~~~\)~.. by-'th'e>:c~r;p-u~duteumithus
:fuldiD.g s :s uggest that .-~me hiddeit- .~r \iji{q{i~ ll.ie--pe;nc plastila1e~-eoin1!itt~-"Withc'th-e-life
fqim of ptogesterone deprivation. b~.-!lot the ca~se dUrationof.tbe ror-Pus luteu~ frofit ff - 12 weeks
of the suspension of uterine phase -() processes in AC;>'G. Levels will siowly it~cJ.ihe .until term~
butnah p~urition :but .w e :qmnot .p~ude th e
-wssibility that the prOgesterone attion~ dUring . P1~:tathyro:id ho;mort~ .a nd . par athyroid
-initia'tio,n ()r pattutition a~,e inhibited by. a .h orrilone-related prot~ln {PtliiPTH-;tP)
pr9ge$t~rQne 1'~c~ptor..:lndepend,ent~ ~ el.ea~ive heptahli~ r-ee_
e ptor l,n~-Y plso setveto ~- ..
an:tip~gestj'n-like rnec~a:nism.. u.terin.~-~b.l:.d.Jl~"V during m:yoilletriru c6fitraction
by its va sorelaxant a ctio_n and may a lso facilitate
Prog es terone also c;;optribute to the myometrial the maintenance of uterine tranqumty. Estrbgen
cell #fracforiri"~ss :of phase Qby increasing t:Qe anQ. transform ing growth factor -~ cause an
-~ctivit,i~$. of:enzymes ,t..~;It cegrade or m.a,c~vat.e incr-ease ~in levels MP1'H~rP in~ A. TheexpiessiOi:l
endogenou~ly pro(iuced UterotOrtins. ~orne of is increased when myometrium is stretched.
t.he se include pto.s tag\andin d eJiycirogenas e
(prostaglandins), enkephalinase (e.ndothelhi~). 'C~H {cortico.trophin-relea~ing hormone) ~hich
o~y-~ocinase (o~tocin), diamine oxida se dramatically increases during th~ last &-8 weeks
(histariHne), catechol-O .. m.ethyl -trans'(erase of pregnancy:m9-ybe also-involved in the initiation
(catechotanllnes), al:lgiotensina ses (angiptensinU); ofhtu~an parturition. Sign als fromthe reeeptors
and PAF-acetylhydroiase {FAP). ' m aybe thru the ::AMP .or . calcium. This means

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j
;
CHAPTER 22: PARTURITION; BIOMOLECULAR.AND PHYSiOLOGIC PROCESSES
----------------------~~------~------------------~~--------~
.. 371

that CRH may cause uterine relaxation or uterine . There are enzymes that degrade or inactivate
contraction depeQ.ding on the isoform of the the endogenously produced uteronins. Some of
receptor. CRH therefore can be both a relaxant these uterotonins and a sample of the erizymes
durin,g phase 0 and 3. uterotoniils in phases 1 and include prostaglandins (Prostagh1ndine
2. dehydrogenase) 1 endothelins (enkephalinase) 1
oxytocin (oxytocinase), histamine (diamine
Most prostaglandins ar.e considered as oxidase) 1 catecholam.iries ( catechol 0-
uterotonin,s but some prostanoids <;ause va~ular methyltransferase), angiotensin II (angioten-
relaxatil)n and vasodilatation. However, 'b ecause sinases)~ and~platelet-ac;tivating factor (PAF-
of a number of G.,.px:otein--coupled prostaglandin acetylhydrolase). -~rQges.t~ may increase the
receptors pn tissues of the different targets, the activities of some of the enzymes and may decrease
effect of tllese prostaglandins ar.! complicated. The ~t~ _in..g~ta:~,Qn.
receptonand their natura)ly.pccuning ligandsare
. zy . (\bromboxane ~). DP {PGD2J~ IP (prostacydin Fail-8afe Systems for Uterine Activation
or roy, FP (PGF2 ..), and EP.l to EP4 (PGE2). DP
. Md IP ~tot.s increase intracellular MP, while There are change's in the m yometrium &rid
. FP receptors. increase int:ra.Cellular calCium. EP:2 cervix th~t prepare ..p:em for labor. .These a:e
and EP4 activate cAMP production while EPl and chara.ctnzed by the <;ievelopment of uteroto run
EP3 in~Si: intci.cellil.lar c alcium:- T lilis;'both $elisitivi ty. .r: improv.ed int~tcelluiar
PGE2 ~d PG:t>.2, and. PGl2 .c an cause .relaXation co:n:u.-nunicabilicy via gap junctions, an<t'alte:rilt:ons
. of.,;va~. smooth JnUSGle and vasodilatation. . in the capacity Of myomeqial ~~. ~ ~te the
. : ..::i j concentration of cytoplasinic ~+tJ~~.- .:.::. ~
.. _ ; :MQ.<iiA~tiCli.S in the ex:r>ression of various - .J.~ .: .;~ it'>- .
sta.ge~.:qr-'ges.tAtion may .account -for L'l.e v;,uied The.classi@_p..r.o_gesterone tvith!;ltawap',Q~ no.t
re,sponse~ to -prostanoids -i.e . pros~~I!.<?Ms initiate ?uP1.~ 11 .. _p~r:turition~:- Prettta::n :ey
$~i;u.ul~t~;-~denylJ.l_ c~].~~-~-J!1_:_i.ily:ometrium . iiiaiiitenance has ..been .a:ttiibuted to":proges~roP.e
..P~~~~'!'at -32Ao . 35__~eeks b~t not at 3,40 .hence .r etreat frcm pregnancy.:mai~ce~~o\lld.
w.~. ';J)o,fher rea$0.n for .th.e varied .~~ponses . mean a dec~~ ll:l. progeS.teione:blOOdl~ehvhich
to ptvstg~dins::is ' the" l~ck ot specificity of is 'very evident iii the sheep :f"ese aicire.S on
prQ~tanOids via different receptors, i.e. PGE2 at parturition. However. in humans,ina:.s ubStantive
low ~CC:*.~tion . .indl.!f~-~_11._9enyJY:l cyaa8e and evidenc~ has been shown for a reduction in
smopth . m uscle cop traction while at high . progesterone levels ~f9x-e. the oriseb)fJabor. . and
c~n~9.!~!!~m..P:9~~~i!J~~~-~deny~yl-ey.cla~ -th~ina:ley_~Ls~liri-
e--o.._!!J.l:~EM 6tllie
. causin_gin~~m.Y-o.metrj~lc4ntraclions;:: ~us., .~:.Piacel),t,a:~--'Thisi:s-su-pponed"l'>Y s t\iaies.snowmg
it i$ highly pos.sible fo:r prostaglandins to that progesterone e.dniinistratipn cannot prevent
contribute t.o both .myometrial ret~tion at one pretenn labOr. Although the antiprogestin RU 486
stage of pregnancy. and to regional myometrial or mifepristone, is :quite effecQve in inducing
contractions in the fundus after the initiation of menstrtiati.o n prematurely and induction of
parturition. abortion during the ~aily. stages of pregri.ancy, it
is less effective in the irtdu.c tioii of labor ;
Guanylyl: cyClase activation increases ____Mjfem:i~.to.ne_ is_aiso .effectiYe...itLri~ninz._:oL!he.
intracellul~ levels 'of cGMP, wh1ch .also promotes .f~(Y.'jx-~d. U;l_cr.ea.~!!1g ~~~~~~~~ .~11~i~-y!ty J o
s:nooth q1uscle relaxation, Both at;OJ!l..n,atriurefu; _..u terotonms.
~~tide {ANP} ~d_:.Q~_:_na~l}reti~.P?q~.J~~~J.
receptors frolll the myometnum and mtric OXlde An c;tlternative to the classical progesterope
from the myometrial vessels, decid1,1as and nerves withdrawal theory of initiation of parturition is the
activate g\.ianylyl .cyclase: The ANP-BNP t~~pto! {un~tional p rogesterone withdraV{~ in human .
molecule is a gu~ylyl cyclase.---m{p"fssecreted . parturit1on: .. . This.. ilie~iY :couict be mediated
).iiJ~(fiiiioiij{tS::i~.tii.e..a:in~.~~ ~ .AijP in the through several mechanisms:
e.I:a_.=e~~ Nitric of(ide reacts with iron in the active
site of the soluble :guanylyl cyclase enzyme, / 1. C.h anges in the relative expressi_trt 'o'( the
...stimu:lating.i,t.J:!Lprod.uce :cGMP. and .acts to ~ause proge$terone receptor or of its . tw~isoforins
myometrial. relaxatiol}. (PR..A :andPR-Br . :> .

Scanned 8y: ~
 372

2. P.osttranslational modifi"cation.s o.f the the placenta. Human .studies aJso poiht to signius
progesterone receptor causing ~ecr.eased that are bloodborne th:at act on the placenta too.
activity.
3. Alterations in progesterone rceceptor a ctjvity Mechanotrmsduction is the process used by
through changes in the expre.s sion of co- the stretching of the myometrial cells to regulate
activators or eo-re.p resaion that directly the myometrium. Conditions that overdistend the
influence receptor function . . uterus e.g. twin pregnancy, hydramnio.s a~~
4. Local inaetivation of pr()gesterone bj. stetoid- associated with preterm labor. Anixnal studies
tnetaboli;ing e neymes or th~ synth~sis of a showed that stretCh was reqUired for the normal
natural S.."ltagonlst. induction of specific .coutr~~t~?:-~!.~9Qiate~
px:.9teins (CAPs}.- ~~also increase.s eXpression
There are 2 iso:forms .of the prpgesterone oi the gap juncUon, conne:rln 43, as well as
receptors ruunely PR-A and PR-:B. PRa isoforin . oxytocin recepto~. 8-tretthing of th,tt fetal
1s more transcdpt:i.lin~uy-~CtiViihan PR-AJ.sofotm, metnbran-es 'nut.Y .merease .ot .s timulate .cytokines
which b.a s actually reen shown t~>"iohibit P~:!.3- and ~n.zytnesthat .can cAuse e9llagen degradati~n
There is ~1-.ift ill relative .raUo -o f PR-'..\ to PR-B a_nd m-etnbt:-ane ru:ptu:re. Pre-P Cell colony
with.ln the myometrium late i:n ge$tii:Q.on. It Wo\lld enhanCing factor (PB.El."l is one of the few c:ytokines
. al$o lippear that there is .a .decr~e..: ,i.tL~o= that ~nds to .stre_tcb. lt.canat~o be $titp.ulated
a<::tivatoriand ftn inm~ in to-~pre$SOt8 :fo.r the .by :.u~~a : ....~~~-...... o"on. ""'ue
::... ~ .........:~
uvn ~ _. . . .~ -ny.:-JJOXI.a

. P1Qgt$t~e .~Pi9t.in' tat;;g~tati()a 'fbere is
..n:~_.Actual proges.te:ro~e ;Jevelreductiqn but.there Fetal con~ibution to~rltion is evident with
is definite prog~st~r6ne wi'L1tdtjwat ~t.IiledJated the .de~y_in ,normal .t:Unh:lg or~ parturition in the
tbtl:ntgh.iits r~ptors;, pre$enee .of::fetal. ~brrun:. :.ano,nuilles-=: ..Congenital
. . .. .. .. , absence. of ~e p ituitalj :t land and ailence.phaly
Thecontractile \1Ilte$ponsiv:n~s$'oithe:uterus is asSOCiated.With prolonged-gestation 'a nd this Is
quppg: IJloSt .ofh~ pr~cy:O~ .-~llSU...~: J>Y. attribu:t_a~le t(t ~e: AAOmalc>UB ~j~..:
. m~qp~~ :p~$$Cs .~that ac~.. in~epep.~cJ,ltl,f-,~d. : ,. ~-d'te~:~ ;.:!:u~C?~n. . The _-a dl'e i:)al :glan~b o"f.
: ~()(j~,raij.v~lf.JQ.~s:tabUsb:; ute$~: .qui~seene; . . .~encephalic~(etl,ts ;j~ YCJY.: small'(onty,about 5-10
uat
..Hen,ee, :.~ge,s~ro.n.e. .ia, pn,l-,i .P.r..~. ,of.:the:~s.eV.e,l:a,l :. : ;.o/o: of.nottn.al Ofelus~ ' :and.=.thlli 'I.e$tiits 'i n. low
factQtJ th.a.tc6ritdbut.e. to . th~ .~yst.em :, th.at C19: steroid production ::and . ev~ntu~!_ly
. )ll.ain,~n..s ~yo~p~triS;l upr~$.pon~iv~p~s. i1J,ld byJlpt.trog~l}le . s.ta:t~ .Qtber Onditioti~ with
tb.~f~m.;<J~_Qf:tb~ .ta:to.ralh,at.:canih~~pUlie . r:el.afiv.e h~poesttog~nism .like.. .fetal ::a<h!.<:..h..~
..qwe~en:~~~dJinktu.phase 2 ..of.p~Qo4.. hy.popla~i,a~d;plaGCn~Lsll11ita~-'(1~~iency-e.re
hlS.o ~sS()clated with pt:Qlonged. gestation. Thus it
.. ~~is .no d~fh~jtt mle.Jot ~iiLin pse is safe to .assumethat there is.plaeehtahpituitary-
1 .o f panuritiO_n ~~ evidned by .its :inetre<;tlvn$s :ad.re:nal axis .t hat ~Y play 'a role in the timing of
in 9er:Vical rip~ni;ng and induc~i~n o!J~b.oJ. partUrition . .
Ho~~:ve~, there is all . ~n:cu::ase. iil p~Jo.cin
:recep_!.O.i~J.P. Jll~_
_:.~y~o.metriiiril ...in. tt.i~ ,.petipd. The f etal adr~nal glan:d s at term weigh the
p;,:if-ta~-iol c~uses a n ..jncr.e~s.e. :in ~yometti.al same as .tho8e.in the adult.. The daily production
o~oc{n receptor$. Pr.ogester<:me .. on the other of steroids by the fetal adren.al glands hear term
hand ~ncreases the degradatio11 of .oxytocin is esti.rna ted to be_100-:..-.Q00-4Dg..f..day, which is
rec7ptors. There are oxytocin ret eptors in the highe;F thM.lhat of the adult adrenats at rest.
endbmetril;lm and in the decidua at term, and Aside. fr:om ~orti~:pj, levels of
these may stiiUulate prostaglandin producUon. {l~i].ydroepiahdroster~me sUlfate (D HEA~S) are also
. :. . . - --
inqeasing.leaCUngtoincre~es mmateillal.estr.iQl.
Fe.t al Contrib~tiQns to Parturition. . However, fetal .adrenocbrticotrophic hormone
(ACTft) lncreases .o nly during t)le stress of labor.
After appropriate maturation ~f vital organs, Studie.s would point to. s_q_t:Ycotro.ifu.!!uel~~~g
the human fetus may provide the initial signal that .h..Q.nnone.(CR!l) Q.f_p~c.e~tal .orlgin that. faGilitates
.sets the paituritionaL process. in motioh: This fetal:. ~dten.al hypertrophy .and st.imulat~ fetal
system .ot fetal s.ign~s .hM .been well studied in . .adreriuifDHEA-S and cortj~ol; b:iQ.synthe~s late in .
. fetal ~beep, where the fetp.l . br~;J,irt, . pituitary. .gestation . The ~ability of C.RH to regulate th~
adrenal glands and fetal blood communica te with adrenal glands and C>f the adrenals to regulate

Scanned 8y: C
____ .,..._ _______ _____________
CHAPTeR 22: PARTlJRmON:
_..,.. . BIOMOLECULAR AND PHYSIOLOGIC PROCESSES
placental pro<lll:ction of CRH has led to the idea of
!~-!o~ en~ocrine casca~ that occurs late
in pregnancy. Cortisol has been shown to
stimulate placental CRH production in humans.
There iseviden~ pointing to a decline in .th<'GRH
binding protem i..tt the later stages of pregnancy
leadirig to the increase il1 free CRH. CRH may
a
also increase as result of stress of the fetus.
There is a four !old increase in plaeental CR:ijj !l
pre-eclampsia as compared to nortila.I p~gii-ancies.
(Figure 22.1 0) . .. .. .
Figure 22.10. P)acental-fe tal a drenal endocrine cascade.
Placenta l CRH may e nha nce fe tal c<:>rtisol
productiQn, which would provide positive-feedback
em the 'p lacenta to produce more CRH. Tht hjg!l
CRH iev'ds may mod\l.latemy~x:ru;.trialcont:i-ac.YJ!ty_.
cortis6i-:aii'e2ti 'tlie myo.tnetrium by stim\llating
the membranes to in c r ease pro s t aglandin
synthe_ifu, CRH s timulates -fetaf -ad~enal Cl9
steroid synthe$is, leading to increased s ub.s trate
for .Pl~cental ar.oma tiz"ation . Ali" ot these
observations would res ult in a n in.o rease.Jn
estrogens which would ~hiit the: ptog~sterone
~~atio :andpr:omote t)ieexpression of CAPs
ln.t~e myome!!}.t!.ro.Jeadiri.g Jo.a .lossi:>fmyometJ:ial '
qljJ.~.l>C.~_n.ce.
Seanned By:
~-----------''
:i~'
.,:;.
373
Fail-Safe Sy"Siems to Ensure Success ofPhase'2 of
Parturition
Just as multiple precesses&:ontributetophase
0, other processes may contribute jointly to a
syst~m to ensure the success of labOr. Many
t~terotonins known to ca use myometrial
contractions have been proposed: ogtge!!t,
prostaglandins, serotonin.. hi's tantine, platelet-
activating !actor {PAF), angiotensin 11, :a nd p:l.ally
others. This led to the widely accepted C()fteeFtof
-uterotonin t:J:ieory ofthe initiati!>n or p&rtmition
During this phase, ether nepta..l1.elical nc:eptors
have been identified in the myomettblJil Whioh
more 90~monly activ~te -~g;L~'*" ~ naedl-.t~
processes that eventuate m increased ttl}Om~trial
cell(Ca-}. . Per haps a t various s tag::$ '()f~cy
and und,e r the influenCe .()f exte~ a~ 'the
heptab~iJ!il.l receptor . phe:notype (tf the
myomeUrum contributes to the tonttactile
response ofmyometrium to either; te~ or
. contract~ . :---~ 4 '-':"~;..~r:: ... ' ).::,~:.- ::: ".
. ..;;..-::.-:
. .. ~ =--. . . ~ ~~
Oxytocin and Phlises ~and 3 ;>f~ .:S~-'.
~ '
Oxyt~~- ~~l!ti.e ~th~sited.Ui - :the
- .~-
sterlor ..,,:1-.,""' ' act. s Jm
-- ...Pl,.~J
...,.T waY of .:,"'......,.~li~'
: . '~~~ ~
~ter which likely ~tes!>h()ID'l't:hl~Jtl'he
effectiveness ot OxYtocfu in indl.lclng~attterm,
the increased oxytocin rettptors inmyiliDetri'Um
and decidua$ neaT the end or ,g~sta$fn, the
u 1 ..;. ' . ' . . r .. . . . .... . .. .
. $..Um;g,.g.tocy...a cti,on:.o -~--on-.~din
..release...ixi.:(mdome trilim--were ..sufficlent-~"SS'ns
. to Sl,lspect .oxytocin as the cause Of iri!ti8fion of
Parturition. However, if -evidence$ are critically
exatnined, they do not favor a role for ox_ytocln i n
thei nitiation Dfparturititm: 'the.lev.els, o~
ip.Jhe.ltl~~rnal blo~o. not ,..in~ 'befOre or
during StrSLstage~_1>f 'l!bci!:J?.~t. on.t:r dtiririg. the
s~n~..stage, .it) the early postpartum period
(phase 3) and during breastfeeding. Immedia tely
after the d eUvery of tl:le pnxhict$ of .c onception,
. oxytocin is the on e respon sible for the perSiste nt
Contraction: and r etractim1 of.the uterUs cssen tial
for the . prevention of p1>st parttim ut~d.n e
hemorrhage. Oxytocin infusion in postpartum
women increases lev els of ml<NAs in the
myometrium which enco<j~ Jor__p~tcins~tial
~u.~~rine~iny..Q_IJ!!i.:Q.n: interstitU!!._c;q~a~e
.monOcyte chemo13:~q.:~~tant protein- I, int#.l.Cukin-
8 (1~~8), and..urokin.?.,~e _pta'sminog;n-.~ator.
,t~~p~r~ Oxytocin r eeeptots in the myoe.pdheliuni
ofmainmary d ucts increase late in pregnancy and
d uring puerperium, they act on the breast duc t
~

374 SECTION W: Cllf'l\CAL APPROACH TO tABORIOELJVERY
cells to effect milk let-down, a component of phase
3 of parturition.
Prostaglandin and Contribution to Phase 2
Previoul;ly, it was believed that prostaglandins,
particularly ~F2a -~d PGE2 .are involved in the
initiation of parturition. The following evi.d ences
.s upport ~s thepry: . "'" .
1.) The levelsofprostaglan<;ijns.or their metabolite
in amniotic ilu-id, . ~:~te"f_l1.~L,p~ and
J,Datemiriliiiic--aie increased during labor ..
2.) The treatment of pregnant women with
pn>$taglandin by any rol;lte of adnlinistratiqn
.. eal,lses ~borti6n or labor at all st~g~s of
gesU\tibn. . . matrix degradation, increase levels of hyaluronic
3~\ the eibninistration of.J~QH syn:the.~ .!Y~ 2
tP<ms:::2l. rr.hihltOr.& to .pt~~ant wom.~n wm
aelay -the on$el :o f 'it1<\~ed .abo.r ti"Gn or
.:s'Pontapeou-s labor. and.. sometimes. arrest
. . pr~efJ:n .labor._:. . . . .. . . . .
4.) -:Prostaglafidin treattnent.o fmyomettiahmP<>th" ..
musck'
. .
tiSsues
. causes
. eo:fltratio'n~
.. ' . ;.
. .~ ...:.....t ...... dins,.ni-ml3..oily P.GE IhutEd.So:PGF )
~ -..~~~ l" .. ' 2 \!'" 2a . a member- of . the -heptahetic:;'al -famiiy of
~te>dcti:cti<!Jn:.,amni~tiQ~'fhiid,:.a.t :~U :,st;:lges.: of
gestiltJoJi:. .~fot~lab.er~begj,n~h~.?. Pf.Q~tanoids'in- .
~~-,nu~:~tl~t~;iby!e,Xret:i~n.~!ct{ll-iuine..
and l:?o$$iblyllidn, 1unge.and umb'ui~ cor.d. As
the. fetus ~'Ws. the. .kveis ot prosqigtaii9iiis in.
amniomntm,'<f'ii'ier:easegr.acruang i:eaamngor.uy:a
verj-iiilillsewelever{al>Qurrug)~iiiitillerm &Tqfe
la'bor beg\ri$.
Bc fore labor., the f~tal membranes ar.e
c9nliguous and attached to _the d-~id~~
parletiili~. buring. c.o).'l_t:mctions Q.f,la)).Qr. th.C.fetal
~~ml?!~~w~ .~e..: .pull~ a\\'ay_:fn:mt..aticL.sUp~k
an~ (oxih :over_!h~. "'- d.eddua.,~ A's labor ad'iance~,
t~e .c:e~-dilat~s and more of the fotebag .is
exi>osed t.9-t4e vagina and vagina l fluids. The
vagi~~ fiuidcon~qs a large number and variety
of .m icrotganlsms, bacterial toxins in. large
a,mounts, prostaglandins and cytokines. .Because
in
o.f 1.) trauma to decidual tissues the .formation
. dr.-the for.e bag, 2.) devascularization of the
deE:iduaHnigments.that:are.p:ql~ed _~~-ay f~()m t~e
utefus, and ~,) .t he action of the c<;mstituents..of
,. tl\ua,gi,nal .flu!d, .an. Jnfl;lmmatory r~spori~e
occurs-~bich releases. pqF2,. and ~he cytd\{ines
J~J3. ~d II,.~. Then these niedi~tors ..enter both
lh.e vagin~ and the fo'rebag axli.niotic fluid.
Studies also
~ . show that . the de.cidua . pax:iet~l!~
.. - in
Scanned By:
.. :
the forebag is the principal site of prostagl~din
formation :t..'lat enters the fore bag amniotic fluid.
Specifically, PGF2" and its stable metabolit~, .
PGFM., are present in the forebag amniotic nuid
in much greater quantities th~ the PGE2. The
decidua produces both PGF2 and. P(IE but
' Cl . ,.
amnion-and chorion leave produce prlinarilyPGE
2
and very little PGF20
Indeed, parturition processes at term are
similar to those of inflammatory reaction but it is
very unlikely that inflammatory processes initiate
parturition. .It is rather clear
~ .
that the. normal
processes of labor result in inflammation &rid
increased prostaglandin -synthe.s is. The cytokines
and chemokines lead to further ej[tracelluiar
acid, and cause: an influx of !eUkccyt:es into the
area. 1'hiswilllead to wea kening of the fetal
mer;t:tbtanes. It is possible that they. add to the
relatively rapid .c hanges .in the -ce~.
. Platelet;.At:.hr.a:~g;Faetor''{P~F ...
. .
The pl~tdetactivating factor (PAF) receptox: is
tran~niembrane. tece.ptors and i:~ts to imcrease
mytnne- t tial ~fCa::O) and: .j:>l":Pniote.- uterine.
contr:cietions. .PAF., just lilce ."}).r.o.sUiglandins.
cytokines and endothelin~l. is. .produced in
leukocytes as a result of an inflatJ;ltnatozy process
th~t oecurs as the cetvi.:'JC dita:tes and the
trauiriatiZed Iorebag tissues are exposed to the
vaginal fluids.
Enaothelin -1
. . I
Endothelin A receptor e;;;:pressed m the smooth
mt).seles cf the myometriun'l acts to effect an
increase in (Ca++) apparently by linkage to both
G.,,- or G..qs ubunits of G protein. . Endo.tbelin-1
is produced in the myometrium an.d amnion but
the ~.xact cellular s ite of . synth~sis is no.t yet
e ~ tabli$heq. . Th e enzyme_en.k~ha-li!!:_a_se
(membrane metallopeptida;se) is big4Iy_ ative ih
the chorion leave. Thus, endothelin-lcannotpass
thru the fetal membranes. However, endothelirt-
1 could play a role in situations like premature
rupture' of-membranes. . . .
Angiotensin and Phase 2 of Parturition
There are 2 heptahelical 0-prote.in~Iin.k~d
angiotensin ll receptors in the myometrium ATl
C
--~~...::....:..~..::.,_ _
CHAPTER 22: PARTURITION: ______
610MOLECULAR AND PHYSIOLOGIC PROCESSES
_:,_.......___...,..._,..--___;.___...., ~----~.
' 375

(predominant in pregnant v;~men) and AT2
{predominant in nonpregnant" women) . When
angiotensin II .b inds to plasma me.mbrane
receptors, smooth muscle contraction occurs.
During pregnancy, vascUlar sm.o oth muscle, which
express es AT2receptor, is refractory to the pressor
efte<;ts of angiotensin II. At term, however, the
angiotensin n may be another component of the
u terotonin system of phase 2 parturition acting
to promote increased myometrial celt (Ca..).
~;: .
't"uere may be n !ate prei.Tiancy modifi,catit>nin
the CRH. Ui/hCG, and for PTll-rP reccptor~G
protein phenotype in myometrium t.ltat favors a
-sw:ii:ch from cAMP formation to increased
myometrial .c el! (Ca~). Oxytociil acts to :attenuate
CRH~stimulated accu,mulation. of cAMP in
my~me.t~ial tissue, an<i CRH augments the
con:t:raction:-oinducin.g potency of a giveJl dose <>f
oxytQcin~ fu,b,utn~ myometri.8:1 ~trips. CRII also
acts to.:irici-ease.~yoi;iletrial contractile fon;:e in
response in PGF:u.
-~9ntrtb.lJ~lon .o f Intraut.e rlne Tissues To
bJ':turltion
. :~ ... . .. : . \9:.~"'~. . . ..
:.... .The ..a~nion, chorion leave an-d decidua
parietalis do
not have a role in the initiation of
parturition asprtviou$.1)'" thought. However, these
fetal membranes and decidua fonn part of an
importent.tissue shel,l.a round the fetus that sentes
:as a physi<;a}1 :im.Inunologicala.n.j me:~boliC"$bi-el<i
that . protects a!!ainst untimely initiation . of
p!UtUntion.
Amnion
...The.amnion_pr.pvides.wr-tuall}'-al~'-the tensile
strength (resistance to tearing and rupture) -o f:the
-"few meml>ranes. J._b.e..~VscJ.iJ~Juuna,n.amnion
i~ highly resistant to penetration by leukQCytes, -~1!-~n.ta~<!I}':~~ctiOil, which is an ine~taole and
microorganisms, a nd neoplastic .cells from the
maternal ccmpartrnent and constitutes a
. part.icula te-boqnd lung and skin secretions from
reaching the maternal compartment. ln this
manner, . maternal tissqes are_pr:ot.ected.._ftom
.c.ongituents in the. i!ITlJJi(;).tic...ilui.d. that. could _ir)cll\d~ tumor_:n~rosis fa~tor alpha "('fNF-a) and
adversely affect decidual or myometrial function
or even maternal well-being such as amniotic fluid -~eutrophil~ and eosinop~s to the U:t~p.ls and .
.emboli$m.
Several bioactive peptides and prostag.f undins .
are synthesized in the amnion. In the late
gestation. the amnion does increase its activity
(or Eh..Q..sphpHpa_$~--1\~ ~_t1q_ PGH..~ It is not
however clear how these prostaglandins can pass
thru the fetal membranes to reac;;h the
myometrium.
Chorion .Laeve .
Sim.Uar t() the amnion, the chorion serves
primarily a~ a protective tissue by p roviding
immunological acceptance in the prevention of
U1l~ely prtu.r ition. in ad9,itiop, the ~porion.
leave is enriched with enzymes t.hat inaC::tJvate
. 'Uterotonins such as pJo~tl:\gtan<!in
.dehydto_genase. oxytbeinase and enkephalinase.
Recent eYidence suuests that the level of
pto~taglandh, deh,ydr.ogenase (PGDH) folUld in
chorion can be ftg111atoo .. "Ptogest~J.~ne ~tains
chorion :~DH expression while cqrti.S()ldecreasell
its expression. PGDH would decrea$e -~te in
geStation ufetal cortisol productior{Jh.~;;;"lf.an.ct;
as part ofprogesterone withdrawal'' - '',:::.:
...~ .
Decidua Parietalis
A rnetawlic contzibutionof ~~~~~-ii$ . .
to the -initiation :or patturitiorl-tffkitibee:~- a~
appealing possi"bility due to .anatorrti~ and .
functiop~ !eason~ Ti};t;.neration~f.utero~ '
_ip_'~~~~5!~a .~~t.!t.~~ ~.ctitie~mru:m~ .on
~n~~~~ myo~.triYmJ.s..anmtetestin~-oe}ion. .
Decl~uafactivafion bas been-shO.wn--w:ilccompaqy .
human parturition. The central que~~ion,
hdwever, is whether decWual ~~-y:ation_p~~
or follows, th~U>~.s.et ,of ~bor. The. process of
decidual activation appears to be localized to the
e xposed decidual fragments lining the forebag.
~~~m~,h~~~ an.~~:~e o~!o~bag~rJ;.ta .
to endo_~~-l!J?.O.i?l"Y_S2~1!~~-e.Tmicroorgarusm~
i:f hd.. IL-IB in the vaginal fluid provokes an
consh;tent 5equela oT labor.
It is a lso in~vitable that this inflammatory
reaction will produce cytokines which.can.iQg~~_!>e
production.oLthe .uterotonins. These cytokines
i!}te:r leukins 1,.. 6, .8 . a.nd.JJ. Theywil[attract
further increase uterine activity and labor.

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 \ . ' ., - .

376 .SECTION tv: CllNICALAPP~OACH TO lABORioEUVERY

POINTS TO REMEMBER

Parturition .a process of :birthing that starts from the retreat from pr~gnancy .malntenance to the
delivery cf ttle fetus, expulsion of the placenta and .subsequent return. to the non-pregnant state.

P.:~rturition is.divided Into 4 functional-states: Phase .Q is Uterine quiescence, -Phase 1 is Preparation

for Labor, Phase .2 is the Pr~ss of Labor and Phase 3 is the Puerpetium.
..

Phase O: Uttine -gule;$~nce is maintained as smooth muscle unresponsiveness to natural :stimuli

whlle the ceMx remains Urrfleldiili) :alld finn.
1 Phase t Jn~se ln myomeltial9xylOC.1n ieceptors, :9ap junctions, uterine irri~bility, respOnsiveness
10.uterotorilns, and 'fomiatiott Of .t t;a towerutetine segment prepare the U\erus for labOr. Cervical
softening isathleved :by the bt.ea.tt.do-Nn of collagen .content and alterations In the amounts of
-~minog~. hyaluronic aCid -and dermatan st:;ttate.

Phase :2: Delivery of.:the .ncepws l$ aChieved thru progres$iva cervlt;al :diJa~tlon whiCh is brought
.. a~ bt u~tloe .'CO~ .Uterine .tontradions ~re made by the -interaction for :the myosin and
acti~ ln the smoc>tb:hluscteflbet$. ...,_
. Ag~rttsan.d.:cncfitlPns~Whl~- lncrea~ inlracellu!ar :Calcium
promote eon~ction While thos~ that
.: ~> tief;re_a$e~'ium't.iV9r~~~:-tnerea~:in cAMPantf'cGMP~aJso-pr:ohiote ret:OO;itlon: ' ' 1

Myotrietnal ,gap ju!'!Ctions cimsist of C()nnexons which in.tum is compo!Sed of connexin's arranged
nexamtrieally. ,
. . . . .
. ~re. are.~;$tages-of.~tr1$tsta.ge s~rts from onset of la.borto.Jull cervia1 dilatation, 2nd stage is
, . _... 'frpqd~~~-~~i!e.~ti6nttc:t!erw.er-y,J>t. tne;.fetus; .anti': 3td :stage'is from deliVery .o f the fetus to:the
expQ1$lononhe placenta. .. . ..

-. e~ce~nt;ls.:tbe.;$hetierl~~J)f.
. .
~.tt\e - ~ieat- canaL
. CeiV~fdi~~~- -pt)ase is diVided into the I~tent phase aM -the actiVe phas.e. The active phaseis
furthersi..d)dividedmto
. . fu~ ~teration .pl)ase, phase of maxim~Jm -slope and the detetera.tion ph.ase.
'

Th~.patte~ ofcervi~ldi~tatioit is~ slgmoid while the descent is a .hyperbolic curve. oescent usually
$.taits.during.the dei:,eletati()(J pha$e and t.h~ maximum rate of descent :is when there is full cervical
dllc$lion.

The 3'funetional. dlvi$i~s:Of ~oor are preparatory, dilatational and pelvic div.ision~.

The..pre~i.itory ~:nvis1on.inc!ude tn.e tat.entphase.of labor with little contractior,s noted. This is i:iffect~d
by sedation ~nd-COnd!JctiOil anal,gesia.

The dilatationatdivision is characteriled by rapi~ rate o.f cervical dila~tion thru uterine contractions.

The.pelvic.divrsion ilHiesclibed CiS the phase when deseef.lt and the cardinal movements of labor will
take place~ This achieV;ed.ihf\.1 uterine :contractions and an increase in lntra-:abdominat pressure.
. . .
" PetviC.floor.will.accotr)modate -the delivery of the fetus -with stretehing .o f the levator ani muscle and
thinning of:ihe -sen~l -portion '()f the perineum.

Placenta may separate.~nd extruded either Schultze or Duncan mechanisms.

. Snanned 8y: C
 CHAPTER 22: PARTURITION: BIOMOLECULAR AND PHYSIOLOGIC PROCESSES 377

...
Phase 3; The pu{lrpenum is the periOd of maternal recovery from childbirth which lasts from 4-6 weeks
after the delivery. -

Parturition is regulated by 2 general theories: retreat from pregnancy maintenance and uter.otonin
Induction of parturU!on.

Progesterone negates tha estradiol effect of increasing myometrial gap junctions and oxytocin r~ptors
in phase 0. Progesterone degrad.es.or inactivates end09enously produced ut~rotonins:

Heptahelical receptors promote myometrial rel~xation by .increasing _levels -of cAMP 'and_gAMP. hCG,
relaxin; Parathyroid hormone and parathyrnid relaxed protein (PTH/PTH-tP), some CRH isoforms
.an~ prostaglandins EP2 &EP4, PGI2 iGn cause VC1scular sm9.9th muscie and va~oditatation. PGE2 at
low conCentration promotes relaxation but_at liigh levels increase myometrial contractions.

initiation of parturition may be expiained by a functional progesterone withdrawal rather than an absolUte
decrease in progesterone levels. A placenta-pituitary-adrenal axis may play a role in the timing of
parturition. _

:'Q1e fetus may provide the lnitjaf signat. Fetal adren~ls pro~uee cortisol. Placental CRH r~ulate the
a<!renat glands e1'nd in tum cortisol,-can stimulate CRH production. These woultj result in anincrease in
e$trbgehs whichwould in .shift the -progesterone-estrogen ratio and promote the exprasslqf).,9f.CAe~ -
.. --:- ieadiQg to a loss -of myor~1etrial quiesi:ence. -- . . : ~ - /,'-'. ....::;;~

Oxytocins and prostaglandins are the -major vterotonins in Phases 2 and 3.

f .:!~.: . . !;/~
,,_. - REF-ERMczs
l. eunnmghani FG, Leveno KJ_, Bloom Steven, et al (eds):
New Yorlc Williains Obstetrics, 22"" -ed, McGraw-Hill,
;2005i 151-185.
2. _Ag8iwiil'A.,Gupta S, Sh~ rut Ro!e of oxidative stress
in female reproduction. Reprod .Bio! Endocrinol 20d5;
3:28.
3, Beshay VE, .Carr BR, Rainey WE. The human fet'll
adrenal gland, corticotrophin -releasing hormone, and
. partUrition. -s-emin Reprod Med 2007; 25(1}: 14-20.
4 . Brown AG, Leite RS, Strauss J-F 3rd. Mechanisms
underlying -functional" progesterone withdrawal at
parturition. Ann N Y Acad Sri 2004; 1034: 36-49.
5 . Chapman NR, Smyrnias I, Anumba DO, Eucope Finner
GN, Robson SC. Expression of the GTP-qinding protein
(Galphas) is repressed by the nuclear factor kappa B
RelA subunit in human myometrium, Endocrinology
2005; 146(11): 4994-5002. Epub 2005 Aug4.
6. F ujimotoT, Savani RC, Wa tari M, Day AJ, Strauss JF
3rd. lnduct;ion of the hyaluronic acid-binding protein,
tumor necrosi;~ facto:-stim.ulated gene-6., in cervical
smooth muscle cells by tumor necrosis.-f<J.ctor-alpha and
prostaglandin E(2). Am J Pathol 2002; 160(4): 1495-
1502.
7. Gol~an S, S~~ E. Progesterone ~c~p't.or.W$.~e.in' .
the decid~a and fetal -m embrane. Fro!){ Biosci 2Wb2: -
634-648. .
-.
8. He~~ll ~. ~c;c:.lAA ~A: Mllf'M K:W, et ~ Gestational
~g~-d_e._PE!l~deJ.lJ ~p_-_r~!nl..il!.tiOJl _Q( prostaglandin D
synthase (PGDS) 8.nd prOduction of PoDs-derived anti-
infla-mmatory prostaglandi11s !.n human plaoenta. J Clio
Endocrinol Metal? 200Q; 91(2): 597~06. Epub 2005
Nov 15.
9. Hertelendy' F, Zakar T. Prostaglandins and the
_m yometrium and cervix. Prostaglandins Leukot Essent
Fatty Acids 2004; 10(2): 207-222.
10. Kendal CE, Bryant-Greenwood GO. Pre-~-cell colooy-
enhancin~ factor (PB~F /Visfatin) gene expression i s
modulated by NF-ka ppaB and AP-1 in human amniotic
epithelial cells. Placenta 2007; 28(4):305-14. Epub
2006 May 15.
11. Kendal-Wright CE. Stretching, mechanotransduction,
and proinflartun~tory cytokines in the fetal membranes.
Reprod Sci 2007; 14(8 Suppl): 35-41.
12. Kim CJ, Kim JS, Kim YM, Cushenberry E,:~charii. K.
E.spinoza J, Romero R_. Fetal i:nactophag~ are not
pres ent in the myometrium of women wiilflabor at
term. Am J Obstet Gynecol2006; 195(3): 82iH~33.

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 13. Ma.rX 'SG, Wentz MJ, M~:ckay LB,' et al. :E;;ffects of
pr-Ogesterone on lNOS, cox..:2;.and co nag
en expression
i.n tlte~ J Histo4lem Cytochem 2006; 54(6): 623-
639. Epub 2006 Jan 6:
U. Mcndels6n CR, Condon JC.. New il;lsights inb the
molecular endocrinology of parturition. J Stero~d
$ochem i-A:ol 8iol2005; 9 3 (2-'S): ll;31 ).9. Epub 2005
. Jan 25.
.. 15. Myatt:L,LycSJ. ~ressi<?n,loCa.lizatio~andfunction
of_. pr~stag~an4in re'ce.ptor.s. i17 PlYQJl}etdum.
Prosttigl.aUdin3:LeU;lcot'EssentFa:tcy.Ac~s 2.0 04; 7.0(2):
1S7~:i48. . .
16 . .()kon D.M.:Anun.imn.C.. Role ofthe .pr'6~s -in
lal>our.(Uld p~din receptor inhibitors~ tne
-p~ent:i~ of pr#'ttiii .u;t>our.. Front :B wsci 20P7; .12:
1.3;29!343.
17. OsmanJ. YoungA.~MA. Thomso-p.AJ,.Jo~
F,. Gmt :IA,.'No~~ :JE~ .~ocyte ensity and prt>-
in{iam,ina~oi;r ~olcine .~;.';:~ion iilh\l.Pl~ :'fetal
manbriuiea. decidWt. 'tt~..m~ myqmetii.tun .before
.8:tid. ~! laix,ur ~Menn~ 'Mol :H\trn :R{:ptcxl-'2003;
9{t):41~5. .. . 2S9.-29P.> ... ...
HL Patni S, Flynn P, Wyne;n LP, S<:,ager AL, Morgan G, Whit~
JO, Thom\on CA. f\n mtroductio,:1 to TQU-like receptor:s
and their possible tole in th~ initiation oflab<>ur. Br J .
obstetGy:n~l2007;
Sep 27.
114(11):1326-"1'334. Eoub 2007.
. -
19. Timmons BC, Mitchell S-M, GP,pin C , Mahendroo MS.
D-y'I1aiD.ic ~es .in the ccrvical.:epithelial tight junction.
comp!:!X .a nd. !filte:rt:;!l!)atbn .occur during .cervi~
ripni:r;g and parturition . E.~~ocrinology 2007-
148{3j::'l~78~t28'7 .Epub !2006 Nov ,3-0. : '
20. W"-tari M, Wetarl.H, Fejimoro t; Yam:a.da ll, Nis:hlhira.
. . J_. ~MJF,.Fu~oti:>S- tiwWiJ~deind"J.ce!:l
~crleu!cin-~ pro~hiction. by htu:q.'an :.Cetiica.l smooth
m;x$cl~ ~na:-J~i;;:ncwl!nv~tlg:2QOZ; 10(2):110-
117. .
.21. Young A, Tho.inSon:AJ, Ledingb.ai:J. M, ::Jordan F , Greer
'IA, Noriil.an~ lpnn\lno~on o!:prol.nflamm atory
cytokines .in;myom.c:triuni, :i:etvix a:J;ld fet:a,l;1:D,.emb!/ffies
duringhu:m~pa..--turition a.t'te..'"Ill. BiolReprod 2002;
'66{2): 44!H49- .
2 2. 'Z;ikar'T,.l#rtcl.cD.dY F. P,rpgesteron:e 'Withdrawal: key
.to ~--ition. A:mJ Otmet qyn-ecol.2<Xl7 ; .196(4):
..

: '

-
~

, }.

..
~

:.
.

... .
.: .
. --:..
. .
.
: . ., t . .~

.:

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- - - -- -.
 23

THE PASSAGES

CORAZON MEDINA-QUESADA, .~ .

I' '(:,_, ,. ., :.v.

. I . .. .'
-I
.
. -It-

Composition of the Sony Pelvis

., '"'~ ' , .~ _:.' It t " "" . .
... , " \,. ' ~ . ,. .'I~ ~' .. ::-) '' - . . . .
I t (

Pelvic A.'1atomy

Obstetrjc Considerations of the Bony Pelvis

P~lvic Inlet
Midpelvis
Pelvic Outlet

Pelvic Shapes

Imaging Studies -ef the Pelvis

Soft Parts of the. Pelvis

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SECTION IV: CLINICAL APPROACH TO LABORIOEUVERY
. . ... Th~ mechanism of labor represents the
.. accOpUnodation of the fetal head to the bony pe)vis.
The a~ artd shape of the pelvis play an important
f.tedn Obstetrics.
CO~SITION OF TH$ BONY PELVIS
:ri.le bony pelvis is composed of four bonos ..:.
~~' :eoccyx. -a nd two inominate bones~ . ~ach
,' .~9~te bon~. !s foiJ.n.e~ by the . f~sio~. _o.fth~
.. 'ijiutn, 1ih!l.Un $d pub~$. . ' rh~ m~#ifri,~tc: . bones .
... . ~jOined t() tl)~--ctUin..at th~ilia,~ sin$<>ndrQ~~ .
Mid to orieanoth at the symphySis pubi's.{Figure
:23.1)
.. ~. ..
~--~1. The female pelvis (D~tta DC. T~xtbook of
. ~.J99~).. . .
. . . . . .-.- -::....:......... .
. . .
. .;;rhe pelvis is anatomically-divided into the.
.:f'~ ~vis and True Pelvis.
..: . ne false pelvis lies above the linea terminalis.
.fb'ls:,:is bounded posteriorly by the lumbar
iVe~prae, laterally by the iliac fossa, and in front,
,b.y-:~Jower porti,ort of the an tenorabdominal wall.
i'he. ':false pelvis varies considerably in size
-.d~pelldihg on the flaring of the iliac bones but
t}$ -~s no obstetrical signifka nce.
.11ie tr~e pelvis lies below the linea tenninalis.
:It. ~ bounded superiorly by the linea terminalis,
~-~terl9tly by the promontory -and alae of the
.,.. ~tn, anteriorly by the upper _margin of the
Pl.Jble:~bones and irtferi'orly by the _pelvic outlet.
TlieA~aVitY of the true pelvis is comparable to an
. .o-b.Uqtiely truncated, bent cylinder with its greatest
. helght posteriorly. (Figure 23.2)
Scanned 8y:
. '-\'~
.......
. ..
Ft&ure .:;13.2. The cavity ~fthe trUe pelvis is comparable~ ..
an -oblique, trun~ted cyfulder v.'ifu its great~st -~t .
posteriOrly.._Notethe ~tru'e' of1he:peMc axis. . ~tii
oe. Fetal SkUll and Matemal.Pd<rls, T:~k of obstd:rica,
. 1992). .
In the upright po.s ititm, the upper portion of:
the pelvic c~nat is di~e~ted downward and .
\)ach..vfird a,n d ~-~s !oVIe.t cg~:r~e curves a~.~
OeQOJn_~_!l~~t_~g- ggvm_~~: !ID..4 .(9!WM9.. .
The walls of the i:rUe pelvis ~e partly bqny .
and partly ligamentous. 'l'hi~ is bouri~ed
posteriorly b y the.. an~erior surface of the sacru!no ,,:: .. .
and the lateral limit$ are formed b y the ~er. ..
surfaee of the ischial bones and the sacro~l\tic ::.
notches and ;U gaments. Anteriorly, the true pdYis
is bounded by the pubiC bones, the asceric;lirig
superior rami of the ischial bones and .tije
obturator foramina.
'fhe sidewalls of the true pelvis of the nqnnru
adult woman converge ther efore,.iflhe planes of
the ischial bones were extended. downward. they ..
would meet near. the knee. The ischial spin~ are'
felt. at the posterior margin of the ischium and~ are .
. of ~at obstetrical impartance. The dis.tai.tce
between them represents the shortest diameter:
of ~e pelvic cavity. The ischial spines can be f~lt. .
vaginally . and serve as an . index in detenniriin.g
the level to which the pr~senting part of the fetus
has descended into the true pelvis.
C
 CHAPTER 23: THE .PASSAGES 381
----~------~------~--------~------------~----------------------~~~~~~.:.:

The sacrum forms the posterior wall of the
pelvic eavity. The sacral promontory corresponds
to the UpPer anterior margin of the sacrum and
can be a !andmark for clinieal pelvimetry.
Oi3STETPJC CONSIDERAT!O:NS OF THE BONY
PELVIS
The descent of the tetus :through the ~lvis
occurs through three important planes: the inlet,
m.idpelvis, .ana the outlet.
curvatu~. In the normal pelvis, it is .d ifficult
to reach the sacral promontory and in order
to do so, the elbow and the wrist (U'e depressed
sufficiently while the fmgers are mobilized in
.theupward direction. With the .fingers closeiy
applied to the mo.s t prominent portion of the
sacrum," the vaginal hand is elevated until it
rea-ches the p:ubic arch and.the immediate
adjacent point marked. (Figure 23.5)

Petrie Inlet

The pelvic inlet (superlcr strait} form.s the brim

of the true pelvis and shares the sa.Jl?.e anatomic
borders. Caldwell'-MOlloy ldentifieq the -sb~~ of
the inlet o f the human Je.m ale pelvist more ntarly
thatl. cvoid. It has fourd.ifliJleters: .antero~terior,
transverSe and two obliques . (Figure 23~3)

l}~J"l~
- ...,.....
. . .. .
~

npre 23.4. Thtee:an~posterlor ditunet~:<irthe '~c

inlet: the ttue conj""gate, the more impOrtant obstc:trical
con~. end the ~;;Dea:surabledfugonal~jitgfde.
The anteropostpior.~eter of the ttrldpeM.!ifaatso shown.
(sy'n\IO"JllPh~-pubis){euntrlhghaDl-. -MacDonald; Gant.
The :NoPJ,ialPelvia, William'a Obstl.trics,l8th e d. 1989). .

Fipre.23.3. Different dianietera of the mtet of obstetrical

sigrillican~ Eispinous diameter is also deinohstrated.
(Dutta DC. Fetal Skull and Matem.!U :P elvis, Textbook -o f ~
.Obstetrics, 1992).

The anteroposterior diameters of the inlet have

three hnportartt considerations: (Figure 23.4)
. ,1\.u# rvJ.. . w lUI" ihA 1\ ,, (.W\
1. The diagonal conjugate which is the .d istance
between the lower bbrder or the symphysis
p~bis to the. midpoint on the:. sacral
prornont()ry. . It measures approximatelY. 12 ...;s~
.cJ,IL... This is th~nly~~t~r:QP.9.s.terio~~~
~e--me.as_\l~d clinicaJly. During
internal ex.amiriation, the examining finger~
are swept up following the anterior sacral
. *"
Figur~ .~3.5. Measurement .o f cU~gonal conju;i{C:. (Du tta
DC . .FetB..I Skull.and Maternal Pelvis, Textbook ofObstetrics,
1992). . ..

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~
 {
'382 . SECTION JV: CLINICAl APPROACH-TO lABORIDELIVERY

The band . is .withdrawn and the distan-ce i~hialspine~ an<i i:S around 10.5 em. Its posterior
between the fip o f the t actating finger and the sagittal diameter average$ 4.5 em and eXtends
mark is measured. from the midpoint -o f the
bispinous diameter to
t\le point on. the :sacrum where the midpelvic
2. The tr.ue or ana~.mic wnjuga:te is.t he distance planes meet. (Figure '23.61
between.the mi4point t>f ~e ~cral pr,Omontory
to t:he upper margin of the inner border of the
~physis pubis. It avera-gee l~_ and is
mea$ured .m<lir:etly :~Y -subttaatin~
from the -d1agO'nal COnJUgate.

. 3. The obstetric co.njugate is th-e distance

between themidpomt of the sacral promontor-Y
. to .the midpoi_nt or the inn~r S:d_n ace of the ;~
cymphy$is pul>is. It measutes l~and is
obtained by ~btmct:ng l .S to 2 .m from the
-di38ol)al-conjugate o.i' by radiopel'vime.tJy.

The transverse 4~~ cf the itile~ a"e.I:a.ges

.~dis th"-' distanee between th~ two farthest
points of the op elvi brim-over the.ilio~o.~eall~.
Thia :.aia:m~ter usually.li~!!J ::loser.. ~fhe .s:atral .
pro~ntoiJ:andf:(liVides~e.'in.let.iiito-apteri,f)t,.~d
--pos~ot ~gmen~

_At e,:poi.pt aro~d~:4 ;.m. m,:ntt--the. prQ1nontocy, Fltuz:e 23.6.. .Fist meas:u.l:c;m~.rit fo:r -a:p.pro:nm~tion of
thetranWel'se diame~:-:Wiilrl?i~et:-:th~ 1>bstetrio . bitubervus .~~et(:r. (Jfty,Lo Ope_rative Ob:itetrics, 1992)..
. ~011j~gate and.. 'tb,e.:-~tpt~tl)4t <l~rrC$j>Ond's -tc
the -~distance .between ~f<his. !>junctiqn~ :an d othe;.
: protitontory: is :canea-lli~::PQ.$.t~_rior s~@fi!l oEthe . Clin.i cal a:ssess~~rit .o f .the midpelvis is not
fnltt. ': . . . .. . . . . . __,_ pa~ble, but~~~ob . ofa rtudpel\ic :contraction
~
may lxt:arou~sea=tr~:y~r:me.rol15W:irig are elicited
Tne fi~f ~an.d, .:te(i--o1i.trqliearameters Xen-d .. on :inti:ij}a[~~ation: -. . . .....,. .
ff-01:1 -the ~~iliacjo.i.nts ..to t he Qppo~ilio_pubic
etllh)enc~ . and :;neasurl!~ __!.3 ..fJn. . ..ght -ot left 1.) Pro~en~ ,J>f the: i~hial spines
dnotes . the sact61li~c joints from w.hich the ~ -) . Pelvic sid~a,U-s.:.ru:e -aonve..rgent
m~asurement sta.r ts. Co11~a\tjty .of the f;,a crum is s.b~ow
. .Bj,;,isP.hkti dia:rriet~r Ol :Ul~ outlet is les~ th:ail ...
. Plvic D!atc.ei:~r
The. Plane. of Greatest . sem. .
\'f i~ ~J. (ttl.W\ ArJ MA1\.;.J)
. :.
. . . ~
. . . .
iPis cqrtesponds tp the roomiest p\ane .of the The Pelvic OuUet
pelvis. lt.occupi~s.an -area boq.nded QY the s~
to the.Jblrd sacral vertebra~ ,pos~. i:.tC'hi~l 'The ou tlet is 'boup<;ied anteriorly by the pubic
bones -lat~rally, ~:tnd . ~e :i);lrddJ~ sq_r'fact;; of'.the arch, latercilly by the ischiopubiC .rami, .ischial
symphysis .plibis ,antcrlor:ly. lts. anterop<)st~rior tubero~ity and sacrotuberous ligament, and
diameter and trnnsverse diameters .a.verage 12.5 posteriorly by the tip of the coccyx.
em.
. . -
'fh'l,l:t; the outlet ~onsists of two : triangular
The Plane of the MJ<lpelv_!s . a
planes sharing .<Xlnunon, base fanned by a line
joiJ}in:g . tlte:: two ischial tuberosities; . Its
The nlidpelvfc Elane extends frqm. the lower anter()posterior- diameters -fn,easure from 9.5 to
margin .OfThe symp}:lysis p~bis through the_lev.el ll.S cro a:nd.theposteriqr Sa-gittal diarileter usually
to
of the .ischial spines the .t ip -o f the satrum. Its exceeds 7 .em. The intertuberous or traps:Vetse
transverse
. diameter
. measures between the . two diameters ~v.erage 11. em. {Figure 23.71

Scanned 8y: ~
 CHAPTER 23: THE PASSAGES : 383
-~--_:.__--------~---~--------------,.--- ,;!f..

(b)

Fipuo 23. 7.. Diagrammatic representation ot mldpelvis,and

n::Udpel~ .plane (a) zone of mid pelvis {shaded area) with
Figure 23. 8 . Bol.Uldary of the anatomical outlet with
. the midpelvic plane coincides with the plane of least pelvic
measurements. (Dutta DC. Fetal skull. and maternal pelvis,
~clination. (Dutta DC. Fetal Skull end Maternal PelVis,.
Textbook of Obstetrics, 1992). .;.
Textbooko!Obstetrics, 1992). .......
_

The'in:tertV.berous di~eter of the outlet may
be measured by placing a closed fist against the
.. perineum at the level of the tuberosities {F).gure
23~8); Th~~JlJO~~ tba~ when -~e
-_ er~~ plus postenor sag1.tt diameters of
. otitlet~ '>-: .Q n, 'by x-~Y-~!YYne'e= - .
bony
r Qtiuet.ls conJdeied adequate .. If n _t.- dyst~ _,will
~Atthe sametime, _ arch
can be ~uated by paipatmg the pubic rami from
The ~~l>P~i -~ Jo !fle ~~i-9:s)ti,~$.. Tll,e arch
is around 90
-~~- - .
to 100 de~-~-$.
~ -
The measurements of the female pelvis vary
from race to race. Normal values for Filipino
women as determine<:l from a study of x-ray
pelvimetry are shown in Table 23.1.
Table 23.1. Normal values ofx-my pelvimetry for the Filipino
woman.
. . :.
PELVIC SHAPES (CALDWELL-MOLLOY . . .: ~ ::.
CLASSiFICATION) "
As previously mentioned, a variety of pelvic
configurati~ns may occur due to racial,
developmental and .evolutionary Changes.., ,J?~:lvic
radiogtaphy.enabled caldw~il and Molloyin . l934~
to deyelop a classification of four ba'sic parent
types of pelvises: gyne<;oid, anthropbia~"- andtbid
~d platypelloid types. A line drawn through -the
gre.C\test .diameter. of. the inlet. wilLdivide. the .inlet
into-_a.Jlterior-and. posterior. segments {tiansver-se
di~-neter). The character of t.'-le posterior segme.n t
de_termin~s the ~~and the~harader of_
the anten~~rmines ..the_teodency. A
summary of the pelvic types and their s!gnificance
-are shown in Figure 23.9, and Tables 23.2A and
23.21;>. .
IM.AGlNG STUD_IES OF THE PELVIS

Tran,sversep.iam~ter 12.48 The .relationship of the pelvic size to the fetal

Interspinous .diamet,er 9 .92 head and relationship of the fetal head to the bony
Intertubero~s diameter 11.11
pelvis may be demonstrated by x-ray pelvimetry.
Actual ronj~gate 12.13
. Obstetric ronjugate 12.12
-r .Diagonal conjug~te
M teriwposteriorm,idpelVis .
l.b31-
12. 11
X-ray pelvimetry may offer distinct advaritages
over clinical pelvimetry in lhe assessment of inlet
Posterior sagittal midpelvis 4.2 and mi<;lpelvic diameters~ but because of the
Posterior sagittal outlet 8.6 potential hazards of radiation, that is, tt).J.}!ations
MJdpe,\1s in<t~ 14.24
and increased incidence of malignancy in l~ter life,
sum of the ~terspfuoU:s diameter and posteridr sagittal the indiscriminate use of x-ray pelvi~e~ is no
~r the tnidpelvis longer s een 8 Curre_n t acceptable _indielttions
derived.from Manahan and Torno, 1978 include:

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384 SECTION IV: CLlNlCALAPPROACH TO .t..ABORJDEUVERY

Ta.ble 23..2A & B. Anatomic features and <>bstetrical significance of the different pelvic types {Caldwell-Molloy claS'>ifica~'
{from Dutta, DC, Contracted pelvis.,_ Textb9'0k of Obstetrics, 1992]. _ 1
. .

T~!e 23.2A.. Ana~omital features ef parent ~!vic types.

~iithropold Andrci4 Pl.olypoHold

Me'~tl1or!y ~~ ,.m. ncunu- . Tr.tn~-..~ ev~l-
-~~ and -~ .6oih ~ Willi -'ohl ~.ot' -~~~and Bolh . ~ .llal
-~.nor~ ante~ ug;'ne!i n&ITOW
Sa.c.i.l ~!.. {4-l mor. -~ 90" SA ,._. t--at~ 90' ~ $Kial ;~ -. ~toan so- S.A. rOori tmn fh
~ -~ -YM~ ~~- ltlog and f\atl'C;Of - ~ -~~ lndl~ pc.t~
-rro~t~ l\eW ~ i~a -alde t~>~ Uwe.l -~e. . _s .li'a\pht. ~~
- ' ~ =tid 'ci r.>lghl
' 111
;.vkl...ii<l ~ . - M~......X:;~~ -~ Nmnw and-'~ Slighl!y ~ ~ ~IN)I
-~ or ~gtilly ~_. ~etply~ Colw~n\ ~ p1verg0111
..
NQt .proti>lt\M\ i-lol :promto.nl .PfO/T".~i>A( Nol pt<>m...,t
c;,~ . "tbl\0 ~~ lD<1!1 .;-4 $\taiON- Sho<t atld C1k'l9d
vi~ ~l Slightly r..-r!JH N'r-r:Q\0< J~ ~ tmcn - ~ SO'j
Normal lofoqnal ~ tbo4 Sllorl Wid

Table 23.2B. Obstetric cutcome-f u :parent pemc tjrpe:!_. '

~tl>BI
- - --~~- - -~~
.. :::. .. ,, .

~- .:._ :r~-w:~ . ._. r~..~

<-;;,- -;_~- - - ., -:
_:::_~~:,~:-~. >~:.~_::~.-. - ~- :. ::~~t:;t . :-: . .'. ~
.' -..nd.'d"cflicut
' . . .. . . '
. '
.o11f~ .o; ~,
-~ale<l~
: pi.ac.-.tatioQ:'- .

:~~ .:-=:pj
Mtctlor l1>b6on

. ...iL~--- ' ..
.No'd~ li4oalncid.nca ot f~ :DilfJcut delft~ ' with 'No cimlculty
-~ -~m' h::t~~cl
~~- -

,(U)''(\))
. '
(a):
_ '- . _
.
.
.

-.
..., ..

.
.
.
...
-
.
.
. .
.
:
. . .. ' . .

. .
- .
_ .
c
---
-
. ;_t
. .. :-_ .i ' .._ Y
a
.
.
.
-~.' . :: .
.
..
'qj)'
. _
.',-'
-
.'
-.
..
-..-.
.
.
.
. -
.

Figure -:2-3.9 . Ax'fatoinicel ;features of parent

. ,. .~ .
'
" ' . ' . .
pelvic~: (a) inlet, (b)cavity, :(c)outlet (Dutta

. _: . ' r{ -~
'' Wf_. - _ .. - ' w
'-
.- DC. Fetzl:skull e.nd mate~8l-pe.IV:U, Textbook
ofObstetrics, 1992).
(b) :}< . ' ' . _:_ / _-. 1 ' -__
. . ' .. . ' : ... .. - .' . . . But m ete ~mmonly-, intermediate forms )91th
combination of features are .foUJfd-. Tliq._are
term_ed as gy:IfeCo-andl-oid, or androgineco~d.

~...f& ~~I. ~.
etc..-The-ru-st -part--<1!-th~oomenclatw:e.rc4J.tes
-to..that..oLtbe. anterior. segment; of the 'pclvi.lh...,
-~~bin~tioo,s: are -possible -.e:xcept
anthropoid with platYPaloid. .~us, there may
:be ty.peS:otparentp~lvis-eitnedn.pure form
Round Triangular Flat or in-combiila:tion..

Scanned 8y: ~
 ' 385

1.) Previous pelvic injiD:Y- or dise.a se affecting the

bony pelvisj

2.) A fetus in breech presentatiol} when vaginal

delivery is anticipafea:- - -
flfA1JM~.Ui\1W~~~Ifltfli..... Pubevaginalis
other . imaging technique:s otherwise
mentione<l in litera:ture9 : 0 include CT scanning, 8~Mi[fllfi[U>j~Qil~~rnt::lfflii~'il#-..... Puber&etalis
ultrasound .and. .MRl but these hav~ not gained
much .application in the local setting.

1'S SOn' P~'t$ OF Til& PELviS

Po;; a 'CQmpletcdescription of the pelvis. some

consideration .must be given to L'le Soft .ti$Sues: .
mus.c les. ligaments and fascial layers that
c;:9mprise the .pelvic.floor.

a
. . ' The J)elvic floor is muscular partition that Fi;aie-23.10: Levawr musctes vi~ed from above. {Outta
DC. Fetal skull li..'"ld maternal peh'is, Tmbcvle of Obstctric3, .
sepanttes t~ pelVic cavity from- tl)e perineum. It 1992}. . .
consists of .three sets of muscles on either side:
the pubo.c occygeus . iliococcygeus and ..:.. ~ ..
iscbi~geus Jmd these collectively.are called .... ; ... _.(..,.
the levator ani muscles. Its upper surface is
. -concave ~"l.d $lopes downwards .and medially, and The perineum is anatomicaily bound~ by;tbe
it is covered by the parietal layer of the pelvic inferior aspeet of the pelvic floor superiorly. and
Cascia. The inferior surlace is copvex artd is also tbe -slc:in between 'the bUttocks and thighs
.covered by fascia. The muscle and its fascial in,fe(iody. Latenl! borders -include ili~ tschiop"(lbic
.covering .are collectively known as the pelvic ralni. i"f;cltial tuberosities and sacrot\.I'bei ous
diaphragm. ligaments -W hile the posterior is limited by the
eoccyx...(Figure ~3: 11)
Each levator ani musde arises from the back
c>fthl!-pllb!c rami~ ftomtheTasda of the obtura tor
mtemusrui(Irrom:ffie-iriner.Suiface oHfie.i$Cf;Ja1
s pine and ins-erts medially from the vagina.
anocoecy.geal body, lateral borders of the coccyx
and lower part of the sacrum .. (Figu.re 23.10)

nie pelvic diaphragm has two hiatu~: hia.tua,

tirog~fliWis~ wb~ch .is"bridged by th<; .m~:><;les and
lascia of the urogenital triangle and through which
pass the. urethra and vagina, and the hiatus
x:e~which ta.nsoiits the rectum. -..{\ f

The plvic.di~phn\gm is supplied by the fourth

sacral nerve. inferior rectal nerve and a perineal Blllhoin'a ~d
:branch of the pudendal nerve. It.a<:ts to support
the pelvic organs, helps in the control . of the
external anal sphincter through the puborectalis,
artd helps to stal?ilize the ~acro ~l.iac and F igure 23.11. The pelvic muscles, fascia, and celhilar tissue
~acrococcygeal joints .through th~ ischiococ- as see~ from the front. (Dutta DC. Fetal skull and matemal
cygeus. pelvis, Tcxtbook:of Obstetrics, 1992).

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 3'86 SECTION IV: CL!NICALAPPROACH.TO LABOR!DEUVERY

The.a.forementioned arearoui;hly resembles a perineal po_uch is formed by the i.nferior and

diamond whiCh may be dividedinto two triangular
spaces with .a common base foqned by the free
"Porder of the urogenital diaphragm. The anterior
triangle is the ~genital triangle and the postenor
o?-e ~$ called the 'a,Ilal. ~~gle.
s~perior layers of the urogenital diaph.r(!.gm
(triangular li~ament). It contain~ the deep
transverl?e penneal muscles and the sphincter
urethra.
y

The anal triangle C<in.tairts the tenitiruil part

. Th:e urog~n~ital triang1e ~s o os:.tit.tr'i<::~ily
il;np1:!rtant and is p~tced by 91e .:t;~~alpoti>ns
of the v.agina -fl:Dd tl).e urdhra. T~~- petiti,eal
m-uscles are sit:JJ:S.ted into tw.o :l::~J.Up.~e.nts
separated by iii.-de:fmed f8Sciallayers :{s.~,t_!'>erllcial
and deep perineal). The superfid~l - po\t.cb. is
f9tm~d Qythe.deep.ley.et of~ super:ficial-pednea;l
fascia (Colle's fascia) and the inferidr .layer cf the
urogenitaliliaphragm -~.tineal memox:ane). these
contain the superficial tra:nsv.er se perineal
.m uscles, bclbos pongiosus and iscb.iocavemosu's
'muscies and
(.1\e Batth6l4i's :glands. 'f.he . deep
........
of the rectu~. exter n al anal sphincter,
ahocotcygeal bod;y, -and the ishiorectal fossae.
The perineal body {central .point of the
perineum) is li p)'ni.mid shaped tisSue where the
pelvic diapb.ragtn., _p erineal ml.).s c:les and fascia ;;.
me~t-. It is located between the vagina ~ the J.
anai opeiling and n:1easures a.rOU.nd 4 CDi x 4 em.
Its .base is
covered oy peri.rleal riiustles and i ts
a pex is pointed and is continuou.a with the
rectovaginal Sptum. It is this .area that is c ut
during a med.ian #:Pisiotomy.

PE;>INTS.TO REMEMBER . .

. . .The :s!Ze and :Sha~Of the .pel~i~~play an .. im.partant fa~or:in",ohste~rics

'Th~ ;;>eMs: iS .antomica11y ~ivid~d ~into-the false pelvis and true pelvis

PefviCtadio9raphy enabled:.Ga!dwell-.;il)d.Mplloy in 19~ to :develop four basic types of pelvis: gynecoid...

anth~poi<f; androidafidplatypelloid

Clinical assessment of the mid pelvis is not possib1e, but a .suspicion .of a midp.elvis contraction maybe
aroused ~sed Qfl internal examination

5. Bai;ton JJ, Oarb~~;i~~ Ryan GM. )1re.effi~cy of

i'. Goss CM. G~Ys ~atpiny qf":th~H11man Body, 20th
ed.. Nework: ~- and ::Ferbig~r, ..1994.
2." Cunningham FO, 1;iacDoualc;l .P i Oan:t.N. The normal
pelvis. Wil.l..ifun's Obs.tetr.j.cs, 19th .ed. NJ Prentice-Hall
Inc., 1993.
3 . Borcll U, Femstorm .I. Movements of the sacroiliac joints
and their .importance to 'changes in the pelvic diameters
during parturition. Acta Obstet Gynecol 'Scand 19 57.;
. x~iay pel~~try. AnrJ~~stct G)'necOll98~; 143 :304.
6 . Fine-EA, Bracken M, B~rkowitz RL. A..'1 ei~uatiori: of
the us~fulz):ess :oi x-Triy .peLvimetry:. C~?mpa.rison of..th:::
Thoms and M.o dified Ball methods with manual
_pelvimetry. Am J O.bstet Gynecol 1980; 137:15. .
7. Bithell J, St~art A.pr.ena.tal irradiation a nd clill&lood
mali~cy:arcview of British data:ffom-Oxford survey.
I;lr J -Cancer 19'75; 31:21 1.
8. Pars01;1.S MT,. Spell!icy WN. Pcr!!Pective random.ized

3!?: 42. . .
study of 7:..- ray pelvimetry in pnmigravida:t. ObStet
Gynecol 1"988;-66;7~. :
. .
4. CQJ.dwell '!fE, Molloy HC. Anatomic vari?.tions in the 9. Surano 1, Torniain en P, Jouppila P, Kirkmen Lahde' P,
female pelvisand their effect in l abor with suggested SA. A low-qose CT pelvinietry. Br J Radioll98 4; 57:
da~cation. ~ J Obstet Gynec~l 1993; 26: 479. 35.

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- -- - - - - - -- - - - ----
 CHAPTER 23: THE PASSAGES 387

10. Stark DD, MacCarthy SM, Filly RA, Parer JT, Hricak H, 12. Iffy L, Apuzzio JJ. Operative Obstetrics. 1992~2 : 27.
Callen PW. Pelvimetry by JD.agnetic resonance imaging.
Am J Radioll985; 144: 497. 13. Glickman Jr J. Phantom Notes OB-GYN. 1995; 3 :FP
17.
11 . Christenses JB, Telford I. Synopsis of Gross Anato.my
with Clinical Correlations, 4th ed. NY, 1992.

Scanned By: ~
 >'i'

. ..,;

.
'

Scanned 8y: C
 24

THE PASSENGER

ANNE MARIE C. TRINn)AD, MD .

Fetal Attitude

Fetal Lie
Longitudinal '"~~!A, ~~
Transverse - ,~ ...-cJ
rnuh (JVbYl~a~"'1
fArlv.l i)'tw.-
Preseotation
Cephalic
- Brasch
Compound
Shoulder

{/V..k_ rov.:
Diagnosis o(Lie, Presentation, Position
.Leopold's Maneuver - /ltttUHq rrtu~ ( ~AiM flAWttlfflv~)
lrlterriat ~amination
Auscultation
Sonography

~~
- -- -~-

Scanned 8y: ~
 ., ..
SECnON iV: CUNICA!- AP~ROACH IO lABOR I {)EUVERY
; '
".~.~

. _:.. The position of the fetus within 'the uterine

caVity is critical to the route of .delivery 1i.nd is
: 'd~cribed with respect to fetal.attltude,-lie,
-p~ntation and position.
' .
!- .f. ft \.P
:' .

-.EUAL ATTI'l'UJ?E (Postu~ .Habitu~) is the

- re'hition of the fetB.lpa..=ts to one another. As a rule, ~: .:. '

' tli~- fetUs forms an ()Void rila:$S th;\t corre-Sponds

. ''to ~th~ shape of the uterine ca'\?:ty. 'fll~ ,fetu~ is .
. -- . ,_'~t ripo.n i~elf .in. a m~et tliat th~ nea(l is
-. bd 'C'hill--iS in ..OOntact.s:With :the -~est; 'back.. :_.
: : ~i&Ji:~~: .c.O'li;e~ :tiljib~; ~--iiex~d pver .::the . . . . -\..;../. . :.-. ' ;. . .
. . .. ....J~~om'
~
. -'t:t
;,.,~-i~'are btn.t-at:aie;lme:.ab:d-~
':e.- .. . . . .. :,.,... . . . . .
.o.r:
...
-- ..- :- \ /;-
.
.--.
" -' th~ ~treet lit>Dil ~~teiio(~!i ofthe,l~. . :_ ~ .. ' -:- .

.: ., .' ~ 'cbaracteclstic -~ res'ctltS ~jr~fr~m the ." .. :. . . ..: ' .

. -:~,hi.Oae of growth of fue fetus an,d partly fro.in ~ . .
Fip;re 24.2. ~ ~lie;-A. Longitudinal B. Tran~~e; 1 2 .-.
-. -.LWtocesS .of .accOmmodation to'tb.e uterine cavity. RedrawnfromTe:x$0okofbb~trics Physiolovic &Pa_tho7 .

. ...{F.%U:re 24.1) ._ iogic0bs1trics.Sum,pai.co, e taLAPMC.2 ndedirlon;p. :ZlO. .

. .. '

:. :.. .
~ .....

. :~: . ....
(.~_1 .
.. ' ~ ... ..
. . . ) . :....~ . r.
'0{tJ\ ..
. . ..... ..
:..
. :. J. . ;;: . . .

' ~ . !
. ...
... .... ..... . ... ~~
..'
.. :.
. . ". -~24. 1. Fetal.a:ttitude.U
.. . :~ea..~wn min TextboQk ofObs~.trics.Pl}ysiologic & Patho-
":1gicObstctrics.
. . .
Sum~co, .et aL\f,MC ~nd edition. p. 110.
. .. J,IE-.'OF THE -F ETUS is the,relatiol'l of th~ .lol)cg
. :_.. ,.:runs Of the fetus to the long axl~!'-Of the -m~ternal
~Women. The two varieties o.f lie are: (Figure
'24.'2}
. vatiant--of-:t.he~rse-:iie,ls unstabLeand.
, 1_ .Longitudinal Lie. The long axis of the fetus
. _. ..: _p2.Iallels the longitudinal Eixi.s of the JJ~s:--.., .
. .- .- . Lopgitudinallitsarep~nfinmore~ ;
' of labors at term~ As terril approaches. the
.. :. :utne ~vity most O'ften .accommodates the
fetus in longib,l.diliallie with either:feta1 bead
or bre~h presenting. (Figp.re .M-.-3)
\I
.; \1. -~
1-. . . .
. .,
.. .. _I
_F\pre ~4.;3 . Ya,rietie~ of.tran:rv~ lie. u : . .
Redrawn.from T~kofOha~i';tiit:3:i-'Jiysiologic& P.atb,o'..
logic Qbs~etri~. 'Slliti.~. et~ M'M.C2 nd edition. p~-~l'o.:
. \ . ..
c) )~ ~1 -i t1'Q lrwf""'. CJ'<;{4\. -~ tU... . .. _.: _
_.uu,,p rVJI1iH~ 'f:Afv t\ff-rr >~ ~MLA. _. .. . ,
T.ra-ns'tle-r.$~ 'Il~ - Th.e -:fetus lies in: the
,2.
transverse o~ orte..of the. o,Plique .diami!t~~-~--~f.
the uterus. The :s h-oulder is usually over 'the
pelvic inlet withthe Jetalhead lyingi<"lon~ iliac~
fos~ arid the br.eech .in tl).e other. Tr~sver~e .
lie is less ~OIIUD,Or). apd potentially sendu~ .
. because w.hen .the membranes .rupture, cord
prolapse comPlonly foll<;>ws. Oblique . h!!; .!i'
becomes either a 'longitudinal or transverse.iie
during !Jle -co.urse o'flabor. .,
. _ . . . . ..
FETAL P.RESENTATION.. (Presenting pa.r tnefers.- ,:
to the portion of 14~ body :Of the fetus .that ts -el~er:?:.':: .:
foremost within. the hiFth eanal or in cl9~est -
proximig to it. !he presenting part' dete~es

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 "CHAPTER 24: THE PASSENGER -391

the presentation. In longitudinal lie, the
presenting part is either the head or breech
cr,eating cephalic and breech presentations,
respectively. 'when the fetus lieswith the long axis
transve~dy, the shoulder is the pres~ting part
and.is felt by abdominal and vaginal examinations.
la. Vertex (Occiput) Presentation - A Fetus
at term . usually presents by the vertex
be~ use the 'J,lterus is pyriform. Full flexion
is the ideal presentation with thetria~gular
posterior fontanel ..as the .pr~ting put.
Whenthe head is fully flexed, the chin lies
in front of the chest and the presenting
anteroposterior diameter ~s the
suboccipitobregmatic (9.S, Cill at term).

lb. S -i nciput Pr.ese.~tC~ticn (JilUtary

Face (F)
. c-OnvetL.P1i into vertex as-labor. pn>gfe$ses . ..
Ficure 24.4. Types of:c ephalic presentation. 13
Redrawn from W.i,ll4uns Obetetrics by 'Cl.mnlngb<.Un, et al.
lc.Brow Presentation- 'fhe _ fe~--h~ad. is
22nd edition p .410. . ' ,
_ _ - ...[ ~-w~~ M.""'~ -~ ~t~t1 . _
1. Ce pba'h;: Pr.ese~tat-lo~. Full .O exio.n 1~
ordina,rlly. achieved ~cause the o~cipitai
:cond)'lesa:re lodi.ted-riear .i:he posterior aspect
of the skuli. As the head is'thtu$t iD.to the inlet,
the longer ~e~t of the l~er yields to the
p-ressure and flexio.n results . Cephalic
p!':'f?,~~~~!jqn ~9\\.t. .itu~._bou.t. 9.5% of .cases.
'rhe.r:e. a..r.e Iciur . ..Y.ar.ieties. of ce-p halic
presentation dependi,ng upon the relation oi
the head to the thorax (whether it is flexed or
extended anteroposteriorly) .(Figure 24.4)
Attitude). When the fetal head is.paitiall.y
flexed, the di.~ond shaped anterior
fontanel '(Bregma) is prsen:ting 8Jld the
anteroposterior diameter i5 .o ccipitofronW
(12.5 em , at tenn).. It militruy attitude
gradu~y -c llanges to full flexion (vertex)
as the head.advan.ces int:Q ~ peMs:umess
mobility 'is impaired in the fetai. neclc or in
the ~tlanto;occipital a.r,t;ieu;l.atiog. Sinciput
presentatiot:l is only transien-~ and is
pa."1ially extended and the occipitomental
plane (13.5 em at- terin) bein_g the longest -
anteroposterior _diameteris presenting. As
labor progresses, brow.presenta:tion which. .
is only transient is aln'lost -a:lways;conv.erted
into face presentation by extension and
does .n ot advance througll the pelvis unless
the head is ex~e!tt.~~y ~m~. -
lll.Face Pr:_~sentatlon - - The {eta! neck may
be sharply ~ended so that the occiput

Table 24. 1. Differenc~s in type_sof cephalic presentation.

Types of Cephalic Pre~ntatlon

Parameters Vertex Sinciput Brow Face

Fixed Point of Posterior fontanel/ Anterbr fontanel Frontum Mentum (chin)

Reference occiput (Bregmo.)

Attitude fuUy llexe~. Par:tially flexed Partially exten_d ed Hyp~exten_c;ted _

AP diaineter Subocclpito Occipitofrontal Occipitotnental Suboccipito-breglllatic

presenting into -bregiiHI.tiC or Trachelobregmatic
the_pelvis
' ~
i!-:. -
Normril diamet~r 9 .5 cms 12..5 ems 13.5 ems 9.5ems ~_t:t; "

values (ems)

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 392 SECTION IV:. CUNICAL APPROACH TO lABOR I DELIVERY

and back of the fetus come in -contact. The and when both le.g s are extended below the
fllce "is-foremost in tlie birth canal and the level of the buttocks, it is a double footling.
sUbmentobregmatic. cr t..T1lcheo.b regmatic The possibility of compression . of a
(9.5 ezh at term) is presenting as the prolapsed cord-Or a co-rd entangled around
anteroposteriQT diatnder. It will allow the extremities a s the breech fills the pelvis
advarice mertt . through the pelvis, but is a n antici~ted complica.ticn (Figure 24.7)
.' vag4lal delivery may result in injuty to the
~rvicill spinal .c()rcl. In gener-al. eVidence
for maj::ked hypere:xteJi).sion oi the fetal -he9;d
once labor has begun is -considered an
indieation !or -a n ab4otninal ..d.eUVery.
. . ~ Q.'MIJ.):#lt\lo't"> 1\IIIV\ 1"'~ .
~; .2. Breec;h Pl'esentatloil .:. Breech. which is on

)

lo~gitudin~ Jje, is ,e6Jisider-ed wP.ett the fetus

pre~nts With the ltut~ks tow$td the pelvis
s.nd the bi.ttoc hanterie diameter (9.5 om}
pr~sents~ There ttte thr~ \ 'arieties of breech:
fnull4 :ct;~mplete 'and incomplete. .
2 _a .i'Nr:r.k Sree.cf?, - The ''thigh.s are llexed on
.the abdomen .~4 .the legs .ar~ extended
: overthe :a,ntenor sttrfa~softhe b<>Qy, thus .
thC: f~t :ot'thecf'etu:rdiiinp~ty'tothe
head,;.:(l;"igure::24i $)"':'.:..: Ftpre 24.6.~pletc breech. 12 (Redrawn from Textbook
rHt )({~ . JaW"'A ofObstetriC11 ~& ~ologk Opstetrics. Sumpaico,
et a}; .AP~C 2rid editio~ p. 2l2t) : .

.. .; ~'

'

Fiiure 24.5. Frank bree~ pr-esentation . 13 (Redrawn fr-om

Williams Obstetrics by Cunninghalil, et al. 22nd edition
p. 41'4.) -~ _ . . .
.u._w.
11
..
-r~ 4 ,. lud f L /-l6}\l~ Fipre-'24.7. -Ineompletebreechpresentation.12 (Redrawn
"' ,; J6J.,._._ ' .I from Textbook of Obstetrics. Physiologic & Pathologic
2b. Complete Breech- The thighs are flexed Obstetrics. Sumpaico, etal APMC 2nd edition. p. 213.)
over the abdomen, the legs aro flexed upon

f
. -~ ~ the.thighs and the : ee_t present -at the level
~ $~ of the buttocks. (Ftgure 24.6)
~ .
2c.lncorr:lplrl.e Breech Wh~n one or both
thighs-are extended so that the. feet and
legs are below the level of the b1..1ttocks.
When.one leg is completely extended and
the other leg is flexed; it is a sirigle footlin~;
3. Shoulder P~et~entatlon. -The shoulder or the
acromion is usually presenting into the pelvic
inlet in transverse)ie and the bisa~romial
diru;neter (11.0 -em). presents.- {Figure 24~8h
4. Com.p ound Presentatlon The fetal hand or
foot prolapses alongside the presenting verteX
or breech. The causes a re conditions that

Seanned lly: c
 "'393
. ri;i.tf:. ..J-1 MnM)\ I~
~1\-.~v ~ tf ~"-._f1\tiW . ~niPN~~~~\\ o\,,~~ ~r
,o I .
~ I0 ~rc..UJt'l - \,U Mut1t '' . c:::. ,. :-J J
~-~~'a
7"
pr~ent complete occlusiO'iim the pelvic irilet POSITIO.N. This is the r.elation~hip,. .of t~e
by the presenting part. Combination of hand ( chosen portion of the fetal presenting part tn
with vertex or breech tends to resolve reference to one of the four ~quadrants or to the .
spontaneously as labGr advances. However, transverse diameter of the matemt'l birth canal.
CPmbmation ofootarull'etal n~d tends to be The fixed point of referencd ~Y lie irJ. either of
co.mplicate.tt bi>a cord prorn~e. (Figure 24. 9) the two anterior qu~drants (tight or left anterior),
i... either of the 't wo p osterior quadrants (right or
left posterior), .or in the direct transverse diameter
{right or left transverse). a may also be either
.directed to the front oftlfe pelvis -( direct anterior)
or directed to the back -{d~t posterior).
- ~Mf-, (,j
0 OA
. ..,...,,
-.) ~
wh4 ._ti
1
~1\1 ~
' -;
' ~" i'-( '"J 0~ ~"" )\. w "'V'LJ
ROA LOA

ROT LOT

Fipre 24.8. Shoulde presentatiops. 1 ~

Refullwn fro:n Williams Obstetrics by Cunningham, et o.l. ROP LOP
22nd~edition p. 415. . .--;:, '" .. '.':; --

vtl OP
.. ......; .. ,.
Figure 24.10. Varieties of-position ih vertc:xjn-esentation.

In defining . position, the. followi~

abbreviations ~e used for }>9i..'1~ directing: 'f!)
(occiput) in vert~-e;~erttation,\F)i{tontumJ. in
brow prese . .n~~ . >ri~mentum or chin) m." face
pr~~on~t"Ul'll) in bteec.l]. presentation,
an~~cr.omion ..j>~---se~p~!a:) --i n shoulder
.pr.esentatlon...The -abbrevta:bons are further
correlated to the app~pria~t t or the pelvis:
(j) ROA J.ri~ t occiput ante.r io . t.<. . (left mentt>-
. :') . ~
po~ t eno to-postefio
. OCCJ.Pl , {le ft sacro-
transv~rse . . At;Pf (-rj:ght Aqromiqt;~orso
. ~
- posterior). (Figure~ '24.1~4~11~4.12, 24'.13 &
v4.14) . . .

DIAGNOSISOFL.I E, PRESENTATION, POSITION

1. Leopold's Manuever
2. Internal Examination

The examiner's fingers introduced into the

Fl,ure 24.9 . Varieties of compound_presentation. A
Prolapse o( the arm in a vertex; B. Dorsal .o r nuchal
d.isplac.!!ment of the arm; c. Le"f.t hand ;lying ~ front o f
vert.ex.~"2 (Redrawn from TI!JI;tbookof()bstetrics Physiologic
& Pathologic Obste.t rics. S1,1mpaico, et al, APMC 2nd edition.
p . 2l3.}
posterior aspect of the vagina and the fingers are
then swept forward over the fetal head toward the
maternal symphysis pubis. During this movement, .
the ~xamineros fmgers cross the sagittal suture
with .anterior and posterior fontanels at the
opposite ends. By circular mot,ion, the fmgers are.
passed around the -side ofthe fetal head until the
other fontanel is felt. (.Figur-es 24. 15 & 24. 16)

AvPA 1 01")( Y"'"'r~"'

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394 SEC110N IV: CLINICAL APPROACH TO LABOR I DEUVeRY

A. . LEFT~R

Fip.rc 24.13. Breech prtaentation: left sacrum posterior

position (LSf'), (Redrawn .from Textbook of Obstetrics
Physiologic & .Pathologic Obstetrics. Sumpaico, ct al APMC
2nd edition. p. 214.1

. ~ ,. ~ ~ .

Figure :,Z4.14 .Sh.b !llder present11tioo: right

acromiodorsopoter {RAtDP) positiefn. 12 (Redmwn from
TextbookofObstetrics Ph~iologic & Pathologic Obstetrics.
Sumpaico, et al. ~C 2nd -edition ..p. 214~) :
i'.l pre 24,11. Vertt:)t :l>re~,en~ti(ln~ 12 .(R'<:d~wn . fr9m
Te'ln}?ookofObstetri~Phfsio~ogic&~~thoio&i~ Ob.s tetrlcs.
Sumpaico, etal. APMC'2nd ec;J,itiqrt. p..214.)

Fl~ 24.'1~. Face pr~s~ntation. 12 (Redrawn :from Textbook Figur.~

24. 15 .Locatibg the sagittal sutur~ by vaginal
or Obstetrics Physiologic &.Pathologic Obstetrics. S~p~co, examination., 1Redrawn {rom William~ Obsfetrics by
et al. APMC 2nd ~clition. p. 214.) Cunningham, et al. 22nd edition p. 417:)

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 CHAPTER 24: THE.PASSENGER

-wall;-fetal -heart sounrt.~..~!~----~~t he~q t::hro~h

--the.few..!_ back in. v~!!~x and breech presentation
and th,rougb-:tne:retallli0ra:ic"1n...face-presentatipns.
The point of maximal intensity of fetal heart
sounds in eephalic presentation is usually midway
between the maternal umbilicus and the anterior
superior $pine of the ilium; and above the level of
the t:.mbillcus in breech presentation.

. As regards the fetal position, fetal heart sounds

Figure 24.16. Differentiating the fontanels by v~.ginal
-examinatlon.~ {Redrawn fro.m Williams Ob:-;tetrics by
~gham,-etal. 22ndedition p. 41 ?.)
are. best heard a short distance from the umbilicus
in' occipitoanterior, mother's flank in
occipitoposterior, and more laterall-j in transverse
positihns.
4. Sonography

E~rlY. rec.cgnition of a ~eech :!)r s~0~er

3. Auscultation -....
By i~elf, this does not provide very reliable
infon:nation concerning .the presentation and
position of the fetus. Because the fetal heart
~Qunds are transmitted through the convex
portionofthe fetus that lies in contact with uteri_ne
presentation .m 4~ubtfuj ca.se~ .e.$pecally m o se
women or in women Wlth rigid abdom.iUal wall is
provided by sonography. By employing
ultrasonography~ the fet;al. head and body can be
located without poten~ hazards of radiation~ ln
some clinical situations, the information ohWned
radiographically far exceeds L..,e min..iful:ll risk from
a single x-ray expc.sure.

POINTS TO REMEMBER

Fetal-Attitude (Posture or Habitus) is -the relationship of-the fetal parts to one another in which the
fetus-foRns an-ovoid--mass corresponding to theshape ofth-e ..uterm(f cavity.

Lie of the fetus is the relation of the long axis of the fetus to tne long axis of the maternal abdomen.

tongituqinalli~ seen in 99% of-labors at term is when thelong axis of the fetus parallels the longitudinal
axis of the uterus in which the fetal head or breech is presenting into the pelvic cavity.

Tran5verse lie is when the shoulder is usually over the peivic inlet with the fetal head lyingin one iliac
fossa and the breech on the opposite side. This is potenti.ally serious when the m~mbranes rupture
because of the possibility of cord prolapse.

Oblique lie is a variant of the transverse lie and is considered as unstable because it can either be
converted into a longitudinal or transverse lie during the course of labor.

Fetal presentation (presenting part) refers to the portion of the fetal body that is foremost within the
birth canal and determines the presentation. It can either be the head or the breech in a longitudinal fie
and the shoulder in cases of a transverse lie.

There are four varieties of cephalic presentation and can either be a vertex, sinciput, brow or face
presentation.

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396 SECTlON lV: CUNICALAPPROACHTO LABOR I DELIVERY
' "~' . ------~------------

Breech:presentation can either be frank, complete fX incomplete breech.

Compeund presentation is when theJelal hand or foot.prolapses alongside the presenting vertex or
breecll C-ombination of~ hanq~andvertexorbreech tends to reSOlve spontaneOuSly as-lab6radvances
whereas :a combinatibn .oHoot =and fetal head .tends to be compr!Cated 'by a cord prolaps~.

Positicn is .t he relationship of .tl:Je ctiosen partion of t:,e fetal presenting part in re.Tr~ce-' to oneof
the ,quadrants Qf to)he transverse dl~meier of:the mate mal birth can at 'The fixed.polrit reference of
in
mayiie in'.either.one of the two:anteriorquodtants (fighto~ left anteiior.); e'iiher ofth~ lwo:p<)steriOf
..quadrants: .(~9h~. or.left J>O$tepor), .ln .the .dlrect transverse di.amet~ (f.ght or left transverse) or
directly to~ ftor.t.(9irett.~nt~r) Pt. dir~ lo the back.(dlr~t pbsterior}.
--
.~

In definlng pos1tion, the fixed Jeferehte poJnts are occiput ir. vertex,
frontum in !:>row. mentum or
chin in face, sacrum in breech and ~cromioh or scapula in shoulder presentation. .

There ~re .s~veral methode whiqlcan 9e used to :determine the fetal lie, presentatiohand 'position.
'These itfclO<ie .at)domln;:i: pai~tjoo, vaginal .examination , auscultation of fetal heart sounds and
wherrirr.doubi-.iil~sbn~tap.hy.or r:a.dl<)g~phy'l;:cin be -requested.
">.. .
. The degree orcepha_lqpelvi~:-4isproporticm ~n alsO -be gal!ged by evaluating l~e extentlo which the
of.
-: ..;: ~nteriorpo:rfi_on: th:e fel31ihead.ovemdes;tf)~e. m.cthe(.s .syirlphyms pubis. .
~ - .. . ...
..

'~cpi. 7. Lyndon-.Rb$elle M, Al~ ;L;.:GopwOda,J; ~raig E;'

(Ju8.l.l3 C. Atcuracy of !.-c?pold\rilan ~t:.vci':l ~ scree!"'.ing'
L ~~ FG,'1>iae,_Don.ald~PC.,L6reilo 'lt.J;.G~t for'm.alpresentation: Aprospeei;ve 'S.tudy.Birth,l993;
~. Gilstrap-IULC. Willia=s Obstetric .19'"'-'Ed, :1993; '20: '1'32.
213, 281. . .
8. Mycr'scough:PRMWU'OKei:r's.~tive 0bst:etri~10"' '
E<h 1-982,;-6-1:- 94, . .
2. 'Ciiriniti&Mm;F:C;'GaiifNF, L.CV:cno K;J: Glliit:CBP'nl:LC, .
Haa\:.tld~, Wc:n.st;romKD. Vlilij.am:s O~;:ct!i~ 2l'"Ed..
2001; 291-307. 9. O.Xom H. The Passenger. Fetus., labor, and Birth. 5"'
. . . Ed. 1989; 54.
,
3 .cunnin&l,lain FG, :J:.iv~no .K.J, Bloo~ S, }l1l.uth JC,
Gij~~ .ll.l+, WetU~<>~nJ<;n.:w~s f)'b~tctriC:3 ~:2~ 10. Scheer K, .Nubar J. Variation.oHetru.pre:sentation with
'Ed. '2 005; 409A1,f). ' . . . . gestational.age..N:n J Oostt:~ 6ynee61 i9'7.6;.1'2';:>: 269..

4 . D .anforth DN, Meclian.i:sm .o f .norn1a1 1abor . Obstet
Gynecaino. Ed.T9~; . 629~46.
S . Ge~er 0, Segal. S . fucidcnce and contributipn of
. p_redisposing fact()rs t:o .transverse .lie ~csen ~tion. h1t
..) Gynaccol Obstet ;1,9:94; 44: .~19.
6. kopold S. Conduct of.no.rma1 births thro:jJgh external
exaroination.alone. Arch Gynaecol1894; 45: 337
11 . White AJ. Spon~cous <;:,c phl!Jlc ve~ion 4i the late
weeks oT pregnanej and it:3 .signifi~ancc in the
managezn:ent'of breech p.,r:es.~htation. Br J .Ob3tet
Gynecol i956; 63: 706.
12. Sumpaico, et.al. Tqctbook of Obstetric &.Physiologic &
Pathpl6,gjc Opstctrics, 2n,de'dition, p210.

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 25

MECHANISM OF LABOR IN
THE VERTEX PRESENTATION

Introduction

. Cardinal Movements o f Labor

. ;,''Engagement
. ,,
Descent ......

F!exion
Internal Rotation
Extension
External Rotation
,.. ~' ,:.:::~Expulsion

Labor in lhe Occiput Postenor Position

Fetal Adaptations to the Pelvis

Synclitism
Molding
Caput Succedaneum

Snanned By: ~
 SECTION IV; CLINICAL APPROACH TO LABOR I DELIVERY

.. ~ability ofthe fetus to successfully negotiate Engagement is considered an impor tant

pelvis during labor in:v9lves 9'hanges in clinical p arameterasitdemonstra tes that, aqeast
of its head during its paSsa.ge through at the levd.:of the pelvic ~et, the maternal bony .
canal. The asymmetry cf ~ll.e shape of pelvis is sufficientl)F1argeto allow d~scent on:he:
lS~'IX)W the fetai head and' the maternal bony pel~is. fetal head..In' primigi;6.vidas, engagement pf the
.. . ...~s these changes 'for a successful passage fetal head usually occur:s by 38 weeks of gestation;
. thri>J.lgh the' birth .canaL 1 Thes e spontaneous The inability of the head to engage by this ~~
;;;.:.:;:~_,__.,. of attitude are made to effect efficient maybe an early sign of cephalo-pelvic.
S~~~:;;~lhrough .the pe1vis as p.rogre:s~iye de~cent disproportion (CPD). Patients +nay experience .a.
;l,illo...A~,... !etus is accomplished. The m~clianisins of change in the shape of the abdo.m en and a
,g~~~~: .known a&.the:cariliri.ai.'IilOV.e'oients;.ar~ "d.ecrea~ sen~ of shqrtriess 9'f breath, Teferi'ed
rw; in r~tatiori~ to a vcrt;e:;c pi:e~~ta:tion a s . -:to .as Ught~*it1g. 'In ~~lti.grav{da~;-howev~r,
of
5'.!)t;>t!::::erl-.;: .ean
~l pregnancies: .PX:~s-#i.i ...~ ~i~ , ,..e,ngage'ment occur. at tl;i~;onset of 1abQr. s:6
'Although .l?.b.or and.d.e.liv.eiy. .OC:Cur in -~ : "(Fi~re -zs:2r
5 fashion, seven disd:'ete c'artlinal
are described, namely ep.gagement,
~l~~~~ intemal rotation, extension,
~ _...?i resti~~?-~_<l?d expulsion.
.

;n~"~.~~,eai entially describ~d mechanisms ...,

The mqst significant
This ::qms t be
~~~~~~ro~;;Iio;;t~raou:.r..,:~"'that::sucp!!ssful~<t. . .

I
Figure 25,1. Stationsof .t he fetal neac;l .

'?!" .t.~e . Pr~senting .Part is

.... """._,~ W1<1!==Bt.:(1U;un~~.
I
At the 0 station, the fetal head is. at the bony
. (.9PD). Engagement refers
. ..
. .tp;W$sage of the wi.cks t diameter of the presenting
pa!t-~o a level below the plane of tht; pelvic inlet..
ischial spi~es and fi lls the maternal sacrum,.
Positions aqove the ischial spines are referred to l
as :...Lt.l},x:qugh -5, referring to. Ure number .of ems,
: Clically, if the' lowest portion C.f the fetal skull is
that the head is positforied;;bOv~:th~-spin~s~ ~As. I
. :at or~low the level of the maternal isch.i.q.l spjg~
the head descenqs ,Past the. iscl:jial spines, the.
: . (s!;atiP.nJ)) engMeroent l~as usually taken phice. 4
,(Figtu:e 25.1)
stations are referred to as + 1 throuj;h +5. I
I
I
I

:. Fiiure 25.. 2. Onset of labor in L.O.A., Engag<;m'cnt or the he~d in the obli~ue diameter of the pelvis. (From TE Steward . j
. :f:3eck's Obstetrical Practice 8th Edition) . ..

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 CHAPTER 2$: MECHANISM OF LABOR IN THE; V!;RTEX PRESENTATION 399

--~ -:

Descent po~i.!J.~,
so that the fetal head may negoqa.te the
shorter mi.d pelvic transverse diameter into the
This refers to the doWnward passage of the ~ .:_pelvis. This s~~- at abQtit the level of the ischial
presenting part through the pelvis. This spines .and is generally .c ompleted as the head
movementoccursintermittentlywcontractions. reaches the pe~G.Jl.r., As the head descends,
~e factors facilitatin~ descent are' pressure of the the fetal ocdput rotates form :it .original position
fundus upon the breech~ .:.contra.~tipn of the _(usually in transverse} toward .the symphysis
a-b dominal muscles and . extefl sioil and pubis (occiput at\~erior} Or less commonly, toward
straightening of the fetal ~dy. 3 It is gi-adually the hollow bf the sa<;:rutn. ~e- -requi~ites for
progressive and is affected by, the for~$ of labor anterior rota~on of the head,are well- flexed head
and thinning of the lower uterine segmcmt. The 2efficient 'l.l~rine contractions>Javo;ab1e midpelvi~
pelvic configuration and the size and position :of plane and;ttone Qf the levatcr ani muscles. The
,-~the presenting part may also play a role. The pressure from the!> spine and the levator sling of
..greater the pelvic resistance or tile poorer ~e the pelvic .ilayr diaphragm accomplishes internal
contractiol'ls, the slcwer is the descent. The rate rotation. This movement brings the antero-
is greatest during the dec.elerati.on phase of the po.s terior d.iam.eter of .the. head in line with the
first stage a,nd durltl.g the second stag~ of .l abor. antefo..postericr d~eter .o f the outlet. (Figure
Descent continues progresshrely until the fetus 25.4) Further de$cent to the level of the introitus
is delivered and the other movements are occurs with the he~d in lhe AP plane.u
superimposed on it.
..
Exte~l~n(tVh1v1il-vt) .
Flerion
With (urt..her::df!scent a:rtd .full~.flexion;~9:f~;the
As the-fetal vertex descends, it encounters head.; the base' of the occiput comes..in contACt
resistance from the bony pelvis or lhe soft tissues with the infetiQr margin of the ~physis ptibis.
of the pelvi,c .floo~. .resulting in .p assive n~~E-_Q_f Up~v~d resistance .from th~ pelvic fioor and
the fetal oCciput. The C,."iin'is .brougb:rmtetcontact downvmro {Q,rces from the uterine con:tra~tions
Viith th~ f~W.;thorax.andthe preSenting diameter cause the Oct,iput to ~P.d. and roia:t'eoaround'.the-
cha:nges.. 'Jr.O.m~oct;ipjtbfrontal U LO em.) to srrmphysis, With :~h : J:lterlne cot;tractloni~':t.J1e
s~l).Qcgp~~bregmati~l~:.s. ~}_for Pptimal passage anterior: portiQJ). or the -s"ku,ll is pushed down,
through the pelvis.3 (F~e 25."3) disten<Jfu~ th~, tes$ . ~gid pMc floor and perin~
SQft ti~es. Th~9Ciput.~tve\s as .a binge allowing ...
extension oftb~ fet'al'-lH~~a. a .process that
culminat~s"ilrthe oiflliofffie-ietarrace tuid Cili.U~ 4.a
This refers to the rotary tiiovetnent pf.the fetal This allows-the occijmt enough room to slip under
head from the ~SV.!!~- to _the -antero~posterior :the sympl;lysis with complete extrusion of the fetal
head. {Figure 25.5}

Figure 25.3. F1Cxion of the head. As flexion occurs, the ocCiputde~cends in advance of the sincipu~ anj'',L
becomes the presentin~ part.

Stanned By: ~
 SECTION -IV: CLINlCALAPPROACH TO LABOR /.OEUVERY

. . . ..:_.. . ..
\ .-

~~}
;...
..
,

~:.;:.;,..1~ ... .

:n_cut~~.4. :Intciil.al rotatiQn. The post~:i0r fo!l.timelle r otates 45 to

ihe Tight ttoWUd :~e midline). The sagittal su4tre turns to the
. lt!l~~rio"r.:diapiet~. .

. i .. : .

~....' . .
-~ 2S'. 5. Extension of the head.

~QlSJ Rotation or Re&titutlo~
External rotation refers ..to t):le r e.turn of the
fetal head ~~ the .c or:rect -anato.rp:ic pbsition in
relation to the "fetal t<;>r:so. wflen:the "fetal head
is free of-resista~ce, it "untwists a'bou.t 4 !;)' left
or tight, return"i~~ . to its or.fgina:l anatomic
po~ition. T:hh is a .p'as~ive movement-r.es\ilti.!ig
fr-om e. release oJthe force.~ exerted on the fetal
h.~ad by the "maternal 'tony .: P~lvh and its
~\lcsc~iia..ture and 01~diated ":by. the basal tone
of the <fetal musculature. The fetus resumes
its face forw.ard position, with the .occiput and
s.pine "1ying :in the ~saine .plane. "Ttlis movement
brings the bisa cromial <4ameter into relation
wit..i-t the antero p{'sterio'r diamter :of the pelvic
outlet. 3 4 (Figures .25:6 & 25.7")
Zxpulslon .
Expulsion refe~ t~ .t,he (!ellvery of the rest of
the fetus. After:. the deliv~t.y. oi the head and
external rotation.- further -descent brings the
anterior shou1d.er to t h ievd of
j:he symphysis
pubis. The anterio.r: shoulder is delivered in much
the saine manner a~ the h ead-, with rotation of
the shoulder u"nd..e r the ~ymphysi~ pu~is. Afte~
the ~houlder, the.:rest _of the. body -is usually i
delivered withou~ difficulty. (Figures 25:8 & 25.9)

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 CHAPTER 25: MECHANISM OF lABOR IN THEVERTEX PRESENTATION ~401

. ~.
:-.-

F igure 25.6. Restitution of the .head. The he;id rotates 4 5 in the

direction of the fetal back..

.; I "

FigUte .25/1 .External rotation of the head. Thi~ occurs to allow the
an.t erior-sh oulder to wedge under the symphy s is pubis in
anteioposterlor diameter.

. -~
. .Posterior s houlder is born by.latef:i]
F igure :25.8. Birth of the shoulder by la teral fl~on. FJgure 25.9. .
flexion.
. . -~
Anterior_shoulder passes out beneath the symphy$is.

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 . SECTION N: CliNICAL APPROACH TO LAsOR I DELJVERY

Unde.r standing ~f the :mechanisms of labor is positiOJ:?.S are more frequently in pelvis that have
es~ntial in order that the obstetrlc4tp. appreciate a greater anteroposterior d,ia:meter or in which
ariy deviations that may in4i~te . potential the transverse diarilet~r is..si..aller than the
unsuspected fetopely~c dispro:portioh or an . anteroposterior diamet~r. Hence, in a patient
abnormality in fetal pOsition :or ~ftiru.de. witb. a_Y). anthropaid pelvig, one w~mld expect an
increased inci:dence of po:s~~~o.r positi~n~. 3 .s
LABOR IN THEOCCIPUT
. ... POST.ERlOR.:POSITIO:tf
~ - . .
FETAL A,PAPTA'iJO!~ TO T~ PELVIS
Although the oc,C.fp~t -pOsterior. J:>O$itions .~e
not truly abn6rmat. ;Uiqo~$ion~ :U:nped~ the Synclitiam/AsyneUttsm . . .
ddivery process . .oceip~t ~#terio:r .po-sitidP.~
occur in an estimated 25 mt~ Q{ hll v.ertex These terms qe~~ the .relationship of the
deli'!eries ~f examin~~ ln !efll"ly labor.. In -90 sagitt~ suture to .the sy.mp~ysis p:Ubis and
percent or the caseS., :imterlQt.xi>iation :t;!lr.dugb s~cruni. hi syn~litism, the sagittal suture is
a 135" arc OC(:;Ut:$ during :fetal. h~d 4e$Cnt to fuidway betw.Uh $~ ~physis and i:he sacral
.t he peLVic floor. In 5 _percent of the.cas-es~ the promontorY:.. Asyncliti~m :descnbes the fetal head
f~talli~d rotat~ to .a.D..ooqipnt pt>:S teript position . that i~ .directed anteriorly towards the symphysis
Willi another S ~t ..:te~~g l,n .tlie ~gM . or posteriorly tow:ard.s the promontory. When the
or tile lefFpostetj:or p<>Si'ij~n. Wllen :tll.e bCiPl-ll anteridr pariet-?11:>6ne . presents and the sagittal
..
-. swings into the :h<)Th.>w =offue ~ctum, . deflexion suture is tnore PO..~le~lor.,' this ~<='-int~rior
.i~. a:,zcompllcati.;lz..P.r9blffi;, ~ tP~ ?euu-ilead: .asym;lit.ism (N:aegek7$. obliqulcy). .In posterior
'r.o.cks .between IleXlon :and de.U~on :duting as.YI:lclitism .{l,;itzm~:(rin~s .ppll~.iity), the posterior
Uterlne=contract1o~s''iii~t:he~~'holl~w):with.- . =parieWbone".p'resent~;a,m;i-'ilie"sa:gittat,suture-i s
llUle" if any preg:~9n=iit-d~t.::.Posterior.. : more anterior.:s. ;. .
. . . ..
..
_.....,.....;...._...,
.,..,.-.;-....;:....._.,.......
.:.:;......:..:FirSf. 'tSge......:..,....,....--...,----.:+-:;.;.._--

+2
t1

0~~~.2.~~~-4~.~~.6r:~==5jt22j10~~~~~2~-~.-1-.1~~a.~~16
0 Hoi.K5 ot 3.bor Deliver)'

. . .
~ture.25.10. Firststage<!fla:P:orwith dw.nges in the position of..t he px:esentlng p-ar:t. Note the ~otatioi:l -~
of the fetal skull.from A. LOA to E. direct OA (internal rotation) bythe.cnd of .t lie firs tstage of labor.
(From ..[S Brown an<! WR .Cronibleholme. Handbook of Obs t e!Tit4 and Gynecology, 2003).

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 CHAPTER .25: MECHANISM OF lABOR IN THE VERTEX PRESENTATION ., 403

. Flgur~2S; 11. Cardin.a l ptovements of labor:. Head ,~ngagi:s in transverse position {A).i ~
Flexion .and descent into mid pelvis (!3);Internal rQ~ation to :occiput anterior .position
(C}; Slcteil.sion.(P.E); External rotation (F). (From JR Sott, RS Gihl::ls, By Katlan, AF Haney. . .-~~;-
Danforth's Obstetrics an4_9ynecology, 9th Edition).
. ~ ~ . .

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 SECTION IV: CLINICAL APPROACH TO .lA80R 1 DEllVERY

Molding_ :,, : to oyenide .e ach other .: and thus reduce the size
of theh~d -~ere.~ce that is to.P.S-S~ through
-:~ labor. :Progre~ses, the :~ha,;pe or the .child.'s . ~e ~lvi$. . . ' . . .
he~d is altered in pr-der thai -i t may !:>ecome , . .o
better adapted 'to the p~ssag9.. This a.lt~r~tio~ CaputSuc~~e'W::l.
in tbe fetal skull is .known as mol4ing and is - . . ,
dependent upon' t:h~ Wta$ ,_.o f the s-a~r.es .and ~liis describes .ede~ ~f the ~calp (so~.s
the -softness -~f tli~ ;l;>9nes .th!-:t<~ake u,p the. : effuSion b:et:Ween:fue;aponeWOsis -.and_:pe&ste\unr
cra:riial vault. ~usu~y ~e two
~e:tal bone~ . -~erlying the. l~g~ _ of the _.:UCull.. :tbis ;~ -a
. ~d the .cranial poliion:ot the .ftolil:tal a:rttl the . normal~; :t:h,ere~\Jlt-o'f:pressitre~tbe
occipital:-bone~ -s:f~. 'o tuy -pat#:S.l! ~.ss:ifie:4; so ...~in~~~<>ua-~i:l:zy,mphatic-~
their shape m~Y~.~wU.j.chang~din~~e course . Jr-om the sealp_ d~g 'labor.. Caput usually
. . ofi.abor~ :B.~?- :~~-~~ illso p~~t 'the 1>?-~~s . 41:~~ w.it!ti.Jl .houts -~ b.ii:th.3 4

. ?OIHTSTOiREMEMSER
-M ~."'~--~~-!l:eu*e.ry,_ocUf'iila-~tiouQus. ~fasn~. : ,,
. .. . . , . . :. ~vettientS .take .p~ :d~ling ~ ~q(;l o~iV,ei eng;lge.inel1~ :descen~ '":
!'te)OO.l,:ln,teclnat ri;>tatidn ,:extension. :e~m at ro~~ .or restitirtiOOand.~xPUtsk>n. ,

~~ancurn:r:tn:e''rrte<m'a.r.is:m.s::ot'!~bOr :is:.~nfiat: 10
. ~~.
. '.dev~:wfiien:rri?YA~~-
.. ~

6. stewan:Te- &ck'~tJbStCtricru -Practice. -~s lind

w~;~~ih~:sth~eioii. :: .
1 .. .Arce::Ct ~-- l L :Th:e<:o:une.
and -cond.uet: :6! . .
'1:19.t:n~-~al>Yr ,~~ ~eliv.er.Y..'Cutr~nt cbst~ir.tes- : . 7. .B':9~.J.~ t4:..
Cro~)>l~~o.1ttre WR .. :Iiandt;.oQk .of
.Gynecpl~-~-~:: ' . . Qb~_.1irtd.C:JI!~!(itr;. Pz:~p.~~-H:allItitematiooal
. ~;ne~ .1~~
. 2.. Cl\en~.y.w~-~al.-Mt>or ~'tci' cl.clm~. Webb 'l:tri:; J~}; . .
2006.: . . .
8~ Shavcr,bC;Phd~ih st, :~ed$.<nc, Lip,.'gFV{.clliucal
M~\iru -of Phstetrics, Me Graw -. iHill''rntemational
3. C\ll\Il,~_g_!iani .'F~ . I;;ev:e"U:o.:;K, a .looill. s,.Ha,uth Jc;
Serie3.
'Gib~p L JI(WertstromK. Wi.ll.iiUn's ~bstetnci.22n'd
edition;. M~J:B.w,.. Hill:. Medi~al ..Publishing Division: .
2005. .. 9 .. N~rwiti ~~- ~Chqr:ge Jo:..Ob~.tetrics -~d,Gyn~l9gy at
a. Gt.ance, Blaikwcil
. . . .sclericcLtd'. ~2.001.
..
'

4 ..~ttJR, O:ll>~s:~$, ~~ B'Y.,.H:aneyAF. I:lanfortks

Obstetrlca and -GYfi.eeoiogy. 9th Edition; Llppinc.o tt 10'. Gabbe. ol:>sletncs'-Nbrm:al and PioOlem Pregnancies,
. . M.a. Wili<hl.s2
.:williain.s : ~Q(f-
. 3, 4th .ed.. ~~ur'chiij Livingsfub.e-200.2.
. . . : .

5. Sumpaico W, Baja- ~ru:rlilloH, Villanueva~Gutierrez,
~th, Pareja ~.{, L\!na L, Rainos :M. Textbook-of
Obstetrics ~ysiologic an~:'Pathologic) 2nd 'Editi~n ..
Association of Writers of 'the Philipp me :reXt:books of
Obstetrics il.nd Gynecology, Inc: Association of'
;p~ppineMedical Coll~g~s Foundation Inc. 2002. .
11. Burnett AlF. Clinical Obste.tri<:<s and Gynecology - A
.Problem 'Based ,Approach,.Biackwell'Science Inc.'-2 00 1.
12. Niswander KR, Evans. AT: M'an:ua1 of Ob'stetrics -
Diagnosis and Therapy . .Little Brown and Company
2001. .

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 26
.. ;-'

CONDUCT OFNORMAL
LL\BOR AND DE.LIVERY
JOCELYN M. ZAMORA-MARIANO, MD .

Definition A-A,(mit

Stage3 cf U:bor
0- dlc.f
lJi;::,~..;tkll'\~~ 'f vJ L~ ~ tfVt'liY\1
Fil'$t Stage
Second Stage I- IV fl~
Third Stage T --t~fWM-

: ,: Admitting Procedures

History
Physical Examination

Managem_~n_t ol Jjr:$t -~g.e of.Labor.

Managemfmt of SecOnd Stage of Labor

Management. of Third stage of Labor

Management of Fourth Stage of labor

~-

. >'>t'J
~

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 SECTION lV: CLINICAL APPROACH TO LABOR I DELIVERY .. .

. DEFINITION the patient i~ in. Management plans will be based

on which part of lal?or s he was admitted.

STAGES OF LABOR

Labor 'is dhided into three stages that

delineate milestones in ~ c ontinuous process.
~r~..%i~ 61 fi\J..tD

~te::i2.6.1. Differentiation o! false from true labor pilits .

. .. ,.. .. .
. .ri~e~
... . . .. .. . False Labor Trud.abor

ch:ilricte:r of uterine contractions

. R~'Ularity/lnterval . Irregular. longer, ;,ariable Regular: sho.rter , rhythmic
Intensity Gra dually increases Unchanged
. JYuration Longer Short
Effect on the cervix
:E;tfa.c~ent Absent Present and progres.s es ,. -:<:-.,:.,. .
Dilatation Absent Present and progresses
Ux:a~on of ~ain Lower abdomen, non-radiating Lower abdomen and. radiates to fuc b.a ck ;'<

=E:ffe~ of sedation Di~comfort relieved by sedation Di.sc;:omfcrt p ot affected by sed~tion . ..

Sl09<iy show Abs ent Present

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 CHAPTER 26: CONDUCT OF NORMAL lABOR AND DELIVERY :.: . 407
--------------------~--------------------~~------~------------------~

Second Stage of L abor character of contractions, status of the an'lniotic

membranes (whether spontaneous rupture has
The second stage .o flabor commences with full occurred. color of amniotic fluid), fetal
cervical dilatation and ends With the deliv~ry of movements, vagi.nalbleeding, or any of the-danger .
the fetus. On the . ~verage, it lasts 2 hours in signs of . pregnancy (headache, VJillai.
nulliparas (median 50 miri) and 1 hour in distlirbarices,..dy$\irla}. "A thorough review of her
multiparas (median 20 min). The ACOG has ..prenatafconsu.ffiltions may be helpful to .check
suggested iliat prolonged second $tage o f labor ,d rugs taken or illnesses incurred during the
should be oo~side:red when the second sta.ge pregnancy. Past obstetrical, medical and Sllrgical
exceeds 3 hours if conduction (e:p idural) information will certainly be . helpful, including a
anesthesia is administered or 2 bouts hi th~ quick r~view of systems. ~ (,f'J<_., : _tl& Jl\"
absence of conduction anesthesia in nulliparas.
For multiparous women, such an impression is Physical Exam1natlon t-1\,\
nrade if the second atage of labOr exceeds ~ hours :
with co0 duction anesthesia or 1 hour Without The physical examination should not .only
it... focus of the patient but should. also consider the
fetus. Thus aside from a documentation of the
Several studie$ performed to evaiutJ.te patient's vital .sigJI:s, the fetu~:.P~~.tatk.>...!!t..!nd
pennata! outCC>mes a,ssaciated with a prolonged "-!~H:_l?_q('ig__~~-al~o . assesse~ ~ . A~domthil
second stage of labor revealed increased risks of -examination qegi.n.s:with a measurennt pf1h
su:rgi.~-~e.li:v~ries and maternal morbidities but fundic hei~t. 'l'he frequeocy. c:lJira9;?n;<@d
no. diltereii&'esuf"iieona.tii o~t~omes. .M attnal . intensity-of-t he-uterine contf!ictions are ~'ilj.ua,ted.
~sk f~~mtis}tJ~ntified.:with p~longe~ ~f9n~ S~ge lncisional scats from .previous .iurg~~~r
mcluo~iemal wetghtjwetght gam)-Jlulli~ty, abd'()minal d.e liveries ~t:l! no.t~d. _Y!JD~
0hse .o f conduction or regional . a:nestkesia6"fetal ' tenderness 'is aS~essed, 49pold's maneu'veti;:r~r
occiput m 1t.\posterior pcsition, andl lncreased fetal presentation, . estimate<i fetal weignt~d
birthwei~t, . . . . location of the ' fetal . back fot .f.etal he8.rtbeat
auscultation:.T}:le maneuv~~s ;tre.showam.{Jfj~ ~
Thirti sb.tg~~or Labot 26.1,. and described as follows: ._.,, :'~f.t-.:~;,.,~.;-
ft.ly:~,.; ~~lp . .. - ''">! .. -
The ~hird
stage of labor begins after delivery Leopq_ld's In:arieuver 1 - . the .uterine funjbls is
of the fetus until the delivery of he-ptaeerita. The p8.lpated to d.~t(i.riillne which fetai .pa.n:~~ies
delivecy-of.theplacenta. may reguirek~ the fU.iidu~: Trrcrfeta.rhea.-a:showd~reetrouna .imd
minutes~ b ut-the -duration of the-thitdstage -of ha:raiffia:met5reecn pre~iiti as::~rra:r&tnOffillar
labor may last-a~J!g~_s_30 .~~~-es before active mass.
intervention is eonsidered. . . f J.. ~ '};! ! '- l (. II !-' . . . . .
LeopoJd:Os m~euver 2 - inV-olves palpation in .t he
ADlrllTTING PROCE.D URES paraumbilical areas with both hands by applying
deep but gentle pressure todetermine which side
Typkally, a pregnant'Woman is advised .to go is the fetal .. sj:>irie (back), and which ha~r the
to the hos.p ital if there is water:LQ.Lb.lQ~ ex tremities. This. particular movement is.
~<?E~g~ ~om f!le ~~gi,rli!, or if sileiSexperiencing important because where the fetal back or spine
contract1ons lastmg at least 30 _seconds and is will be the area where feW h eart tones are
~.9.1\rri~g regulru:ly__B.t..inte1Val3 -of a~~~~' llli~:. heard best.
,. ,. 'I . ..

History Leopold's nianeuver 3 - also known as the

...Pawlick~s;. grip,
i!l a suprapubic palpation using
The jhitial. asse_ss_I,nt!P.tof -laoor' shouldcm~lu de the thumb ana
fingers of the dominant hand
-uikint -t:;aentl:tylng "i.nfonnation' (gen<?ral data) of to. a~certain..!etus....p_resentation. and-tQ~es,ti.niate
the patient ~d a review of her ,Prenatal care, !!~tion.- lfthe presenting part_is no~ ~$aged,
incJuding ;confirmation of ::th~ estimated date of a movable body (usually the. fetal occtpW) ~-
can
. delivetyotconfmement (EDD or-E DC) to ascertain be felt. This maneuver m ay allow asses~,went of
whether this pregna ncy is term. Focus is given on the ~lmt and th~..Y9J:Ume.of the-~niotiG
the labor history of the patient - onset and fluid. _
-----

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 408 SECTION tv: CliNICAL APPROACH TO lABOR I DELIVERY

Leopold's maneuver 4 - involves palpation of If the membranes are ruptured , examination

bilateral lower quadrants with the aim of
detei'mining if the presenting part of the feb1 s is
. ~l}g~g~..J~ ..~~--~~!!.l.~T's ..p~J~s. The examiner
stands facing the mother's feet. With the tips of
the first three fingers of both hands, the -~iner
exerts d.eep pressure in ~ . e dlrer.tion of the aXis
of the pelvie :in!et. ln a cephalic pre:s entation, the
fetus~ bead is considered engaged. if the ~iner's
ha..-ula div~ as they trace the fettis' head into
the pelvis. If the occiput -isfelt oppos-ite the fetal
back, the fetus' h~d i~---~~U.:.f:l~~~- However, if
the occiput. is felt along the sanie &ide liS the back,
then the fetus' head i~ .e:tended.
with a sterile speculum is done to visually confirm
pooling of amniotic fluid in the posterior fornix. If
no pooling is vi~ualized, the patient i:1 a.!!keC;l to do
_vatsa!va IJianeuver {like .co~hing) and fluid
cominil"romt:li~cat os is noted. Likewise,
the examiner looks for fe~ on a dried sample
of \l'agirial fluid under ilie microscope if it is
amniotic fluid. 'fh.e pH of the collected fluid is
ch~ked by usmg a nitrazitl:~ .~tick or_li~l!.s..~.
whch turns blue if the amniotic fluid is alkalotic.
Digital examination o( .t he vagina .allows the
clinician to evaluate the folloWing:~

l . Cervical dilatation .. increase in the diameter

of the ce.r vical o pening measured in
cehtimetets and which ranges from O.. cm
(dosed or fir1gertipl to 10 .e m .(mplete or fu&J
dilat~d).
' 2. Cervical. eira~ment ... pt'Pgreasive shortening
and .thinning of the cervical length which is
-.. often:r epvrted::as a. perceniage:~nf.:.tbe.:.nQnnali .
'3 ..to:..+.cm4ong,:Cen"..x.. (Figw:e 26.2) ...

...,....._
..

A---... a------ ~_ .. .... .... o-----e..

~
. __.
~not . Ce.IYJx.pait!y ~ ~ ~
e~ . elrdeed. fully dilated . diiaiecs
~~at lifiQffi Qf iff.iced . 3'~cm e'cm
. ~ t!ervk:aJ
c::anM em ei~ s 2 em

Figura 26.2. Effacement arid dllatation Qfthe cervix.

3 . Cervi pt>J>ition .-r- .. relationship of. the - ~rvix

Flgure~6.1. Leopold's maneuvers.
A pelvic examination is performed with 2
fingers of ~- .giove.d hand t~ evaluate l>rogress of
labor. Jf bleeding (pa.rtiGulady if it is.hea\ry) Hf
pre~en~ iffs iiiiportii.ifto "delay e.Xa.tiii.rlaiion until
place~tal .location is cpnfirme~ . .Vaginal
examination can initiate severe hemorrhage if
bleeding :results (rom pla~enta previa. Vaginal
.bleeding along with- hypertonic uterine
contractions may be due to placentai a bruption.
to the vaginal axis (posterio-r, or i:nidline)
4. Consistency~S<>ftness or firmness of the cervix
5. Fe4U Position ;- relationship c>f an arbi~y
chosen landmark of the presenting part to the
ma ternal pelvis
6 . Station - evalu~tes the des cent of the
present}:ng part. This involves quantifying the
dist.a1)ce of. the body or P!.esenting part that
is pr:e~enting relative to the iriatetnal ischial
spines, whe:re .o Station is :in line with the
_m aternal ischial spines. t he ievels.of_mtion
are divided ,into fifths in centimeters aJ>ove..(-).
or oelow (+) the
ischial spines. to
(~s +S)...
{Figure 26.3).

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~
 CHAPTER 26: CONDUCT OF NORMAL LABOR AND [)EUVERY 409

When there is a significant degree of ~j>ut or

. moldihg, assessment. Qy.. abdominal ..p,~p-a4Qn
usinti fif.ths of head palpable is ..more useful than .
a&~ss;ment by vaginal examination..

7. Clliti~ pelvimetrY - a: clinical assessment of

th~ adequacy of the pelvis is do~e. Certain
landmarks of the th<! pelvic inlet, midpelvic,
and .outlet compartments are .assessed
whether successful vag;..nat delivery may be
feasible.

Routine laboratory examinations are usually

requested on admission. '.These include ~-complete
blood count, blood -typing and sc.r.eening, and
u:rinalysis. Blood 1S saved for possible
Fipue 26.3.Asse'$S\ng'(lescertt oft.heletalhead by vaginal . ct~ssroatchirtg in the event that excessive blood
~on;:O a:tapo,n is at thel~vcl Qlthe . ischiru
. spine. . ioss occuts {~excess of 500 tnlfor vaginal-del.~,
,.

>lOO.O...Jnl...for.,cesarean--sectio11)
-- tnay be given.
traro.$fuSfon ann
Th~ de~nt of the presehting part maY.a tso MANAGEEN'l' t>URING THE FIRST ST.ACl-~:OF
~ :ttsst~~(f abdC,Jll1imilly. Thisi$ eXpressed in LABOR . . . ,
t~tJns ()!.:J?iths . otfe'411 head p.:llpable abo\e the : ..~: ~--~~}~~~,:: .
. . . .'
symphy~is:;j_Jubis.the fetal head ( hat is eniliely
:

Women are admitted to the lab6r . rcom~:.ior

above the .s yntphysis pubis i.s five~fifths (S/5) frequent ob~r:ation until delivery. . .c'"''
palpabl~ whtte the :fetid head'tluitis entirety below
the ~'ph.ws pU'bis is ~<rii{ths:(O /5) .palpaple. .PClsition .and Movement J?,urlng .Lab.~r..-.. :." :_. :' ...
(~ 1 26:~): . . . . . . . . .. :. . .. ~ . . ' '. . . ...
. . . . : . . ~. . . . .
A woman in labor should be ent:Qurag~to,
assume the position that she finds tilo's t
comfortable. 2 Optiop,s include walking;.-lying
supirte, sitting, or res_t!n~J~~-l(!f~@t~.~-s!~J?!m.~
posttron.-severru ~~-d.~~-~- ~-~-<?\Y. t,l}a~
Iiiifs~ge.oHabor. the su.E!t}e_position.affects .the
--biood flowTn t:h-e u~_i}li:i:he pregnantuterus can
cause compressiOn of t,he aort~yaJ systemand
thus reduce blood flow which . can comprotriise
. feW condition .. At the supine position, llkewi~e .
reduces t.'le intensity
.
of the contractions,
_ . : : - - - -- ..
anq this
A. Head Ia mobt1e a. Head acconmodates intefteres Wlthth'e progress of labOr. In a large
&!love~ ful width Of five
aymphy$1$ fingers above the randomized controlled: study of >1000 women in.
pubiS"~5 symphysis pubis active labor, 'ambulating during tabor did not .
change . the progres~ion of labor. However,
changing positions during .l abor may . improve
discomfort. Sitting in an upright p<:>~J..tic;>n_!!l~.Y
increase comfort ~nd spee<i. _contraction~. ID...cady
iabor~ Trials that have comparecCiiiese optional
positiohshave shown that labor was eiperienced
as less painful (less . need for analgesia), and
augmentation was less frequently in th~. non-
supine positions. ~
C. Hea<Ht 2!$ i;>. -Head eccominodates . . . ,. !~,
two lingers above
Various constr8:ints may limit th~e ~fions: .
above l'fl'llphysls
. pubis . ttae_ fyn)J'hsls pubis
design of the deiive.ry-suite bed .t o delivery
Fir;urc. 26.'4. Abdominal !lsses~ment of fetal descent. protocols, or the presence cf routine intravec.ous

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 416 SECTfON N: CLINICAL APPROACH TO lABOR I DELIVERY
lines M monitorin'g eq11ipment like : the
t~ynamome'fu:. Another constraint: ~d
exeepfion i3 wh~~ the m~mbranes have ruptut~
in the presence :oL~.JJ.pn-:engaged fetal.he~:
~tien~o. are clso sedated rna;/ not. be .at_ll~ to
.stand. and sit. but r{laj assuri_l.e the .,left" lateral
.decubitus po_sition. The woman ill l<i.~r sf\auld
be enCqui-a,ged..'tb cho~>se the position- ~e-P,refers,
as ~_Q:pesi?on .is e<>Plfoit.ibl'e.'f9r a long _titn~.
:Ut~e eo.nuactions
With the examiner's hand.contin_u o.u sly .o n the
fuh"<i~s;'~fthe ute!'U$;,:the utef.in~ co~tractions are
a-ssess~d. t:h~- int~ns~ty 7str.e~gth c;>t .t he
c:Or~tra'ction n0ted .an:d. evaluated as ~9-. :..p:~k_rgrte
or -:Stro?J,&:..9~P:en.ding O.rl tl;lc .q.egre~ . the)mgers
i'nd:erit on .. di:e uterus during th~ ,acme Of
CO.nti:actioP.. (f'igut'e Q.6.5J The ~ontr~go~s .are -p attem is a baSelineheatt,mte of H OtG 1'60 ~ats
then determined accptdi.ng ta the duration .(start .~T- I!!i!!~l t~ fh:~.t vazi~!>. py_~~-~~9.4~~-j?eat; ';j_fu
:_en-erst-.
o!- .-titet:iJ'teri:ife :.c:&n fractioh :il:n-til.. it iill'd . fuoV~J:i?.ent .P.r :ctn;ltta:ctions,: thaf a~celerates
.interv8.1 (tii:n'e between~. one :con traction~ to. th'e: appi9piia't~ly
rieitJ: ..... - .:.-- .. .-.._: ' ; _. .' decet~rat~=
' .. ~;
:I:igute 2 6.5, . tu1 initial abd.Qminal c;XamfuatiWiiis .qujied
b,Ut -.o n ;adinis.sh;m"t?y laying a han.~ .on. tqe: :utp-tls .and
p,~p_ating,_notir:i the d,~gr.ce .Qf hard*ess :d).lring a
.co~-bitcliop..~~ t,i.ining ih leri_gth. This.:Sh9t!ldqe.r~peatca
at
in~cr:vals thtpugnout l~tor'in .or'der to B.ssesi th~ length,
of
strerigth:,ahd frequency contractions .an!i the de.s ttrit of
the-pi:c3i1ting_pitl1.' The utero:~ should always feel:so.ftt:r
betWeenconlra,ctio~s:- .--.. . -~- . ..- --- -- . c-
. These. -parameters
.. of -llie
, uterine
. contr.action!i
t r'
:~
assessed ..e:very: -15 minut~.,.Th~~- .is
expressc~. in seconds, and thei~is r~port:ed
in minut~s. In the ~iyphase-of the :first.stage-of
labor, contractions may be infrequent occurring
ev.ecy 4.-SII).inutes lasting foc30 seconds :an.d with
m-ild cha:rac.t er. Thts usually. progresses to good
~traction s ..until -delivery. During the aCtive
Scanned By:
... ,.
pha,se of labor, contraction.~ that effect progressive
an cervical dilatation .a nd effacement are d~bed
as tpo'se occurring every_ 2~~- lJ?in);l~s ~g_fo_r
4C-60 seconds with coderate intensity.
Ccn_tractions whic_h happen .at shorter intervctls,
longer dl.lrations _and strong intensity may clbch
on hyperstimulation and ra,J.se the suspicion of
complications lik~ 1 piacenW aprupti~n (:Pi-emature
separation of th<: :p lacenta).
Fe~ Mcnit?.rl.D.i
'fP.e fetiil ca~dition must~ ~!l.clto:-cd d-cring
labOr. The ma.W- .paraineter.s ar~:'.fetal heart rate
a~p~~tal heart iat~ yariability. particularly in
relation to uterine contractions. This. is usually
asse~ed'basoo.on .r ecord..ings while th~:p:atient is
hooked to t4e el~ctro'nic retal .mo'nit:Or. A n ormal
-.
:for :gestationa:f.age,. and dee~ not.
. . J .' ' . . , .
.4\iring:cori.tract:i:qil.s::-~: . .. . . ..
..Mo.nit~rX:in,g._ ~ b__:m!mw!l:~~ii:lteOnitten.t,
~a!'f.~t.Q.s._q~;Qi;!ft.;stiilio~~!,o~,a~~~tiori-
.of fetalheart.....rat-e~
-----=--~- ~ . . .- Tlie~electroriic'
.. . 'ietal;nioilitoring
. .. . . . .
nas~beco~efue.,stan.dard:. of~~eforhigh~risk
pregnancies~ anq::ma.."1y-c::f4liians~use it. an.. for
: pregnan1-es. 1ts: value ~has parti~ly been a
.R:Q4}_~ }>i:dtl?,;~t~...P.!!i..b.<2~1!~~- 'HJanj_~PJ@:'F.P. t
ab.n....o..r_rru;\liJ!~s p _e__J:al-::ie 'po si ti'{es, _k_agjng_tp
!
unwarranted: .ce.sarea~ deliveries.' 'Fetal pUlse
_?~etry is being'__e valuated as a-~~
abnorm.a l or equ::l.v0$i results' of :d~nic fetal
morutorip._g; .feW o.xygena~on in_a:y help qetermine
whetfie r ' a cesarean s edion.'-is neeaed. For
oxipi~lty, an}b.te~ahensormus't .bepl~e0.insid~
the ute.rus ap.d-.~~st thefetal skin to ensu:-e.a,n
adequate ''17eaQ.ing of fe'tiil oxygen.ation. .
An -e'v aluation Qf t:lle fetal status o.n admission
using th~ ele'cln::iniC:' fetal moJ!.itor., called the_la!?:Qr
admission test, was introduced t6assess w"'Eet.her
th~s:e fetuses t;ay p ose problems early on and
who may warrant continuous fetal monitoring.
This i~ a 20-miriute'EFM strip done.on admission
from \V.niCK'baseline:feta1'h~rt rate, :variability,
presence' of .acc1!ler:ations and dccefe~'tiohs in
relation to uterine contractions are nO't~d .. If i
norinil:l :trace is o btair.ed; intermittent. fetal
mbn:rfc(ring may be qone. HoV{eV.er;iran:Y:or the
parameters show abnpnnal finding~, __cq_rr.tinuous
fetai monitorini{Is~ d.b'ne.anq mtrauteoae
~-------------
 CHAPTER 26: -CONDUCT OF.NORMAl LA~OR AND DEUVERY 411

resuscitation m~y be done. The labor adn.ssl<m about fetal well-being or uterine contraction
test (LAT) has been questioned at so~e point intensity.
because apparently no differ-ence in neonatal
outcomes colllpared to those who had ~anual Mi<temal \Titel. Signs
.moPJtotiJlg oniy. In a lOCal studyofMallen, Roque,
and Gonzalez in 2005,~ it W'a$ found out. that the The vital signs ofthe pregnant.patient in labor
od!i$ _of developing fetal distress was 3.86 times is n:1onito.red hourly. This includes the blood
bighet ihthe.liigb:-risk-gfo\;lp co:mparedto the lo~~ pre-s sure, pulse rate, respiratory_rate and
risk population. A reactive labor adnU.s$ion te$t . temperature particularly u- the mePlb~es are
resW,ted in a lower incidence of nort~re~ssurlng . ruptured, as a s~gn of chorioamnionitis. Blood
feW -h eflrt rate pattern in low,..rls,k pregnancies . pressure is taken more frequently during _the .
Thus, ihe use of LAT has.ben recomme~d~ to active phase Of labor and is usually timed after
be 'limited to high-risk ptgiUmcles~ ' the conuactidn. A rise in. the blood presSure is
usua.lly noted .d uring contraction.
.If manual -auscultation .o f the fetal heart rate
is. used, it m'ust. he done throughout lab.or Oral In.t.ake -and b!.bavenous FlUids
acccrding to specifiC gUtdelinesw:he:re -0~-~ ~ti~
to on.e attendant _i.s needed. For Jo~'"tislc: Food a nd n~d:s are usually withheld d\Uing
pregruindes-Witif.fi~:mru tabor~ fetaln~art rate a.ctive 'labor-@d -delivery..Gastric ~ptying time
must be evaluated . .
~
caftereach txm,tta:ctiotl 'a t lC;ast .i!l prolo11cgedd uring ptegnal:lcy. Gastric .cQDtents-
ev_eey SO -$utes. .dUntlg:theJi!_St s~e ~ o( .la"'WT may , .be -_a am)tted. Jmd ..consequently .a,~p~te4 .
and -~~ecy.:~t~-mm.u-te.~amw~ :fhe- secon4 ~~e. du:riug the. ae.tive tJhase of labo.r anddeli~.m_o~,
"'p'Or.;_hign~r~pn!_gna.nciea, feWJt~tt rate -m\tJU impgrtar:i..tiy when-th-e patient is ~ated ,or.uri.Aer
b e c.bek~~~~JQ.:minute.s .during.the~e anesthesia. .
:iui(feV"er.Y'3 to.: SJilin\ite$duringthe ~~d.stage:
- ~ F'etarh@ff:
. - ~~tt>netf'ShoUld
- . be -~.,C[i(;(fio-
. .. at)'...- the .
~ . lnnavenous _ nuids.-are given when the patiep.t .
rontracti011ito'.a llow-the;-fetu$to recoveJ: J'rom the bas bactnoUling:pero~mfor 6-8 hours ta~;a~ent
stres$ ;<.~ the uterine cant:ract;ion wl!~- a; . dehyd$tio~ 1>r When she is alren4Y - ~~or .
d~~:::~;fl)e _ heart rat-: may OCCJir. ~erlOOic when am.niotomjr was-done. Intavenous.dlWds"
auscwta&n .has a lowe.r false--positive Tate .for also ~provide gluco.;:;e_and .: water to the\fJ;lli,g.
abnonnalities and in,tiden<:eof mtervention than """ri-l'"ent
:n---.......... . ~-dtna .1:--!~t..---'
. JY~ WI~~ a t60-12Q
. ..... IJ\. 1
LlfJf""our.
to:4f1rt\lqtl:S ae't:rqtn.c .moriitol'ihg, and it pri:Wides th:~ intr-avenous !in~ ca-n a1eo be u-sed to
oppm'timitie9" Ii:J~'nroYer-p:etso~arcofiliC.'t-wUfi .. .~-~ir?I~1~~~i.li.~~P:<i.~-~J!k~-Piit2a~~:aw:mg~the
~ dunng-Iaoc>l': un"\lle-offier-:-rian<l:-lt~ay . third stage of labor or during augmentation, or
1--..ave disadvantages- as well. UnleS-s ausc\lltation sedatives. .lt i~ also nece~eary to ,p rovide an
-ls done accurately, auscultationmay not de~ct intravenous access for blood trailsfuskm in case
abnormalities. i"oUoWing the standard guidelines he~on:hage ensues and bloo$1 products are
for !:l.Us~liltation strictly m.ay mak~ oheb.JH>ne needed~ . . .
continuous auS:Cultation difficult and may not be r
th~.~J.. 41\t"l\ . ro-r ~ttli ~101t~A k-f fM ""' ct"'lt'.A,t--w\ N-1''~''
cost~effectiv.e. ;$ Paln M~~e!Jlent . ir ~t"'.....u)
r r-:-.
If~xternal electr.onit fetal. heart rate A woman has many options for managing
mofiitOring, devi~s are applied to the maternal discomforts during l?:~r and birth of the fetus . It
abdonlento recor~Uetalheart sounds and :uterine is .the objective of both the patient and the
contra~tions . Forlintemal monitoring, amniotic physician to use the safest and most effective
membranes ~~-~~ be ~t:u~. Then, leads -t;rre method t>f p~ relief fcit both mother and the fetus.
inse-r ted through the: cervix; an electrode . is T he cl)oic;e will-.be <;letermined by the patient's and
attached to the. fetal scalp, to momtorhe_a.rt 'rate; fainuy'~ preference, the health o.f the patient, the
-:and (catheter is"puice<rinThe~~~dne~~ to health - of the fetus, and; the physician--' s
measure mtraut6rihe p~ssuie. External and recommendation. There are .t hree main ~s of
internal morutoring are :suDit.atly fellable. External. pain management for labor and birth:'.2 ::w.
devices are used Jor. women ..in .;normal labor. ~- -
'Internal methods .ar-e used .when eiterna1 1-Non-medicat~d-measur~~ proVide comfert a.'n d
:monitoring does not ,s upply enough information r-e lieve stress, sometimes called -natur.al

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 StCllON IV: CLINICAL APPROACH TO lABOR I DEUVERY

childbirth. These include special techniques find it cumbersome to void using a bedpan. If the
nrn!akethem comfortable and in eontrol bladder is distended and voiding is ncif effecte(i
during labor a-nd birth.: a) relaxation, spontaneously, ~trnjgll.t.. c_atheterization
..
is done.
~ - -. : ----

b) touch- includes massage or light stroking,

jetted bath or. shower duri.n g labor, c.:) heat O!"
cold therapy, d) imagery - us ing the mind to
fonrt'inental pictures to create re~axed feelings,
ej m:e ditation or f::>cused thinking; and
n breathing, artd .J>013iti~~ - roekL~g ih a
rocking chair, sittln,g in the "'fliilor sit position;
sitting on abirth.itig ball, 'Wal.'dng Md swaying.
Drug~free options may .a lso in tb'e form o( a
support person or douta who 1n:ay proVide
coachingand .supp()l't throughout labor and
delivery. Sotne women eount o-n their ~ners
for etnotionalsupport and help with t>reathine and
telaxatio.n tethhiques they teamed m ehildbirth
education da$Ses. l~or me; 1l soqtli\ng bath
tempoTarlly relieves labor dis.comfort. bi some
institutions'; women m l~bOt .:a te :otl'ered soaking
tub~ , for which the witter :te~~tu:r,e is-s. kept
.aro\md. bodytempetatu-te.,- .(~84l.00 49.};;): t:m"prevent;
fever in the mother and the b~l:>y.
3.) ~~thesia ~ medications that .eause loss of __ )irl~t:~un;
.sen-saiion during labor inClude pudend~l
blok, epidural anesthesia an~ a-rralge~ia,
spinal anestheSia .a nd analgesia ahd gencFal_
ane.s thesia:
.Bladder FUnction
AsJhe bead clescends., .it may .c ause pr-essure
onJh~--llladde.t and J,nay ~take . voiding
difficult. A distenP:ed bladder :d}.uing labor may
lead to <?bstructed labQr; bladder hYP.Q.~Qni~, and
~P-~JJ~nt ~tciSiswit:ll infection. Thus, apart from
the digital examination and monitoring of the
~tedne, contract.ion.s , the__~~p_ra,pu:b.i~.. ~rl!.~_:. is pro.g ressoOaborand.t o identifywh~n intervention
p .a lpated at-regular intervals .to ev~uate if. the
bladder is fulL The mother -is.askeq.to -void and
empty her \;~ladder in the toilet.. or bedside -in hours. StUdies have sh'own that using. the
commode unless contralnd:icated (ruptuted
membranes or under sedation). Some V/Om~n may
Ene~a and Vulvar and Perineal Preparation
hi the presence of true lab0r and vaginal
delivery is anticipated -in early labor, enetna .was
traditionally done. This is to m.iilimize subsequf!nt
c;~Jltal!rtg.atiOt1...:of U1e newbOrn b y :feces during the
delivetJ. The woman i~ put in a lithotomy posltiOrt, .
C\hd the vulva is deansed prior 'to e xamination.
Perineal scrubbi'ng i s d-irecte.d fr~m .a.b o_y e
do\\nward and away frQm the in:tro'itus. Patients
who hav.e ruptured membranes (danger of c ord
.prc)lapse) ; and those whoare sed ated are usually
I}Ot givert -. enemas. Recent llterature however,
shows that enema a:hd vulv~ . clipping . are not
neeess:uy ptoeenures.-d.U:ring tab.6r.~
S-gbs~que:n,t-- Y,~ginal .&:ainiJiaUon.
.ln:nomral .cl.ill~birth,;fuere;..:$hOuld ,be;:a ,ya)id~
r~son to .irited'ereWith t he nat1mllprocess. 2 The
nut:nl>ei.of va,ginaf~tions :s hould be liniited
to the ..$trictly.nete$sary..t>14rirtg theJirst stage of
lat)tj_t:f~~ -~-ations: ~ijo'Uld b ec atried.o ut
at:l~s:<Qnce C\'ecy:~ou;r:bpurs~~~~-ruptute. .
tbe .. membranes .'Howev6'r. =-i~ne .
con~ticm:s ~~e eom..itlg sttcng and tegtlla:r, a
neeesia"\Y evaluationis.done:usu~y With effective
ucetine co1i1faoti9n~dfJlt(; P:ltiera comes in -With
riijitiir~:m~m~~~~~.JtJ's-::_~st~tii'Jmirr'va~
examnia.tions .:to .... _decrease the incidence of
.
Monitol'lil'l the l'l'o_g re-ss of L abor.: the
Partogr.aph
The evaluation ofthe progress of labor fs made
by observation of the woman: her appearance,
behavior, uterine contractions, and the descent
of the-presenting p~. The most rrccurate measure
is the- dilatation..oL~~- Deviation from an
arbitrarily defined nor.mal tate of dilatation should
be an indication for re.view of the labor
management pla.ns. The p~rtograph 1 .a .sigmoid
curve, is a tool that .can be used to assess the
is neces-s ary. It:is a graphical. recor.d of cervical
dilatation in ce.r itimeters.a:gains~:duration ofiabor
partograph can be highly .effective i~ reducing
complicaticns from prolonged labor for the mother

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 CHAPTER 26: CONDUCT OF NORMAL LABOR AND DELIVERY 413

(postpartum hemorrhage, sepsis,. uterine,rupture, 515 . 4/5 3/5 215 1/5 . 0/5
etc.) and for the newporn (death, anoxia,
Abdomen
infections, etc.)~ In a WHO Multicentre Trial,
improvements in maternal and fetal mortality and
morbidity tcok piece among both nulliparous and
multiparous women after the use of a
partograpQ.. s~T
Pelvic cavity
The WHO Partograph has been so. designed to
.identify problems in the course cf labor. lt has Completely Sinciput .Sinciput Sk)clput Sinciput None
been . modified to make it ~pler and .e asier . to aboYe high. e~ily ff!lt, felt, felt, ofhead .
OCCiput . Occiput O<;dput Occiput .palpable
use. tbb-!fetal condition, thevpl:ogress oflabor and easil'jfe~ felt just felt . not'fe.lt
the:?matemakcondition are the three cl:>mponents
of the partpgram. The-latent phase_ has been
Temoved and plotting on the }'iUtograph begins in
#le ac~ephase wh!m th~.~~.IY.iiJe..5_C,Jl\ dilated. . Hours: Refers to the time elapsed sine~ onset of
(Fig1.1re 26.6T The following infonriation are active phaSe of Jabot (observed or extrapolated).
wiitten on the partogmph.
'Time: ReeoJ;"d actUal ti.qle.
.
.Patle._t lnfo~tlori: Fill out :::l.~e; gravida, Para..
. .

Contractions: Chart .e very half hol}!; palpate .the .

ho$pital number; date and tim~ of admission and
time .t>r nw~ed. membranes. number of confractioris in 10 tniriutes and their
duration>ili :Seco-ndS. ~ ~ -~ -.;~ ... ~.~t\{;: ;~~-
?~ ~~._l .. :.-~;_:;:.. .;.';,~\~~}:_; .
'F etal heart ~te: Record every half hour.
AnmtotlcJJ~d: Record the colour of amniotic-fluid
at evezy~t~ ~ation-: Between. 20 .and 40 secon4s_: ~, .. ,.. . _, . ...
. : J: D.iembni:Ues .iritact; . .
.. c!:$.l'til;lbranes ruptured, dear fluid; . -. . . . .. .. . ..\... ~~>- ~ ;,~~ rl";\~~:i;;;:..;~:~:-: ~-
More than 40 ~ccinds: """;: , ~-.< ,-..~.-.c:~
-:;,....r.' ....~"""{<:-
.. ;;. ..,
.M.:')iu~conium-staiiled fluid; . . , .. _ : ...
::-~-"' .
B: blood-stained fluid.
' . t ' .. .... : . : -

. Oxytccin: Record the a:tno~nt of oxytocin per

volume IV fluids in drops per minute every 30
Mouldlil~
-~rm!i~!~~. ~J:l:eil u8ed. ----
:. l! Sl.ltUres apposed; .
2: sutures ,overlapped :but reducible; given~ Record ~y a~ditional <tru.gs
Drugs give!l.
: 3: sutures overlapped and not reducible. Pu,lse:~ry 30 minutesahd-Il)atk with a .
dot {1%).
Cetvlcal d Ua:tatlon: Assessed at every vaginal
;e:xainination and marked with a cross Q9: Begin Blo<)d pressure: Record every 4 hours and mark
plotting .o n the parto~ph at 4 ..~ with ~"TOWS. .

Alert line: A line st.arts at 4 em ofcervical dilatation Temperature: Record every 2 hours.
to the p()int of expected full dilatation a t the~
of 1 em per hour. . . _ -....Protein, acetone .a nd volu~e: Rec~~;d every time
urine is passed.
.
the ..!l~rt .lifie .. .
- - -.. .. . .-..----=-
Action line: Parallel and A hours to the .right of
.. . : . In the partograph method of WH05 7 the alert
. line is passed if the d.i latation is slower than 1 em
Descent asse.ssed by abdominal palpation: ~r hour; if the woman is in a health center, this
Refers to the part of the head (diVided into.S parts) is a -reason for her to b e referred to a n~sl$al. The
palp~ble above the symphysis pubis; tecor9ed as action line is p~ssed if delay in progress ~tipues
a circle {0) at every vaginal examination. At 0/5, for four more_lio~: A. critical asses~me~t of the
the_sinciputjS) is at the level bf the symphysis delay s hould be m a de, and a decis ion. for
p_g_R~~ . appropriate management be carried out.

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 SECTION tV: C'\,.INICAL APPROACH TO LABO~ I DELIVERY

PARTOGRAPH

$ -
:' ':.' .. .l / (7 .
7 !7 .
. .1 loo!- -.~~w.t.ffl~
":" ' . .-.'"'t...:ftt""
. -~-
. .-.. ~+_...,C-+ . . ., .
. .: ..
.' i . :f;. ~~ :;o u .t .? .!3 . ~ t~ . :.; . iJ !'& ~ (If: . .7t '2.'l :r; c.J... .
-. . ,.. ....
:
~- .

"dc:fin~t.:,thl~c.::-tvlx,"~;~ilili::ll lias .'

or'fas-ter c!uri:rJ,g,tl~ ,phia~v.11:J.~:~uei1;~line: diawr~J'roril' . .
~.3.~cm.:lo:11:0~(l;m'~t:F~nt6;~(~#1te.: . . ri'tht. oUhe: .
: .1il:fHne..rlgn'ffi~~Y promptaction to 6vercome delay is made. Th:e iieseent;ofthe tet'al h,ead
~. meaaumpn.~;fifthz..: .

Do a c0n1plete physical. ~inatipn. A.ss<:;ss

the..following .on ~om:inal .e.xam: 1) fundic
height;.-2) .lie and ..presentation ~by .t.eo.pold's
maneu,ver, 3} ;fetall+eart tone, and 4) frequency,
d\l~tton. and ii').t~Il.sity :'Ofilterln~ contractions.
Unless. .G()n~~cat:.eQ., dp a vaginal e,Xa.h
under .a~ptic f~l$ique .to evalufl,te .cemc::~l
Summaxy .o f tP.e J4a:nag-~ment of First Stage of dilata'tiol;l. a,nd effacem!!nt, presentation, and
'Labor assess fP,e . pelVi:~

The management-.oftthefitst:s!;.age of 1a bor can M - Monitor t;n~temal ,rital signs a t

least eve_!Y
be summarized in ~e mnemonics ADMIT.. hour, including the tempetature(parlicularly
.if the patien;treports.r opture ofthe.meinlmtp.es
A "'-Admit the pa:tl~nt if is . sh is.in tru,e :labor . and .r ule out .beginning. choi'jomaniol1ili.sJ.
Monitor Ch!l.,...,a;;.ter ..of u~erine coritratti(;'ns and
D -.Diet a womaninla:l;>o'r :should receive littl~ or fetal heart tones.~Vry: l5,.30 .minutes. In high
. .nothing py .m~ut.p . t6 pr:ev,ent p.o~sible' . risk pr~gnancies,. us~ theEFM .
v.omiting and:aspirati~ :du:ring delivery or in
1;a.se emergeh~y . d~~lv.~ry with. :general I - Start irttra.venousJiuid,s if the mother ha~
.anesthesi~ is neessary. : . .n othingp.er.orem for s...:a .!!Q_urs :and i{seda tion
.

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 CHAPTER 26: CONO.UGT OF NORMAL LABOR AND DELIVERY 415

and amniotomy has been done . .lnu.e.stigatiue effective descent of the fetal presenting--part':
-~.Jlike laP<>ratory examinations if not Many women with epidural anesthesia who do
done during the prenatal or . to help in the not feel the urge to push may aUow the fetus to
.a ssessment of medical co-morbidities, descend passively, with a . period of rest before
doeumenta.t!:o n of the ruptured membranes) active pushing begins.
are also dune.
The mother's legs are firmly placed in the
T . - Therapeutic m~asure are giv.e n for lithotomy position or frrmly on the mattress with
ma..'1.agement of pain (sedation); amniotomy . legs apart. The mother is .instructed to breathe
may be done in the active _p hase, normally until the start of the contraction then
antimicrobials are started if chorioamnionitis to exert downward pressure as what happens
irJ ec>nsid~r~;- dntgs tor co-~stiD.g~Jiiedical while straining. The "push" is sustained as long
probl~ms are also given._:_~_E.~entatj.lan With as possible and t:4e breath slowly released as
oxytGCin JDaY also be s tarted further on the contraction disappea:rs. Bhe .is asked not to
~ssme.nt -o f the cours~ or labor. strain hi De-tween contraction~ to allow ~ and
the baby time to recover, Coaching instructions
..rJ c.xfwtM ~ ll.<iv4. in the vernacular or bcal dialect <luring each
:MANAGEf.tEN't or '!'HE SECOND STAGE OF contraction with acGotnpartying reassurailee may
LMIOR . allay t..,'"le fea.rs apd decrease th~ .a nxiety of the
~ ,. ;.1-t~A~rnl JX-4 ~~ . mother op. how she ls doing. t1iis a18o -~ows
1'h ,e
_., __ ~nd .stage oflabo~ commences from f~ll synchrony and cOordiriation b:etween .~sive
cervtcal c,lililtation to .e xpulston -of the fetus. Thts forces (pushing) and. contractions: s~~ssfu.l
(
stag~
.
:is U~ally caJ.led the pushi...il( stage cr the expulsive . forees contribute to. the ,Cie.scent~()f,,thc
"'bearingdown stage. !tis cllanicter.ied by :uterine fetal prese nting part .u ntil the b.u1ging:;of! :t.Pe
~nli'iaions wliieil." aie
stronger~ longer (60-90 perineum. . .
secorid,:s)..:iW-d, .more frequent (1-2 minutes). The
secona .#t~]s rclativ.e ly shorter fu.an .the first Several randomiZed controlle~t-~s,..rui.ve .
stage;~'lt~.i;Jald!" 2Q" :miritite:~ tor llie multiparas shown "that, hi nuliipar.ous woni~_n.; .d~l~yed
and 50 triti1~tee "for the nulliparas. 2.s pushing is not associated with adv.e~~tai
-. .. ;;
outcomes or an increased risk fof''s ui-gical
deliveries despite a.'l often prolonged secpnd.stage
~~--~~bor._,~~-!1~.~!! .~~~ -~~ ~2I}g_~~ !!?...~ .
li'Crtbw"fik .pr~gnanCies, r-etarheart rate _inust sJ:?:2.~~~.'=-.....P.Y.. .J~ .-JE:!!tU~~-~ .J:!! t.h~ - ~~b,~ .!~HlP
be cfi:ec1C~-a --eve-iy rs-ihinuTe-s'
aite~r - each versus the uncoached pus hing group V~.ith co .
cont:rad:ion. Fetal.heart tones are best heard after differences in the immediate--maternal or neonatal
the contraction (ACOG 2005) or 1-2 minutes befot'e . outcomes.
the peak of the contraction. In high risk
pr~cies, the fetal heart rate must be checked Preparation for Delivery
every 5 minutes. Slowing of the fetal he~ rates
during this stage may be secondary to When delivery i.s imminent, the mother is
compression of the head during de5cent, However, usually pos itioned supine With her knees bent
not all decreases of the FHR is due to head (dorsal lithotomy position). Although this position
compr~ssion. This may also be cord compressio-n is idealbecau s.e it is said to increase the diameter
o.r tightening of the nuchal cord, or. b~cause of of the pelvic out;let, dellyery can occur with the
premature separation of the placenta. mother in any position. Variations may include
the lateral (Sim's) position, the partial sitting or
~he MatemaJ Pushing Efforts squatt:ing position, or on her hands and knees.
Strictly asepsis and antisepsis must be observe d
Ouring the . s~~ond stage of labor, the iri the hospital setting; i.e. use of sterile gown,
parturient ~ay beencouraged to actively pus11 in cap and mask. The perin~al area is scruQ'!ifd with
accordance with th.e contractions. Maternal antiseptic s olution, and antiseptic appli* before
pushing effort is us~ally reflex and spontaneo~s. stedle drapes are applied, while tJt,~ birth
However, for the primigravida~. a certain degree attendant m eticulously scrubs, wears th~;sterile
of coaching is needed to n::.axi~ize efforts for goWn. a nd gloves. .
c~~.vv~'~.'..~~~~m tt lliVTJLJI lvJ.). ~'&ft!\0'-Y ~ /tntnlv-'l~ --11-tl tylv(~~ ~

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 416 SECTION w: CLIN1CAL APPROACH TO LABO~ .i OEUVERY

Delivery of the Head an:d. Epis-iotomy skip and muscle layers. There is an increased risk
of 3n1 .'alld 4th degree extension te.a:ri.Iig. causing
As the mother continues to bear down with one qf the things it is supposed to prevent.
ea:ch eontradion, the fetal presenting part Epi-s';otomy is of no benefit under usvil bi.r.Jl.
ev~tualiy descends 5.1.0. forcibly distends 'the circumstances. It causes pai.."l. :an.q debilitation
vaginal outlet, The perineal opening bccom:es ovoid post-partum. pisiotomy rnay interl-ere with
.to c.:-ci.llar, -witl1 the pe,rlneu~ stretched t.tJ almost reSUtnption and enjoyment Of int ercourse, both
_Mper ~. a+ld spm~tiroes the reetai 6.p eliing is short-'term 'a rid 1ong-terin.-9 10
alsq stretched. This .st.aze -~3 ccrevffiing. the' event ..,
wherein the fetal head .is encircled. by the vulvar However~ there are certairi conditions when
ring. an episiot;my may be needed. T4ese include:
. . . 1) the fetus in
definite s'tr.ess and neetls to be
An episiotomy is. -a surgical in:ci~n .ef the delivered ~edia~ly; 2) .s~ Of the baby- very
.moL'ler's Perln~u:t;!l-,:pe:rlo:trned as.~eba~yshead stnan .preter.n tQ .Pte~nt c~ tr:a~. or very
emerge~ fro~ the :vaginalcarutl .du,rirtg ~irth l~ge babies with .anticipated. shoulder d yst6cia;
irttended':toprev~ttcltiS cfihe 1~rineal ri;lu'Scles :7 3) the.moUlerWith certain medical conditions that
Maternalbert~ts initially $ought to be 9erived make her vaglp~ tissues ~usceptible to ~e.
'frorn epiMotoci,y :iricl..,:tde r.ed\lce~ r'i'sk of and 4) matetnal eih.austlc>n. .
. 1} $~::~~a# 2) .$~'b~w~nt p-e.l;vi n.o.or .
d~il~~1:.P.~~3}l?;~in~tipnence. i:>el~ve-ry of ~~ Fe~ Heaa
4) .fec81meon:tinept<:, .aJ.: ~)~ dy~ctio.n, .
. Po:tential ~bene"fitst6;:the;f~tu$'iil:clti'Ele:~~:s}:l0rtened A od.It- dR ~ :bepciti ed
. :... .~ ~dc.~~roflalx>r:~~~~.l~otJrapiP:- : lo\i~trzer'-U:~~oit~~~j)~.'th~.m::.nme .
sp~n~enu'lf .lieliv:~.o/.. :O.-r: .fr,o:tn;; in~W:me~t?d vui~ar rmg'#a,~hes ~ dkmetei .o f 5 ~ draped .
tigi.nal d~!ivecy. :~ pr9'tctiQ!l, e3~ially f~r wifu:a ~furlletov-iet 'th~.h6elo1fue:cliciciari~sliand
-~~~;-~~ :~uc:d~tal ~~phJ'Xia: ~d ~s...I51~c~'d oV.Er.fli~ ~~t~i..~eBm. :"~Jftng.
fe~~~Str:~.:hi~el'~~~:'~~~.~ft.ess.:f~tal _ .tJ:l~ (~~Anm:., ~~. J#'~~~)~}i.~~~; \1~ to .
~\atl4-:few.et:~co.tnplieati~.q.~:'fr!rin shoulder . merid:Uie {Hil:$' head..'T he ~p.they\h:and: is,pla~i.
.ciyst~l~~\:J,..., : .. :-.~ . ' : . . . . . . . . ove.r;-. the fetus' ~ttipu't;: ~tb.' P.~'$'srue applle'd
ownward to flex 1ts. b,-e:;~,g:,'Jjij,!J :(illows Cl:>~trril of
Th~.~ p.(~9:t941y i$5~ew.l$.e .<mpare~. dtb,e. rleli'l'ecy o( the.hea4!. Wi~'ion. .. ro':tb.at
Midline:-~pi:~toiri:y--a)m~e-d''i9')ffiiiolafetru:"is
easier- to r~pillr,.~1i~S-ioe'fter.; .r osulti...ffi.~.~ress .the ,srnalles_t ,diame~_e.rco.t:thec.head.;pa.sses.ov.er-the
introitus .. ~e h~d.. i;> ilien.-delivered slowly with
.postoperative .pai:n; P.rod:Uces~ceUent:!Uiatom~cal
results, :C.a llses' .}e~s bl~od .:ro~s ail~ less the :ba~ :9fthe bd.Pu(usl;n_g the ~ympeySis ,p ubis
dysPateUtri~ A m~olat.e:ffil ~pisotot:p:y may .be . . ..base.
as .. . .

jndicated if"the ~ewn is very short; or if more
io9m is :needed beaaus :of :an .anticipatetl large
b aby J
. .
f ..~. L>P1fu{'\l
~~1,.1.: .

. .

The AI:neritan: :C011-g~ :of ObS:t ctt.icians -and

GYf1ec6i.o gists {A.COG),l.n 2006 isS')1e<l. a statement
t h iit r~iiew~ .goo!l. a:nd. ~op:s)ste~l :>den tific
evidence that -the resti;icted use Of -episiotomy is
prere:r ablt to :r~~ti-ne ;e.p 'isiotomy. 9 Med.J:an
episi0tomy iS .a~sbeilit.ed W}th .bigheT n:t:tes .of anal .
sph).ncter a nd .. re.~w,l injury a:n :t;n.e9iolateral
episi.oto:qly. lnc.o~sist~nt ev-i,den~e s~ys
m.e.diolat~ral epi~iot~nny .may. be :preferred to
)nedianepisiotdm.Y' i.ti 'SO~ s~tu~tion:s..and 1 that
rou tine:episiotomy '.does -notpro:~ectagainst pelvic
floor' 4amage leading.:to. ihcQ"ntinen(:e. G'reater
b :l ood Joss , d.ud~g delivery Ts. achieved with .
episio.tomks since 'the cut is made .through. both Figure 26.7. Mod.t.fied Ricgen's .maneuver. .

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 CHAPT-ER 29: CONDUCT OF NORMAL LABOR AND DEUVERY .:417
------------------------~--------------------~----------------------~~
"':fo'-. .

After delivery of the head, the face .o f the fetus 2 -3 em frorg, it . This obvjates the need for
-~'f'
is wiped and the nares and throat quickly additi~nal nursery cord cutting.
suctioned to prevent the likelihood oi aspiration
of the amniotic fluid .
..
Cheek the fetu$; neck for a wrapped umbilical
cord, and promptly reduce it ifpessible. if the.cord
is coiled loosely,.it may be slipP<'.d over the baby'<>
head. II the cord. can't be reduced but is not too
tight, it may be Slipped over .the baby's shoulder
as it is born. If the cord is very tight, d.o uble damp
the cord and cut before the 4ellyety.
. .
Following the de)ivecy ()f the head) there is
rotation of .the occiput to o1).e of the maternal
thigh& 1;>0 that the hea<l assume~ a transverse
pattern. This e~ternal rotation moves the
tra.nsv~rse diameter ofthe thoraX into the antero-:
posterior diame.t~r ready for .qe livery of the
shoulders. S~etilnes, deliv~ry. of the sh,oulder
pcc~s spo11taneously. but it delay occur.$, t:lle
~eM'ls _gra.~pe9 witb.the ha.nd~ placed :over .the
. ears_-~AAJl.P.oolced . ()n the m~udible. G:n.tle .
downwa..rd traetion is dcne :until the a.t:iterlor
. $houldet is deUve~ a:n.d then upwartl movement
is done~H;lelivet the PoSterior sho\llc:ler. {Figure
2.6~B)Th~st<>ftb.e.b,ody us,.;lSlly.f.oilaws. Jf it.does
.no~ ~~te ~tion is place<l. ~ong the iong
B.X~s .o f th.~ feW b9dy lh"'ld pressure..is pla~ Gn
the funtlUs. HQOkingthe fingers in the~ or
(>blique trac:tion w~ bending fif the ~eck shou).d
be awi<Jed to preveh t brachial nerte plexus
irrjuties-:
Summaty o~tbe..Secon:d--Stag~ of~Lal>or .
As the l;x>d.Y .is-~eU'veted, one hand remains to
support the. fetal head and another hand is slid 1. Once the cervix is !ully dilated, bnco~e the
~ong the fetal back in otder to .g rasp tht: f~t as mother to .bear down ~gether with 'the uterine
they a,ppea,r. 'Th~ fetus is he1d.. with the head contm,ctions. 'Cheek fetal heart tone after each
directed downwardts to promote drainage of bearing down (!ffort. Never turn yocir back on
secretions. .~er suctioning by usin.g the bulb a bulging perineum.
at this point if nnt done previously.) The 'inf~t is
held at or below the level of the introitus for 3 2. Asepsis and ~tisepsis with draping a.r:e done.
minutes. This ,.allows an additiona1 .30 ml of blood
transferred from. the mpthe...- to the.newbcm and, 3. Orice the fetal head reaches the perineum and
concomitantly, 50 mg of iron .w hich .prevents icon the scalp .is seen . with a diameter .or 2-3 em,
deficiency ane~ later on. Addition<U blo(xl may an episiotomy ls done, if the a ttendant' feels a
. be added. by QlUlqng the the cord towards the need to do SO. .
baby prior to cJ~ping. Clamps ~e placed in the
m..iddle of.the eord between the mother and lnfant, 4: . Whether or nor:an episiotomy w:as done, the
. penneum is supported with one h<0,lusing a
about 4-5 em from the fetal abdomen. The cord is
then cut between the two damp:s. U umbilical hand tof'el (Ritgen's maneuver) an~e other ..

cla,n1ps are to 1;>e p~acedt then one .d a.mp is placed hand tries. to keep the head flexed to .control
4-5 em from .the fn(ant's abr:\om,.en and another . delivery.cif the head. ~~~ .
.. . ~

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418 SECTlON 1V: CLINICAl APPROACH TO LABOR I DELIVERY.

5. Once the head is delivered, and nuchal cord

-is noted, s~ip the cord Dver the shoulders if
toose, or cut between 2 cl~lps if tight. Clear
the baby's nose and mouth with a bulb
syringe.

6. Await external rotation or assist by bririging

shoulders into anterior-posterior position.

7 .. Deliver -anter-ior shoulcfer l;iy gentle downward

traction followed by. upwa,.rd tractipn to" .deliver
the posterior shm.tlder. Slide one hand. afthe
back.of the .baby an~ :prepare to grasp ~tli. of
the:baby.'~ feet.fjn:rily: Newborns .are slippery.
Don't dtop.-t he baby.

8. Clamp cord -halfway Oetween mother-and .fetus,

milk .cqrd towards the baby ;;md damp 5 em Figll.re 26.9. Deliv~ry o(.the ptaeenta.
..
from
baby;s ';l-riibiljcus . .Cut between the
'--..

9 . ~:iQcy a1,1d wtap, tlie.iiew~i-n. tra .n.a:ttendapt.. to . Deih~ry of t.he :pi~ceP.~a.m'sua:Uy ha.ppen:s.
:itl}ectie~bo:rp.:l:s,;pms.ent;:hand-.ihe-baby.~to ;.her w:it.hin..:s:..-ao__-iilln.utes aftei--C.elivery.of" the fetus:
~"'-.fqf:furfu.~r:suctfonfug"aii'd'"'rrewborn~e;~_J ~ .: but:is,coJ1~dered.:'tol>!lo~m:a:P.mp~tc.i3{};;Iitin'U~ ..
. ... . after deliv~ry . lt is' not wis:e to"fiddle. witii the..
MANAGEMEN-T o'F ~tHE THtRn .::.s >tAGE OF u1:~$."-'uci:ore placntal s~~~!.5pn~: lnttrenCI!
L~oa .. . . ~t ..~s-,po~t .iil the:abselic:;.~of:ne~otr.ha-ge .t~ay.
l- . .. ,. . . .. . . . .. . .. .. ca1!se .prohle.ln.s.:_s:uch:. ~s ;l:t:e.m::ortllag~. :\lt~e.
. .'r'Wfter-:thettel&ervof .the :fetuS::tb.e"tabor.prooess-,.....;,m::v.er.sion.;._~ ; at..d....:;, ~lac~;::i.. taa~.- .;.,.en tf~pmen t :. .
has ~:aow~-e*-"tdcii~the~tll.iTd.--:-stiig~-.,"#htc.h;is'<ihe' .Complication:;; of;, pli:cent.a:I <tinsecti6n\may:.8lso.~be. .
delivery of the'pl.acenta,...:As the placentasej>a:rates cq~'sfdered s-hould ther.e he i:H(uulty in: the
from its a.ttacinn-ent, there are s igns that have to expulsion .of-the 'p lacenta. Vigorous IIi~, or
..ik.~t"9h~A~lf~t-: :Th~~-fu.chjct~: i"}.gush.ofblOOd oxytOCin ffifilsioi:i .. iscnrit :a:rsO"al_Iowe""d'"'toilasteti
.frorp. the va~;;t; 2) .Jengtj;:en.ir:g.:or th~~;r~. delivery. Ihrusion :of"oxytoGin _'ii(large-~auiit.s .
3) Calkin~s sign tear.liest sif9.:1)-change-in the shape may ca1;1::;e .the ce~ to damp down preventing
'o'f tpe \ltetus .fro.:m -dis~oi.d to glo}?ular a;~ it tp.e descent and explt;l:sion pf th~ placenta. V.'b.en
ci?-ntracts, :~~ A:')u.tet:u,s:ri.~e~ in th,e -a.lxion:tc:.n as the :plat:enta i~ h\'lpped; id:aXa.tiol_lof the ~ti:n1s
the placenta de sce~d.s. tq the lower uterine l;lsU<if!Y in tbe.fottn of general anesfuesiai~f:give.ri
~egmegt '.Or va;giha -.a:nd. di:~place,s ""the ul~rus .foilowed by ~ anua,l eX.tni:~tion .df the 'placenta.
uP.wards. Meu1ua1 :s eparaticn or the .placenta-.iS -achieved,.by.
pass'i&g a ~and between the plac~n:ta and uteiine
Q~gital exani~jJ.atiqn during _this time often waiL
shows&e placenta to be W'ithiri. fhe vaginal vault
an~l:;may :}I.e iided JO: t}?.e. in.troitus anq out\vaxd After. "th e placenta "is delive.r ed, inspect it Icir
. 1:>yaddi~o~ eXJ)ulsivft efforts, or .Qy gentle upward c<;> nipldenes's of the cotyle"dons and ior .u.'1~
an,~ .dciWt:l"ard tractio:a q n the cord. One hand is presence of aile umbilical veih and 'two umbilical
placed .on th e uterus C;Uld pressure. applied to the arteries.
b-ody . .the il.te.r us .is pushed cephalad with the
. ?-bdo)lli:nal 1ia,n4 unti~ .the plac~nta reac;:he!> the ~>;pe~tan~ m~nage.men.t of the third s_tage
introit:]l~. (FiguFe 26. 9) nnce the bulk of the involves allowing the pla.centa to d .e liver
p.lacenta"is outside Of the in:troit~s ,.-the whol"e sp~:mtaneously. 5 .Attive m anagement involves
placenta is'gqtsp.ei:l with.bbth hands -and pcilled arninistration of a.uterotob.ic .agent" (us !la1ly
gentiy while -twisting the p lacen-ta .a.llow.i ng oxytod.ri., an :e rgot :alkalo~d. :or pros"taglandin)
separation of the fetal membranes and hence before the placenta.is delivered. This is done with
comple.te expulsion of the placenta. early damping and cutting of th~ co<.d and with

Snanned 8y: C

controlled traction on the cord while placental
separation and d eli,very are awaited.
Sununary of the Third
1. Wait for signs of placeiltai separation.
2. Do controlled cord traction.
3. Deli>Ter placenta slowly rotating it a s it is
....pulled.
4. Inspect placenta for completeness. Massa,ge
fundus until eot}traction is felt.
5. Start oxytocin drip or give ergot deriva~ves.
(Do not give ergot derivatives if patient is
byp~nsive)
6: .JnspecUor laceratioits and hematoma. Repair
episiotomies
After the pl~centa is delivered, the lab(>r and
deliVerfperlodare ci>mplete. Palpate the patient's
. abdPJ:P~ to cOrifh-'m reduction in the size of the
utemsant!..:_'.it$ firtnness. Ongoing .b lood loss.'and a
soft;~ bogg.Y!'a terus suggest . uterine ..atony. If .:t he .
utc!lls'is:fu;m a'nd;h emorrhage continues, consider
the 'pae:m'"bility of eervical or vaginal lacerations.
Thoroughly~e the birtli'canal, incl~ding the
ceroxandtUlevagin~theperineum, a:nd the'dis4U
.rectu.m; iRepa:Ur episiotoniies .a nd lacerations. A
-di$te~d~ladder may .p:tedisp<>se to hemorrhage
~aking :th-e'Ute.rus not contract as expected.
Consider -d<>ing catheterization.
. The .~ of vagmal ~d perineal lacerations
'depeh<t~otiwe~crep.rtr<>itissU:~~dnvolved::
- -- ~ - - __ _ _ __ _ , _ _ _ _ _ . ._____ ,
1. i'l."'$1-'degree lacerations in,volve the fourchette,
perih~ ~kin, . and vaginalmucoS;a sparing the
underlying fascia and muscle.
2~ . Seconc:l-.d~gree lacerations involve the fas cia
and muscles .Qf the perineal body but not the
anal sphincter.
3 . Third-degree lacerations extend from the
vaginal muco.sa, p.e rineal skin and fascia Up
to the anal sphi ncter but not the rectal
mucosa.
4. Fourth~degree lacerations involve extension
up to the rectal mucosa.
.Episiotomy and subsequent repair has been
the mostoonunon surgical procedure in Obstetrics
for approxim~tely 80 years. However, a:s previously
dted'm the management the trrst stage of labor,
the current Practice Bulletin highlights clinical
. outcomes regarding the routine versus restricted
use of episiotocy. 9 (Ta ble 26.2)
CHAPTER 26:CONDUCl OF NORMAL LABOR AND DELIVERY ., 419
Table 26;2. Study highlights on clinical outcomel on the
use of episiotomy.
Study Highlights Americ~ College of Obstetrics and
Stag~ of Laber Gynecology: Practice Guidelines on the Use 'Qf f:;pisiotomy
Although the usc of episotOrnY appea.rs. to have fallen
slightly he tween 199.2 and 2003, it .i s still performed in .
:a pproximately 33% of a.Jl vaginal deliveries.
In either II).edian or.tn~ohiterru episiotomy, a 2,Jayere<!
closure can ill\prove 'postpartum pain e.nd healing
C9mplications vs a 3-layer closure. A minimally reactive
polyglycolic acid derivative suture is recommended to
reduce wound inflrunmatipn.
Common complitalions of epiSiotomy iri"duae bleeding
and iiUectio~ Fot S\lperliciaJ wound bre~down. the
or lacerations. authors recomm end conservative treatment with
perineal care. Hqwever, wound .~plications involving
the ~ sphincter or rectum ~ay require surgical
dosm~ . .
. Thete are P.9 evidcnce-l>;~.se<qndicati()ns f~ episi0t9my,
wh'ich has tt~d~tiollally oe.e n used . in
C:ase.$ .of
complicated shoulder dystocia or non-reB..ssurit;l'g fetal
he.~ rate I>atttm, orca:sea judged~~ pre5ep~a--~gh
risk'for spontari~us 1acer-~uon.:'l'be'uselof'i:pi$iotbmy ' .
.appe~'mostly based on anecdotal e-.r.id~n~.c\':: . .-..
Umiied v$ .liberal us~ of episioto~y ~(>i>earii '~:J>e
associ{lted wit.~ areduced risk forperir.eai ~
Median epi~otomy was the nio.s t sigri.ificant-riSk factor
for thitd~.or fourtb~egree le.ccilitichs~ m; on'Ci!atudy.
Episiotomy bas Il()t)>een d~tel~:i(l..~i:nP.D.:~~1-;.to
rc:dl.lcc the.tisk for Utinaty or anal.i.t)coi;J.tinericeiigeirltal
Jl1Qlapse o r pelvidlo<>r d~age.
... --
.. .~<>..~~ ~!!l..~Si!h.~ .a n _;pW,.c.!,b_i!J.Y.9.L g !'!im~r:i\c~e
. .
_ . : -- ~ -- ---- - - - - - - w
~eJ1~~~~:~~;~~;~r~~~-;}~~!:~
occurs at ~proxim.ately
the srune ti.Qle.
. There is little evidence .that epi~iotomy improV:es any .
fetal outcotiles, including ib use in common situatiqns,
!\~Ch . as. should~r dyst()cia . Research .bas not
conSistently demon,strated that episiotomy rectuce~ the
duration.o.f t11e ~~qd stage o( labor.
Overall .t he authors!o~d good and consistent scientific
evidence that the testric;ted use of episiotomy and
median episioto[!)y is ass~ted with higher re,tes of
anal sphinc~er and rectum 'injury vs mediolateral
episiotomy. They found liniited ot inconsistent evldence
that mediolatetal epiSiotomy may be.preferred to medial
episiotomy in some situations and that routine
episiotomy does {lOt protect against pelvic floor damage
leading. to. in~ntinence .
of . Should.vaginal and .P:rineallace~ti~s .r esult
or a repatr of an . eptstotomy neces s,~ry, the
following procedure is done: The incision: is closed
by layers using absorbable suture . .The vaginat
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 l-

420 .SECliON IV:_CllNICALAPPROACH TO lABOR I DELIVERY

m-ucosa is closed first using interlocking sut~res nop.-phannacologic ways of promoting IQyometrial
until the level of the hymenal ring. Itis important contractions because of ~e release of_ Oxytocin
to start the repair 1 ctn from the a~ Of the from the posterior pituitary gland. 11 It is important
:mucosal def~t so that. any re~eted b~ood vesseis to take note of the bladder, wbic;h when .filled,
Will be ligaud. The su~utaneous :and fascial may impede effective uterine contra:Ciions.
_}ayers are closed next with one or two _layers of Ut~rotonic agents like. oxytocin, ergot derivatives
interrupted sl.lture .Care is done not to leave a~y and prosta glandin ana logues may be uSed.
dead space which may be a pot-ential site for
h.eiJlato.lila fcx:.m atiou. Blee.diilg v.essd!i are O;,cytocin is commercially availabl~ 1 ml is
identified, and 1igated.tl th~ sphincter-muscles equal to lO USP \lnits with a .J,t-a.Jf-life of 3
h&ve been eutj it is i~p()rtant to identify the minutes, and h effect,iv-e as -a n infusion.
-l!).uScle bundle~ and coaptat-e their -eqge~ with Stan~ard _-practice is to a~d 20 units. (2ml} of
2 - 3 interr~pted $uturei to' prevent f-ecal oxytocin per liter o.f inftu~ate. Tbl$ solution is
incontinence .The s~. i$ '-C?losed using either administered after the delivery of the placenta
il'lternlpted or s\ibcu-t:ic:;l,ilar !Sutures. .at a ret.te of lOmL./lilin (-20QmU/miri).Jor _a few
minutes until the ut.erus -r etpains firmly
In.~oUtth~egr.ee lac~tio~s. ~tis itnpOTtl;lpt to contr-acted and blee ding .is controlled ~ The
ide!ltifY. ihe rectal .nu.c::oSsrl defect . fot: thi$ is !-nfusioh.~te is en--decreased to -1 ~o 2 rill/ min
repaired f i.tst before the -vagjna l mucosa. untiltA'ie mo_tber i$ stableand~c;ly-{or_~sfer)
lhlerril,P~ _$U:t\tte.$ ~~JJ 1 em. &,oove _the a fter whic-h the iniusio.n i~ . dis-cotiti-nuced.
a~e dojl~ until te>r th~ ~t 1~er \intil the Oxytqcin..is neve r .siven 'i n hltravcmo'i.Is ix?tus.
~~19-P.~n~n~~ J:Qllq~ed 'Qy. A.~?t'h..er layer. of This'causes tnm~ie:ut but mark~d :f~U in arterial .
.(:Qntfuuo\ts: -tuttu-es:: ~.:is:-W;>'tl~-:toJnvohr.e"'th~- - blc:l;~p.-:.es.sure, thil.t,:is ~ foUowed.;;..:lzy oan>. abmpt:.
fUll tb~beSs:.~f-:tb:e, 'muco.~ to:privent1X;-ssible.-. -incr-ease- in -e~r41ac ..o~t,-pu~.- - 'this ..could be
.fis~.fonn:atton. Repair of the vagi,nal:xnucosa is da:t1-gerQ:P$ to. wo~en- w}lo ill3.Y aJr.~:a_~Y- be
~eJi;~Cd- out. hypovo.lemie .:fr:i;l~ . hemQr~~g~ .,br. who had.
_ . .. . . catdia,_!Hse-ase that Unii~ -tardj:ac:outp:ut~
- .. 1~s;ptu:dent>;to:in~t,-,fhe --v~lW. wultrfor' ..:'- ._. . ,_... . . . . . ..... , . -.' . ,_.
an.y :retained- ~~nte$~~ $~, o.'b.1~g ,whi~h. .-. 'Oqtocin -may : aJ:~o- anti<lhtr.ese ca\,lsed by:
n)ay:hawbeeit nll$~ -D6ihg ~:TteW m!'l-Y reveal r-eabsorption of:wjiter. With)bighdoseoJt}'t9cih, it
..any ~hlr$. ha., :gPti~ t.hi:Ough ; epi'$1~ttlJ:;~,phy of is po~~il>le to pr<:>4'!4C:e ~t,t mto~~ij~n _if.:the
~--:~ ~u~:Sa:-l>t'.any.i$Chtor:eetat-tbickenin:g oX:)Ytdin: j$ .adtilinist eretflr.'-.Mg'e-v oluttre of
tlia:t maypof:!\Eto l)emi::t formation: elecffoty~-:::fi;e-e aq-ueous-a~--S1>im:iqnt T1fu:s.
if oxytocin i~ to be :a~b:riini~tcied in h igh doses fo;:-
lol.AlfAGltMENT DtiRING TilE ''FOURTH STAGE a '~nsiqeta:ble period .c;>f tiine,. its (:Qncentration
. -OF UBOR should _b e increa~d r-ather ~Ji increasing the -
rate of flow of a filore_.dilut~ .~luti~n. It should .
:t):ie hou_r- ~~di~t~ly follQwing d_elivery is .!Uso
. be infused
. . in either normalsalinc. .-t>r lactated
. ,. . .
_. cruCial and lias 'been ca.n~4.~ th~: -"foutth -stage" or Ringer -s olution.
ta.b:or. Even thol.\Sb ~c).dC's are admfuist~red,
,p ostpartum hemo_r tha,ge as the- result Of ~rgGnovirte, ergometrine or er.gost~trine, is an
postpa,rtum .h emorthage is .:tnor:e likely this time. alkalol.d that is obtained from .et:got, .~ fu_n gus tha t
T-hu:s., h is 'imper.ati-\re l)-l,it 't'he uterus a nd grows .o n rye and som~- other grains, and is
. P-erineum ate ~valu~ted :(reqliently: M aternal Vital synthesized from lysergic :acid. Methylergonovine
.signs are -in~>nltore4 immediately-after delivery and is a similar synthetic a lkaloid made.fromJysergic
every lS ,Jliinutes for the fir.:st hour. a cid. There is n o a ppreciable differ~nce between
ergonovine and methytergonovi.ne. Whether given
Mter the uterus ba~ :bep. emptied and the intramuscularly or ()'rally, they produce powerful
placenta has been delivered, hemosta sis is uterine contractions, exerting an effe~ that may
primarily - achieved 'by vasoconstriction at the . persist for h()urs~ Eyen :.a s little as 0,.-1 mg ..given
p lacental site p t:i)duced l)y -~ we:U-con-tra!:~ed. . intravenously or 0.25 'mg: giv_e n . or.ally- they may
, myotnetrj~m. - _G:e nt-le uterine :ma-s-s age- will- produce .tetanic ut~rlne contractions :tb~t develop
stimulate uterine-contractions. Te nore ' cit~d . tha t al~ost immed-iately whjch may .be su-stained with
breast ~d nippie stimulatio~ may
be, one of the little tendency t owa rd r elaxation. It is for: this

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 .. CHAPTER 26: CONDUCT OF NORMAL LABOR AND DELIVERY ., 421

.r eason that it is effective for the prevention and
control of postpartum hemorrhage, but may .be
deleterious for the ietus and mother prior to
delivery. The parenteral administration,
particularly the intravenous route sometimes
initiates transient but severe hypertension. Thus,
this is not 'given for these with known
hyp~rtensives or those who manifest with-elevated
blopd pressure post .Partum.
. .
Analogues of prostaglandin like miscprostol
have been recommended as utero toniCs. However,
oXytocin or oxytocin-ergot derivatives were found
to be more effective.

POINTS TO REMEMBER

Labor is a physiologic process .dUI:ing which the prooucts of conception are expelled outslde of the
uterus.

. True labor is marked by regular painful uterine contractions resulting in progressive cervical
~ffacP__rr,ent.and . dilatation.
There are three stages of tabor:
:;-... .~!St slage ... begins with regular uterine "contractions and"ends with fult""cervical dilatation.
secorid stage - full cf;lrvical dilatation to expulsion of the fetus
.:Thiid stage~ expulsion of the fetus to expulsion of the placenta
Abdominal examination on <;idmissicn allows one to assess .character of uterin~ contractions, feta'l~-?~ '
1>j~esenta6on, location offetal heart tones.

;:: Qjgital examination of he vagina establishes cervi~l changes: dilatation,..effatement,: corisistemey;.~., .: '. .
,and positi()ni rupture of the membranes, station, and, clinical pelvimetry. .,;..)_,,,:, , , _.,,e-,:;r;..;~;:- .
. . . ..
~ ~- '

Uterine contractions are assessed every 15 minutes: duration is expressed in seconds, interyal
reJ)9rted in minu~e~. and intensity is recorded asmild, moderate, or, strong . .

~etal~[f~!~ji~~~~J~tji h~~f..t @t~ _yg_a<ilbJ!i~ in r~J?1i9.n _tq ut~rlne ."contractions..are ..recorded .by
using the 'electronic fetal monitoring. A normal pattern is a baseline fetal heart rate of 11 0150 bpm
theitvaries by 6 to 25 beats with movement on contractions, that accelerates, and does. not deeelerate
during contractions.

The use of l<ibQradmission t~st {LAT),a .20-minute electronic fetal monitor strip done on admission,
has be.en recommended to be limited to high risk: pregnancy.

For low :isk pregnancy, fetai heart rate ~us't be evaluated by manual au~cuitation after each
contraction every 30 minutes during the first stage of labor and every 15 minutes during the second
stage.

Maternal vital signs is monitored hourly. Th!s includes blood pressure, puise rate, respiratory rate,
and temperature particularly if the membranes are ruptured.
Oral food and fluids are withheld during active labor and delivery to prevent aspiration of vomited
gastric contents. Intravenous fluids are given when the patient had nothing per orem for 6- 8 hours.

During th~ first stage of labbr, vaginai examination should be carried out at least once eve,ry 4
hours, and .after rupture of membranes. -:~

A partograph, a graphical record of cervical -dilatation .in ~entin:'eters a~ainst du~ati~n of_laq~f. in
hours, ~n l;>e usecf to assess he progress oflabor, and to Identify when 1~tervent1on ts n eces~ary.

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422 Sl!CTJON IV: CUNiCAL APPROACH TO tABOR I OEUVERY

Active management of the first stage of labor aims to optimize uterine contractions and shorten labor.
This includes strict criteria for admission to labor .and delivery, early arnniotomy, hour1y cervie;;ll
examinations, early diagnosis of inefficient uterine activity, and high dose of 'Qxytocin Infusion if uterine
activity is inefficient. - -

-The second -s tage of labor is the "pushing" or "bearing down" stage.

TheACOG has recommended that restricted use of .episiotomy is preferable to routine episiotomy.
Median episiotomy is associated with higher rates of anal sphincter or rect::il injurt versus mediolateral
episiotomy._

Conditions when an episiotomy may be needed jnclude: fetus .in -definite stress who warrants immediate
delivery, size of the baby, materna! medical conditions, cr maternal exhaustion. -
a nt at or below the_level of the _introitus for 3 minute's aUo~ an additional 30 _ml ~f blood
-Holding the ihf_
(and concomitantly 50 mg Iron) is transferred from the mother ihe -fetus. to
-Signs 'Of placental ~eparation include: gush of blood .frqm the vagina, lengthening of the :cord; change in
the shape of the uterus from. discoid to globular as it contracts; and -uterus -r ises io}o.the abdOmen.
Expeotant management .of lhe third stage of labor allows delivery of the placenta spo_ntaneoosly.
' ' ' ' . . .
Active management of the third stage involves administration of a uterotonie ~$Jent~fore -the :placenta -
. - is deUvered; .

-irrfourth:degree lacerations. :the r:ectal muco'sal.defect is repaired first before the v~ginal mucosa.
The ~r-immediately foliQWing :(;Jelivery is the fourthstageoi:l abor:and is.Cil,Jclcl~pq$tp3rtum nemonh~ge
is more likely this -time. -

6. ReveizL. Gaitan HG,-'G\terVo LG:;:~nemruuluiing!abour.

1. Cheng Y, et :;1. Howlcng .i s t_OQ }l)ng:_Does a _prolon~ged
aeeond s~e of b'll>Or in nqllipatous women affect
J:natemal arid n~nataloutcorneS?. Am J' -Obstet Gynecol
2004; 1-91(3);933~9.38 i(Me-c;l141e) _
2. Fraser:w o, etal. Errect-_o farly- 8:mrii9tomyon iherisk
of dy3tocia in nulliparou~ women. BMJ 2004; 328:
314.
3 . Roque R, Gonzalez R. ~allen MT. A:retrospective study
on the use oflabor admisi6n .test in low risk and high
risk pregnancies.-2005 .(unpuplish ed paper)
4. ACOG. American -College of Obstetricians and
Gynecologists Practice Bu-ll.etin. Dystoc ia and
- ~ugmentation o{ lllbor. Clinical Management and -
G~delines No 49. Washington, DC.:Ametican College
of Obstetricians and Gynecologist!); Deceml-Jer 2003.
Coclu:ane.Da~9f$ys~f(~~vkw3--2007; Issue .
4. Art. NQ.: Cp000;3,3() .pOl: lO.i002/l4651858.
cD0003"3G.pub2 . .
7. World H _e alth OrgiUlization. M!Qlagement of
complications in Childbitth.Md-Delivery: 'A Guide for
D~tprs ~d Mi<lwwes. 2003~ -
8. Cunningha~ FG. G.ll;rit Nf. Lev.eno J<J, Williams
Otisu:trics:22....ed. New Yt>rk. NY:McCraw~Hill; 2005;
409441.
9. ACOG. American Colle_ge of Obstetricians and
GYJ:lecolo_gists Practice Bulletin. l::pisiotpmy. Clinical
Management and Quidelines No 71 Washi11gton,
DC: American C-ollege of Ob-stetricians and
Gynecoiogists; April -2006
10. Hartinann K, et !_11. Outcomes of routine epis iotomy: A
systematic review.JAMA 2Q05; 2.93 (17): 2141-21-48.

11. Tenore J. Methods for cervical ripening and ind.u ction

S. Ganesh D. Preventing prolonged l abor by using oflabor. Am Fam fhy~ 2003; 67 .(10). -
partograph. ThefutemetJGynecolObstet 2007; 7 (1).

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 27

INTRAPARTUM ASSESSMENT

....
VIRGILIO B. CASTRO, MD

Monitoring of labor in Uncomplicated Pregnancies

Electronic FetaiMonitor
Indications iorContinuous Monitorin~

Intrapartum Fetal Heart Rate Patterns

lnteiptetation
Recommendations :
Specific Features and Fetal Outcomes:'

.:.~eF.etal Scalp Sampling

lndlcatJ(ms/Contraindications
Compiication s
Technlqve
Values ..and :Interpretation

Fetal Pulse Oximetry

Cord Blocd Gas Analysis

Technique
Acid Base Values

Meconium Duling labor

Amnioinfusion
lndlcations/Contraindications
Complications
Technique
Review of Literature

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 ..... .:.: .

SECTION IV: CLINICAL APPROA~H TO LABOR I DELIVERY

~TRODUCTION 3.) Presence of intrapartum risk. facto.rs

(Grade A)
. Intrapartum assess ro'ent of fetal condition is
. essential' to prevent or decrease the incidence of II. Use of Continuous Electronic Fetai Monitor
'.fetal/neonatal morbidity and mortality. This can
. be accomplished w ith the use of the differen t A. Indications ( Level II-A Evideqce)
,~'procedures such as the electronic fetal
.monitor, fetal blood samplillg using the fetal scalp 1. Matemal Cond itionsjRisk Factci:-s
.pH and the unibilical c<:>rd blOod to determine acid. ,
. ' . . - . . Hypertension/ Preeclampsia
,. .
. ,base.. . statu~.
. .. . Diabetes
. It is recoilp:ilended PY the,~e_o- that.all wqmen Ante~ Hemorrhage.
.- : 'in labor s'h.~rua have .an. electnm.iC fetai' monitor.. Cardiova~cular Disease
... N~J';F:M ~~g~ h~ve.~--.~&h. prcillcttve ~alue, ~vere A.nen.iia .
whiclJ. means tl~at .the fetus, at the time or Hyperthyroidis m
m:onitoririg, is not . co!ll-promised when it has a
Renal Disease
.. nonn:al baseline. rate, variability. presence of
- ... ~lhriJ.tions and absence. of any .decelenitions.
ff:;;>H:~~-;;:~;. clinita.l tri~s ~dicatt that t}:le EFM 2. Fetal <\X>nditic;~ms
E?;~~ -tta<*-:igs with z?:on~teass.uringpattems nave a high . Ihtrauterini -Grow;th R eslii ctio:h :
tg,;~-~f~a.~.p~>s~tive !"ate, leadir1g to an- increased Abhoim.alUmbiliCal Artery
...y:'r'fucidence of operative ddliveries.
-D oppler. VdQcimet;ry
~!r . . :':.k~: . .... ~ . . . :. ~

:.~. :~7;!;..:r:..DUring the intrapa_rt-J'm._period,"womeu who an;: ,. Posttenn

. ' Pregnanr;:y
.
,.:: ;:.~:~n~ii:fei-ed 1ow :-.i~k ma:Y be mqnitored b y 0 iigohyQ.ra.r:tni,ios. .
~- :ii;.~!C:'r,mit}ent a'usc\l'lta..ti'ori. Go.mpa.:ris<m of . Pret:n:&turitY .
;: :~-i~-:~mea 'e.In:mg:\tjlese -v.:o-i:mm. showed,. that. the:re. . :: Meconium-'st:.ai.ned A:i:i:miolic Fluid.-' :' :.
;.. -:6;~.J:lo~:~igntiicant.differenca 'in the perinatal, ;o ~' ,.
I ~ .'
Intrauter...rle.:Infecfion .
: ~i;y ,bet.v;een.t hosemcrutored l;ly;:in tennittent' :
' ,_":~~.~.tJ.on v~rsus continuous ele,ctrbriic fetal . . Sfispkio~~ :Fim, <?~ .'1\uscultatio~. .
: : rii.Offil'Oifug. EF~;{ is recoinillended{or women with Breech Pr.esen~tion
. . . :~aver'&ri~J~t9i~" a.Ild ".fii:<>S.e\;;ith . ar)_no~al
...1- ......__,;- - - .... _ _ _ ..__ _ ___ - .

1-.~lliti-P.l~ .f>r~gq_@_gy I
.. a~~lte.?on fmdihgs. Isoi..mmunization
L Monitcring in Uncomplicated Pregnancy .
3. Others
rn e.n otherwise uncomplicated pregpancy,. Trial :o f Vaginal Birth -after Cesarean: ' :
. 'intermittent auscultation is recommended . Settio~ . .
. . during labor to monitor fetal wellbeing. (Graae !
. .
... .A) Prolonged Rlfptur.e .of Membranes
Induced ot A).lfP)iented LabOr .
puring i:he active stage of labor, intermittent Hypertonic' Uterine Contractions
. auscultation !?):lould be done after a contraction Vagir.al Bleeding During Labor
&t least r:.very 15 minutes in t.he first stage
.~. :~ct every 5 minutes during the second stage Practice Recommendations:
: .{G'rade A)
.;,
Continuous electropic feta l monitoring is
-ContinUO\J.S electronic fet a l moni toring is re~ommended for high-risk pregnancies at~risk
., : recommended in uncomplicated pregnancies of developing perinatal death, cerebra.,l.pals)r
41 the presence of the following: or neonatal encephalopathy. (Grade B) ... . ..
.
. ' .
1.) Baseline FHR of < 110 bpm or >160 bpm Continuous. electronic fetal monitorin.g.' is .
on auscultation retomt:hended in l~bor induced or augmented .. ,.,
2~:) Presence of any deceleration~ with oxytocin. (Grade B)
. ' . . .. .

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 CHAPTER 27: INTRAPARTUM ASSESSMENT
B. Intrapartum Feta!. Heart Rate Patterns
1. Baseline FHR
a. Normal: between 110-160 bpm
..... ;
b. :Fetal Bradyeardia: <110 bpm, lasting for a
minitnu.m of 10 minutes
A rate between 100- 109 bpm in the absence of
other ~hanges, may not represent fetal
compromise.
A loW normal baseline m ay be due to head
compression from an occiput p.osterior or
transverse position, especially during the second
stage ~f la bor. Causes of bradycardia are:
1) Hypoxia and. acid.o sis, 2) Complete Heart
Block. 3) Drugs (Beta adrenergic blockers) and,
4} Hypothermi~.
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425
Fetal hypoxia will stimulate chemoreceptors,
stimulating vagal activity, causing FHR
deceleration. With prolonged hypoxic insult, the
fetus may not be able to ccmpensate resulting to
myocardial depression~ ~videnta$.!eW b.ra~tyCaidia
en the electronic fetal monitor.
c. Fet:.1 Tachycardia; >160bpm. ~g.fur a
minim\Ull o f -IO,mi.nutes
..... . . ~ ..:
: The . ~~ :or -ta(:h_ycar.<,ija :,Ptpe.\a;~:D.ee
... cfpe!iodic e)mngesmay not~ignifyh~~u,~~~
The .most q:,minon cause j.s maternal~~~ff.Oin
choiioalnnjonitis.. o~ Non-HypOOr;ie.~u~:are
. beta . mi~y::~it; . <!w.g~ (e.g/r~rb1i~ljne),
par~Y.m~.lli~tic...:blo.ckef~t.(e.g...Ahopi.QeJ.:.and.
~~b)~as.~:. -..... .. .
w.... ~ - -- : ..
2. Fetal Heart .Ra~ Variabil,ity .
a. Mbd~tate ~'bffily (amplitude r.mge
9--25 bpm)
~
426 sECT10N '!v: -CliNICAL APPROACH ~0 LABOR /-DELIVERY

b. 'Minirp.al Vi:lriability (amplitude range ;:. 5 Sinusoidal Patt-ern

bpm)

.A true si.n~S<>idal' pattern :i s .Qb$eJired':in :severe

fetal~ ai)e:n:ia:,.fu~~offeto~IIl:~~riu1i heillbttl;i~c~
Rhmimmul'liZ;atio,t), rnptun;d:~sa:prey;..a, :or 1;Wln~
.:l, .... . ... . . .
to-twin tran.sfu:s!oU. :Pseudositiirsoidal ---p~~em~
.
~-- . . . ~ ; ,, ... ' . . .
mav be obserVed m cases of drug a:d.minlstration
. . :q .,A'Q$enhY.~~~~--(atnp1i~deiBmge:;:...::; . .. . (M~.Pericli#~. --~tj.t6tPlic0ol, : or -:M~-r.p~-i~} :
u:n~~-..
t'e_te:ble) '
.. .

':". : .. ...... .
~-

. ..
3~ Deeelmtions
: .Eiriy o c deration
.a:.\.: -~ ... : .. . .

Causes of Redl.).q:d or Absent Varia bility:

1. Hypoxia .
. 2 .. Non.,Hypo~e .C auses:
a.) .A_nen~phaly
b.) Drugs (Morphine, Meperidine; Diazepam, Significance:
MgSO~) .
c.}. PremlttUiity 'Not-t\SSOciated \vi.th fetal hypoxia, acidemia or
d ;L Fetal ~le'ep .sta~e .low .Apgar score .
e.) Va:gaLbio,ckade May be pathologic if acGompanied by lqss or
f.) Defe~tive ..cardiac conduction ~ystem variahilit)r.

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 CHAPTER '27: INTRAPARTUM ASSESSMENT . ' 427

... .., b.) Late Decelen;~.tion 2 . Moderate - FHR < 80'' bpm regatclless of
duration
3. Severe - FHR < 70 bpm, > 60 seconds
duration

Pathophysiology

. With mild c;:crd cofnpre~sion (umb!.lical vein

only), there .i s decreased blood flow going back to
the heart, preloa d is decreased, causing a
compensatory reflex tachycardia. Further
compression of the-umbilical arteries, in~reased
peripheral resistance/hypertension sensed by the
baroreceptors will increase vagal stinullation,
resulting to fetal heart rate deceleration.

Persistent umbilical cord compression will

decrease p02, s timU.lS.jln,g thechemo~ptcrs and
sUs~ed 'Va-gal activity Will cause a,dday in
T:h.e etiology of late decelerations i s : the. :rehilii
~ . -~fthe.FHRto
. . . . . . b~seune
. .
ute~p@cental insufficiency. With ac\ite hypoxic
msUl4 such as a decrease in uterlrie blood flow, . F.eatures of a pure vanab1edele~~n -ar~ .the
ch~~o~_e_ptors .sense _the decrease moxygen follo~g: . _ . . ' ,-:,:: :-.::.::~ .;.::-.
tension, stimulating Vagtl.S nerve, causing FHR .... - ..
deceleration. -Roccurs late because the circulation a.}. 'Wtial; .a~leratiori phase
~e.fro~,placenta1 ~ite to the chemoreceptors, and .. , b;)': dec?.lerati~-~Ph.~
the;:-aecre:a se in oxygen ten$ion .must attain a ' c.f Jate)1ceet~rati~n phase . --'::'-:--:,.;
c erta_in .,,t}:lreshold before vagal activity is
s~u~ti~a. . Fea~ <>f ~typical ~Ole <iecele~~~,~~'~\c'; .
Causes ~.)_ bo-~~ pf ; ~49tt19:~rin$. ; . ... -- .
.. Pia~~-- pathology
h.). Pe~lsten~ i$l'o~ersh()Ot
-c-:r~sn>w-:recov.ery to~n:-aSeffii-e-
..... "{L) ~LQss-of vii;.abllity -'~~--- . --
uecrea:sM--utenne blood -flo~
Supine hypotension 'e.)'- Biphasic qtcel~r.ation
Decrease<\ uterine artery perfusion
Uterine hypertonus These may be.indicatlve of hlability of the fetus
.. H~morrhage to cope up with hypoxic s tress.
Abruptio placenta
Matemal diseases:
Chronic hyperten sion (PIH)
Diabetes mellitus
Collagen diseases
Postmaturity

C. Variable Decelera tion s

Etiology: Cord Compression
Nuchru cord
Cord prolapse

Classification:
L Mild- duration < 30 seconds, regardless of-FHR
level, or FHR of 70 - 80 bpm, r egardless of
duration

Scanned By: ~
.4:28 SECTJON.JV: CLINICAL APPROACH TO LABOR t 'DEUVERY

Variable Deceleration showing a delayed return

to baseline and loss of shouldering.

"PROLONGED DECELERATION

Causes:

. L) Co -compressio:n
Z:} Progress"bp. of .sev~re variable deceleration
3.) OcciJt cord -pro~pse .
4.) .Profound uteroplacental in,suffici~ncy
- 5 .} Pafficervi<!l anesthesia
.6.) Abt:uptio pla~nta
1,) .-Ma~en:l;B-1-.h_yppxiB: .
seiZu~sJre$piraiory depressionjMgSO

interpretation Cf .Elcd:ri>ni~ Fetal Monitor

Ca:z:diotocp_gtaph s~tting.s should be

stan~ tP the Jo~Q~!f-

.,~90~-
-- . - . . .. .
~~-~-~-
-
-~ :
~-.
. .
:= -_ca.tewrr.
0 - - -

JJ1 '!omJca~s.fN.l tilt o the .rea.S.ruring .

category
SuspicioQ:j
. -. On_c of the~four fee.tures-Liill ~dC! .the
:nQ!l..-~.ca~egor:y.and.the ..
.J!g.. Ali~~g.' . . . .
.Lc..!fU!ln
Pathblogical 2 ori:~!:t~::&der the.non-
or .
on c :or I%lO~ fall under the abnormal
~t(gory

CategoriUltii:m ofJctal beart rate:.fcatuz:es,o~ CTQ .

.- . - . .. _ .. -
~ . ..
~ -. . .... . .,
'

V~bmty.(bp~n} _ Decelerations Accelerations

Reassuring 110-160 -~ 5 < 25 absent present

Non-reassuring 100--109 <~fo re~ 40 'min 1. E arly The-abs ence of acceleration:: wid\ a
161-180 but< 90 min 2. Variable normal CTG pa ttem is of uncertain
3. "Single prolonged significance
decelcrntion

.<1 0 0 > 180. <5 for90

,. min l. Atypical variable
sinuscii_dal:pattem 2. La(c
~10min 3. Single prolon ged
deceleration> 3 min

Saanned &y: ~
 .CHAPTER.27: INTRAPARTUM ASSESSMENT '429

The impact of individual Fetal heart rate 5. Late Deceleration

patterns on perinatal outcome may vary. In
practice, .E lectronic fetal monitoring is analyzed as A ~ystematlc review showed an association
a whole and not merely onits individual features. between pres~hce of !ate decelerations with
Overall assessment must be ~e with i!ll;x>rtant reduced Apgar Scores .a nd metabolic acidosis (Level
considerations. given tO the clinical .factors . and II-A) .
stage of labor. For it to be effective, EFM must be
performed correctly and reaults should be Occurrence of multiple late decelemtions was
.interpreted satisfactorily, and appropriate decision associated wit:h an increase in Odd.s ratio of
should be made. cerebrol palsy (OR 3.9;_95%.CI 1 .7-9;3).

D. Specific fetal heart n\te :features and outcomes: The risk was further increased wheh the late
decelerations were accompanied by reduced
l~ ::BMcline Fetal Heart&ere. ' be.&cline ~bi!ity (OR 3.6; 9.5% CJ1.9-6.1). These
were predictive . of subsequen-t abnormal
UncoD:t'plicated Qradycardia (90.119 bp:n) and neurolQgical outcome$. .(Letiet -U.,A)
. Tachycardia (.160119 bpm)t ~cluding .infective
co:tnplica~ion-s and presence of otber F~R 6. Variable Deceleration
. abnonnalities, hiui-,a poor predictive value foi'
neQl1htal acidoSis (ir.AdVerse 'neonatal outcome. Uncoro,plicated variab1~ decelerations ~ete n,ot
.{Level n-Al. - a$sociated withJX)Or. Apgar sco,resof. :n~4ibolic
....
acidosis. H'ow!!'!ter. atypical variable:deceli~pons

2 ..._~;:l~~. nne vbili
~ . . ty were aesociat~d . with.. poor ad.yerse Q.e.'Q,natal
outcopre. {ievetIi-A) . ... .. :. : :: / :kt: ;, .
Rf!duced basline .valja'bllity is encountered .
.d,~~:Ietal.quiescent :st&te, whiCh ::w.r iast up to
.
. ..The ,roUo~ .a..re.atj:p~cal feaWres As~~~
. .

.. -4 0 ~~~~o..:..:.-:durln
.~wu;D IY1~>"-nr lln(litl
. c;o-v-t . . a - 8Ih~lll~"'"'"e
. .r---"""6
.1-this :reducW.Wria'bllity JMY :b e .e xtended up to 9'0 With Variable 'd~lere,tiP.n; . . . ,:':_:,; . : .,i~:::~;~ .
niliiutes.. (Level J:-A). , J,.9:s8, .-of primacy ot. secoridary~~-fj~'~ ' in
- - ~era~
.In one case :control ~tudy J:>y Nel~n et al., . siow:return to ba:selihe
(n:-c95}a correhiti.Qn.~ ~tioo:t beat-to-beat Prolonged ..fucrease ~n secOndary .rise .jn
vanamJif'if"~~orar.parsy.~~ffounO.'Tiierewas baseline rate-- ... -
a ma~tfaln-crea$e"'m"oodi-~f~btaf pais,y:s-een Biphasic deceteriltion .
in decreased Qa.selin~variability (OR 2.7, 95% CI
Loss .of variability .d uring the deceleration
1.15.~) (Levet .U ...A)
Change in the baseline FHR pattern
3 . Acceleration
7. ProlQnged Decdera~on .

Pre$ence ofaccelemtionsw as a gOod indi~tor

of pc;rinatal o1,1tcome~ More tlui.n ~ aCcelerations Its presence is assOciated -with poor neon.S.tal
in a .2 9 minute .n:1onitodng bad a 97% for a.'1 Apgar outcQme. Systematic reviews showed a correlation
Score o!->7 in 5 .minutes~ (Level II-A) .v .ith significantly lower .rnean arterial pH values
,. compared. with.controls .(pH 7 .06 0.07 E1d 7.09
The amplitude ofacceleratipn may be less than 0 .06 -c ompared with '7.24' 0.06). (L<;:vel ll-A)
15 bpm above the ba~line as well as its incidence
in a fetus of~ 32 weeks gestation. 8 . Sinusoidal .P attern

. 4. Early Deceleration Sinusoidal pattern is observed in cases of fetal

anemia. In cases , where this is enqo:U ntered,
Presence of earlv .decelerations is not {etomaternal hemorrhage must be excl!:!ded. Its
Msociated. with poor Apgar Scores or metabOlic presence is assoc~ated with poor neonauftoutcome
acidosis. (Level II~A). (Level 1~-A)

Scanned 8y: ~
 4;30 SECTION IV:. CLINICAL APP.ROAGH TO 'LABOR f DELIVERY

'I\~

Qverall, there was a significant trend towards Ill. Fetal Scalp Sampling
neonatal acidosis (pH <7,2):and 5 minute Apgar
Score of < 7 'in ca~s :with abnonnalFHR p~ttems. Several techniques ma,y be :used to evaluate
Omfuol\s p<!.tlerns were associated ~Pl increased the fetits 'during labor including direct 'analy~is of
'incidence of :neurol~gical morbidity {neo.natal fetal: plood::o bt.&1n.ed. from via: scalp sampli."l.g~ -1twas
. encephalopathy) (OR '2.9; 9:S!}{CI 1.07- 7.77:) first introduced -b y Erich Saling of Berlin in the
early 1960s, .a:pd has been .. used by many as a
. . . A non."reass.u rin:g ..FHR . pattern requites Sec<>nd test to highlight those 'fetuses truly in' need
~valuation of the.possible cause~ and ~e folio "<Wing . uf delivery or in utero .J.7e.s uscitation.
st~ps shoUld bt eroplqyed: : . . .
The' procedure.is perfoq:ned only in select:cases
. L) DisConti.n11e .?~~. dJ:ip. .. of deliveries in which the . fetal heart 'rate .fr.acL"1g
.2 .). ~oryn l!.n:~~ .exam.inati<?):l to as.~ss...tlie or other conditions raiSe s'ome concern regarding
: .P98-Sib.ility onl.(Gb.ilicial cord proJapse. or rapid fetal $tatus.-but not enough;f u mandate ~ediate
Cervical dilatation or fetal head descent delivery. Examples of these are 1) combined
3.) Change ~t~al_Po~iti~n to the left ~r ri~t , patterns of vmabie :and late. decelerations with
Iatcrar decuhitous position to reduce caval decreaSed ~variability, 2) variabilit-; of.lessthari.. 5
compression. thus improving uteroph1;ceni:al bpfu with/Witho:U.t per-i.o dic. 'Chariges; 3) Ietal
pe~s~~m. .~c~a.:~, in:!X~d deceleration pat tems
. .... ;4.) :M<?nitor:mat~~ Vital signs, .e~pecially. blood with. equi~OC<il interpr.etatio~s. Ob.ta.i.n:ing a FSs
. ..p-ressure, f9r :f!V'iden'ce of.h.Y~:!nsion. shan
gtiide one m the true ~cid baSe status of. the
.. ~~r ch@!: f9r .4ti:fine 'l~y_pdtoni.l.s. fetus in ~~es w here a bnonmil fe.i:al he&.rt .r ate
. . .pattem's:,are enc~mn te.re4'.Ciilri_Tig71ab<;>r:-ThiS. will
.A prsiittnt:no.ti;.reass~g..W:ttei'Il. :with. t!:le~ .. :decrease: o~:ratfv.t ddiv.ery : iil cases c.f f alsely
.a:bsen.ce .C>f. 8P9n~eq:us a'eel~ra~ion :may be ' .P<>sitiy,e fetal'hea...rt ra.te-ctiekrati<?Iis': H6weyer, :in .
~nolhitei-e<i)..~g .'the t~ :.quisc,ent .~t;ate, - cases}~/})~:~v.Mdraqngs'. ,refl~ significant; fetal
:SeY.~iiTI:~~~~ :I:fuiy;:~ ~tiliie.d 'to~ s:ti.in,u1ate d~mpej},~onreq\jiring:hn:media_te dfllvezy~ :.FSS.
.C he 'reni.s .e.ii'd: exclude>.acid6s1s :ii'S'~ihe"cause;: .: ;is not recommended:. . . . . ' ' .. .
~'n.C:C ofacceieratldns~after.sfunufution:mdicat.e :: .. .
'a.goO<ra:o~i:00.~ 3s~ffi~w:dfi.iir.tV.ro~af~~~mtiionly. . . Theprin:~i,ple in obta:irii.ngfeta.l ScWp pij-is iliat
Utilized beCause tliey are:lOIP-traUmatic. dwmg .j~.erfo,d~ .pf .lij.po.,-..the fetUs W;ll.l,'use
...... ~ .......-..::..... ::: .. :..::.; ......... . . . . and'erB~ic met:aOOJic>p~~ys:, :lnusiilcr~smg
l.) Vibroa~us~--stimulat:l6n lactar~-1:eV.er~:-vtnrre--::p'll"rnaY...-b'e.. ltaiisientiy
2 -.) . Digital sCaJ,p stimulation . a:,bp.or.m~l.. seco.ndary to ca:rbQn. di oxide
.3.) Allis '~P ~tiiD\llanop. ac'cu~uta,tion as;0C!at~awit.h respiratory,~dosis,
4~); F~tal ~p !sainpJ.irig : _: . lactate accu.~u;Iate~ only int:hi .more iinpor+..ant
setting of metabolic aciqosis.
When .a. nop~rea.ssuring .pattern per?ists afte.r
s.t:jmulation, on~ ~Y:Prieed to doijig feW .scaip If the :PH in this sample 'is .greater than 7:26,:
pH or Jact~te lev~ls~ However, thil> proc<!du.re is . lab?t--is !lll:owed tocontipue with resampling,.should
.hot c:Ommon:)y perfqrmedih our settirl~. the tra~g deteriorate f}.i~er:'Dhose fetu.5es V.ith
pH <T:2o. are :delivered, as :~n aa possible .either
A'scalp.pH:of <'7'.'2-1 to p~~dict t:.nil5iliC:al :~ery . oy cesarean or 'O~.I:a.tive ':'agirial <;ielivei'y. Fetuse s
pRof'<. 7.:h.3.s ,a: .s~ns!Bvi.ty of 36% :and. a pos.i tive with intermediate p H values are .followed cloiel.Y
p redictive value of 9%. Th e sensitiv:ity .and anq r~sample4. in 2.0 to 30 min).ltes if..the .FH.R
pQsitive pr~dictive value o'f a low s c a lp pH .tr~cing does not spontaneqtlsly improv:e or
(<7 .21} to a newbcfU with hypoxemic-ischemic det~riorate to th,e point CO\t Which tnencedJor u.z:gent
ep:cephal<;'PathY is 50% and .3%, respecti~ely. delivery is obvious .

..Fetal pulse ,o~et:rY: has .a n uncertain:bnefit
.bequse.it ..may r~fle~t a falsely reoassurL'1g- status
of o?C)"genation'. Fu~er'resi!,arch -i,s needed be fore
iLcan be recciminended for clinical practice.
A correlation between scalp blood pH and
.newborn out~om!!sw;ls done: The.Apgai score at.
2 minutes is
.n~lated:.to :>calP blo9d..pH .co'tlected
shortry before delivery .. In thls.investigation, a ~lood

Seanned By: C
 CHAPTER 21: INtRAPARTUM ASSE:SS~~NT
pH greater th~ 7 .2S was associated with a 2-
minute Apgar ct greater than 7 in 92% of infants.
A pH of less than 7 .1'5 was associated with a score
of' less than 6 in 80% of cases. Although. blood
specimens may be .safely ol;>_tained from the fetal
scalp during labor, the need for- such sampling has
been dramatically reduced in recent years by t;Jle
use ofother .n on..invasive tests such as fetal sealp
~timulation or Vibroacous* stimulation.
The drawbaCk to thia
procedure is that it is
invasive and traumatic to the fetus. Results may
~ irl8.ccurate once the sample is contaminated by
.amniotic flujd.. -or if the fetus has caput
succedaneum.
A.. Cc)ntraindleatlon to FSS
E\"idence c>f ~ere fetal or maternal .distress
. {~g, prolonzed arici ~ustained bt1ldy~dia or
\,profu_$ e hemorrhage) is ,a n indication for
iin.l.nlediate dethre:ry; delivery which should not
..~i,J>e .d~layed hy statp sruuplmg.
COrtcein for verticat t:ransm:ission of maternal
mfectit>n (eg;.inV, hepatitis. c, active .herpes)
-h:.orfqr~(etitl blteding-di$o.r ders (eg, hemophilia).
~}Miiliri:ihl cetViciU dilatation :or extessive fetal
. /';.~~P~t~~edema) m~:ty limit orie~$. ability to
.:succeS$ftilly obtain a scalp Sample butare not
in and of themselves c6ntraindications to
attempting sampling.
B . .Posalhie-Complications-of FSS'
Hernorthe.~c or 'infection compliCations
. The inCidence ofscalp infections has been Cited
at <1% .
.Numerous samples (eg, greater than 5 to tO)
can result 1n soft tissue trauma to the fetus.
Use o f a vacuum extractor fot delivery is not
contramditated after FSS, but one s hould b e
wary or' its use in the fetus who h a s already
.haq scrveral samplings.
The complications of FSS are quantita tively
minor and are of less importance than i s t.\-}e
potentially irreversible problem of a sphyXial
brain injury or maternal morbidity ofcesarean
delivery, bot h of which , FSS is designed to
minimiZe.
Scanned 8y:
' 431
C. -Technique
Through a dilated cervix, blood specim~n i~
obtained from the fetal scalp.Access to the fetus
is facilitated by melllls of a cone-shaped endoscope
\vith a light sour:ce, placed through the vagina
ag~~t the ietus. It aiso permits cleansing of. the
sampling site, .remotf.ng amniotic fluid and bl90<1.
Fetal blood is .s ampled by stabbing the. fetal
scalp with a small blade .(2m,m). The blood is
collectedin a 20 em heparinized capillary glass.
-It i~ r~ommended to obtain FSS just before
the next expected contractio~, because it l:>est
reflects the baselliie state of the fetus .
D . Fetal Blood S!lmplt Values .and
Interpretatlop
Fetall)lbOd
Sam_ple Result (pH)
~7.25. R~ f'<'.,s jf FHR continue$
. :-
ti>.'~ ..
... . ~}: ):~.
7.217.24 Repeat~ within 3,0;IJtins,., "!~. ~T .
ConSi.d er dellvelyofW;..th ~griffi~t
chan~efrQm he laSt F$S ~pl: '.
ln:!.iate dcliv.e y:< . ,. '">;~;,.:>- :.' :~. -
.AU s.c~p !'H val~e~ _sl;lould be inteipr~~e~. ~:;.into
conSideration tliei1IUtial:pH, stl!ge or progressoflabor and
. concomitant~~~ fetal cog.ditiws.
Fi nn scarp-salil.pre ~pu ca:n :_provide . the
obstetrician an accurate assessm~nt' o'f
intrapartum acid-l;lase ~tatus. However, with .the
development .-of other ancillary. tests and ~ensive
s~dies on electronicJetalheartrate lnterpietation,
its practicality, the needed skills and equipment
and co.s ts limit its use .i n our setti,ng.
FETAL :PULSE OXIMI:ITRY.
The u se of fetal pulse o.ximet.ry during la bor
may give a reflection of the oxygenation status of
the (etus. This procedure is less invasive and le s s
traumatic, In patients with non reassuring fetal
status on CTG, this. technique may be employed.
Once the atnhiotic membranes are ruptured, the
scalp electr.qdes are attached to the fetu~$nd the
monitor will display the oxygen saturatiph of the
~etus (f S02) an~ fetal pulse. Uterine. col1traction
1s also recorded Jil the CTG. .' .
r-..
~
 432 SECTION N: CLINICAL.APPROACH TO .LAB.OR 1 D~UVERY

A systematic review was done by the Cochrane MECONJ:lJ14 DURmG LABOR

Database 'on 5 trials involving 7424 women "in
labor. The purpose.was to determine if the overall Meconillm.-passage in labor is not uncommon.
cesare~ Section rate was influenced by the It occms in 20 o/o of women in labor, with varied
addition.of fetal pUlse o:ximetty to CT.G v~rsus CTG cha.i'acter, light or thick..On:one hand, th.e.passage
alone. Results ~he.wed that 4 -out of the 5 trials of mecoriium lill!.Y be physiologic because -as the
.had no $ign'ifkant di.fferen~ in tlr~ overa]l CS :rate fetus matures, colonic.. matur.a:tion promotes. in
between th~ two groups. They concluded that utero.passage of:!ne:conium. The p:r.e sence ~f t.hick
t~cre is ~ted ~ta to sUppbft the use df 'fetal meconium is :mo.re. <:cmmon in postdate
TYUlse:oximetry i n ili:e. pre sen~ of a non-reassuring .Pr~gnancies. On the other hand, it may he
Jetai:heart tate pattern on cto.. Further testing is pathoi~gic as a result of'hyjxlxia, by stimulating
stili tequ1red before it :ca.Il be recoinmended for v~sqp:res~in s~tion in the posterior pituitaiy
cli..~cSi practice. . . gland, fullS promcting mecbnium p~tss.age . .
U.i:nbilical ccrd ocel~sion, as.~ociated with j
.c ctm
BLOOp COLLECTION FOR ACID-B:A:SE oligohydr.un:nios, may result in parasympathetic
ASSESSMENT stimulation ca'Using passage of mecon iu.m.
Mecoi'ium .aSpiratio~ dur4:tg labor may oocur asa.
.h.na).ysis cifcqrd..blqbd gas is 4one in con<:ijtioris re:ou).t of fetal g;;tsping .; which may be .caused:by
.s uch as
non~tta:sS'~Jetal heart rc:ite pa~s~ mild h~,xia 'to SVere .acidemia:. .
CGrd prolap~~ .low Ap~ seor.es (S m!nut~ a pgar.
of iess :ih?.ri 7':),. .ces~u::e~:. ae:tiorl.s for .fetal . Met<Jf~PE..as.P~ti.on syndr_o]D.e occurs ~ 7 to
:indkatl.or..s or pt~~nce of dsk .fa~toJ.rs that. Will .22% .of fctuse;s With:tbic.k.~dinium ,during birth,
. reault'~ .a: 'possi?le.':ad.ver~!etakoutiomew(e:.g. , ..~?: ~ ~ 5~4%~f~~~~~jf.~Yf.:~ed;~.tic
ant~pa:rtu~ ..hem()ctr;iY~:g~H.maternal...mediC.a-1. ... ~w~....~t ..~ _a ~.J:+afu:i mertalitytra.te .of 20"~ ..
;~~; lpG:R. .P.temaPlrl~. mec6Di1im'-stained . . ~~. J?a~P.:tiY~~ :f.qr. ~e ~~elqpment.:of W}3
'aitin>~~}fuidf./
...
. . .. .. 1~: ..r.~_late<} W Pi\~:?~~~~.~: ?b~tr.u,.c:tiqn of :tile.
~.rwar~ . ;clle~paL.~nJ:U.fY {9 ,lh.~ resp~ra.tory
.A. T6ch.rilque . epitheli~ '~~ ~~v~~~n. ~f. svnB:~~.t .~: th~
-mee<>~ ~,.J>'B.~ge .o f tl;leco11hi.m by itsclf iS .
~.. . ~ ~ . .....::r..1..: .r--....;...&.;.._ .
n....!~ to not "a"u.~ ~~. .;; A stti.d_y ~
: . ..... , .;. : . t

. :..-~'
t..e. proce
. _....~ : "_ ..dn
,........e . a
h ~K;._~..,..
-n.-;.,.,'7.-.A eyrm.ge
"'J
Ytiii &.. Ido, et al
is pi'ered. oncethe:ba:b fu -deli.Vere<:t .blood. : eval~tin.gth~:~h~s.~SSOGi:ated. with.M econium
tl.bubte~aarii-~.:
. t;"'U . s~en:r~6r-~~~~
""'t:r"'- LU
e:_:um
..... ::~ill;~,-~-
.. .
~ -~
CO lU l o:> J.;,J ......... : . . . - -camp
. .. in.ja.bbt
A.spitafioiLsynciro ' ' uct;.t&i:_liY
. . . . ..,..
..i5l:)ram.e<t-'i:'fiemi'Ol.JTiUllfamounf1if.15~reqUired meconiqm..{>ta!~tng,.~ con.~luded ..that-affected l
ls '0.3 .r ill. . 1t is preferred to obtn both a rter.a.l fetuses, during the intr8,f)artum p~rlod had
and venous 3iimples,, b~t u O"nly. .orie is pQSSl"bl~. d~lemf:W~ :fe.tal tacho/,dia, reduced beat to
the:ruter.il:i:l blOOd. is prefetted: because it.J;etieits beat ~arlabllity, r:educed pH in .cord blood ~d
the B.cl<l"oa~ dta:tus offetal b100d.retutriirig :t o the :poPr~r A.P&ar !>(:Ores in the. lst.and. 5th :mihute.
:PlB:Cerita;~~ s~eri is .s.ent.fora~d baie tests.. Thick meconium. by it~l{ is ,not. as~ted 'm.th
ad~rse fetal Q.Utco.me. Howey.e r, . the i:ticidenee of
ll~ 'COrd :Bl~()d Acid{.Be.n Y!lluea InC<CO~:am:>i@tiO.~ s)'P:dt6Jfie increa~ .in .cases..
of.a?on~r~Fh"Rpa;tt;e~: A ,s!;Ueywas d one
Non:n.el ~bilical cord blood pH e.nd.b loodgB..s values in term
by M~ydan:Uu an9, Dilb~, et aJ. on the risk .factors
n~boms_ for meco~ aspiratiqn syndrome in infants born
thro.q.gh ~Ck mec;onium. They conclud~ that
:V.a.lue Mean(+/-P Range. fetus es wit:b non'7reassurihg FHR tx:acings
Sumda,ni"Dcviati9n {0Rsl2.2, :95% c_Il and the presence. Gf meconium
bel ow .v ocal c.o rds (ORs 3.3. 4, 95% CI) are
Arteri81 Blood-pH 7 .27 (0,()99.) 7;2 - 7.34
pCQ: .(mmiI~ . 50.3 (11:1.) 39.2- 6 1.4 . as~~iated with an increased risk for MAS.
. . l. . . ""
HCOi;9m3qfLJ 22.0. (3;6) 18.4 - 25. 6
B~ ex<:ess (meq}q .~2.7 (2.8) -s..s.- o.t AMNIOINFUSION
.. .
.
V c;nous bW pH .. 7.34. (O,Q63) 7:28- 7.40
. 32.~ - 48:6
.. .. ...
pCb,.{in.mHgl . 40.7' (!:9)
BCO.i(1:n.eq]L) 21.4 {2"."5) 18.9 - 23.9 Am.nioin:fusion is defined as fluid fus'tillation.
-Base exc.ess (meq/L) . -2.4 (2) -4.4 " - 9.4 into the a mniotic ca vity thrcuglj a catheter;.

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 CHAPTER 27: . IN'rRAPARliJM ASSESSMENT 433

perform~ .t ranscervically during the intrapartum Fetal bradycardia or ta~hycardia

period.It is a method of intra,partwn. resuscitation Amniotic fluid embolism
that may be con~idered Jcr patients with variable
decelerations, oligohydramnios, or meconiu_m ., D. Key polnta in settmg up for an
stained .a mniotic. fluid . amnloinf'uslo~

Vari&.bl.e decelerati.on~ caused "by cord

A,fter asepsis and antis epsis, IV solution is
conneCted to theN tubing. To avoid introduction
compr:ssion. ~omplicates a pprorimately so% of
laho~s. . . Cord cpmpression . often occurs in
of air . in Utero, the tubing is flushed . . An
intrauterine pressure catheter is also inserted.
situations that' result in oligohydiamnios .s uch as
Intrauterine pre s sure tone is .assessed and
premature rupture of membranes, J>ostmauuity,
recorded.
and. uteroplacental insufficiency.: .By s.rtificlaily
increasing t)e v.Oluine: of amniotic .fluid,
.~iri(usion bettr proJects the umbilical cord
Sterile l~ctated Ringer's solution or normal
from ~mpres51on, thereby reducipg ihe .number ~e (0.9 NaCl) in iooo ml bag is reccnunen~ed
for the procedure.
e,nd severityof va$blc de~eleratioiis. .

Passage of meconium in utero may be An i~iti.ai 'b olus of 300-500 inl is infused.
pathologk: or ,phy.si~logic. ApproXitnately 12 to 20 Ulqasono:gtaphic ~timation of fluid volume :should
pen:ent9f {etu~ pas$ :.mecopium 'before birth. be a:
o cutnent~ after the initial bolus. "This. is
R~t s~<P~ sbC)w that this event alone illight . followed by an hourlymajp.tenance rate of 150-
180 nil. .
notOind.ica.te .fetal distress. However, .a thick
-meeoni~:;:may lead to :meconium aspiration
sjndtoiiiFwb,ich is associated with increased The patintis hook~d continu~~~1iJ.i;!.;~e
perinatalDlQrtalityaridmorbidity. Ithasatso been -ca.rdiotocodynamometer to document.;anJ;~id
p~~ that diluting m~ck, meconium-stained .
c hanges in fetal heart rate patterns as w~ii:: a.s
.fltild'reftuces~'the m.k;of m~cohium aspuatiort ilild . . Utexjne .tone. .C!hanges j n meco.r uum :con~istency
sho'uld al~ ~ as~ssed.. . .. .
~~~~:O~~tnplicavon~. . . . .-...:. :' .' ;. .>'f. . . : . \_

.Amnloinfusion has been proven to be safe and Uterine t esting tone should be a8Se~ and
effective. Nonetheless, it is usually perfo;rmed .in m~tained at a resting baselltle press'..u-6'' less of
c ritical sifiiatiotis, where the benefits of the th~ 25 ~ Hg . . Discontinue irifu:sion- pnor. to
. .deliv,ery..ox: iLu~rme .-. resting,:tone -is- > -25 mmHg
Pi-oced~~~~~t_he risks. . -does .-not-r.elax-m -between-contractions.
n. Contr'alild1cat1ons:
.E . R eview of Literature
P lacenta previa I ~ a Cochrane review , Hofmeyr .(199 6)
N~;>tt-J-eassuring:or Ominous fe tal heart rate exammed 2 RCT's comparing prophylactic versus
pattern therapeutic amniomfusion . Re sults showed no
Chopoamniortitis beneficial -eifect for administering amnioinfusion .
Fetal anomalies incompatible with life p rophylactically compared to withholding t h e
. FeW malpresenta tion procedure until fetal heart rate (FHR) decelerations
Impending d~livery or mecon ium-staining of the amniotic flu id
. Multipre gestation occurred.
Undia~osed third trimester bleeding
U.terlilc an<)I:nali~s Pierce, et a l. (2000) evaluated the effectiveness
. of intra p a rt um prophy la ctic amnioinfusion in
C. Possible complicat(ons pre gna ncies complicated by MSAF in a rne t a - i
analy~is. A total of 13 R crs were analyzed . A l
Polyhydramn ios
Cordprolapse
comblhed total of 1924 women were e nrolled in I
I
the trials. Pooled da t a showed a s ignificant
Abnormally h igh jntra uterine pressure d,ecrease in the incide n c e of MA$ with the
Abroptio placenta . . . / a,mnioinfusi.on gro~p(n=950) compared to controls 1
1
lrifection

I
(n=97"4). The inciden ce of fetal acidemia and

!
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 434 SECTiON IV: CUNICALAPPROACH TO lABOR I O'tUvERY

cesarean section rate were significantly lower in Fraser, et al. (2005) conducted a mult:kenter
the a.mnioinfusion group. . Rcr to determine whether am.nioinfusion reduces
the risk .pf perinatal death, moderate wt :aevere
In another me.t aanalysis . Hofmeyr (200.2} meconium aspiration, or both.- Electronic fetal
reviewed 12 RCTs to asse3s the effects ~f mol'litoring and neonatal resuscitation measures
am..'lioinfusion for MSAF on perinatal oUtcpmes. were avai}able in all participating centers..A total
Atnnioinfusion.was fou..'ld to be a$SQ:Ciated with a of 1998 women w.ere ran4onlly assigned to receive
.Teduction in hea\'}' M6.\F, variable ;fetal .h~ rate either amnioinftision or standard -care. The
deceleration and ()Verall cesar~ seetion ~te in composite o~tr.::omc ofpeti~.talde;;t.tb and/or MAS "
clinical Settings with .o r Without ele~tro~c .fetal pccurred ih 44 infants (4.5%) or ~en ill the
mmiitoring. The . author noted ~t t.~e ~uction amclOitt.ftlmaxu~rQup (n-995}and 35 infililur(3.5%)
:iri the incidenc:t of MAS after am:nioinfusion seen of.rwomen in the eohtrol grOup 1n.1003kAn equal
in the~st\i<Ues may .po.S.sibly be d\;le to a !-eduction number (me) ot perinatal deaths Occurred in each
in fetal distres~ re~te<i to o.lig-Ohyd.-arrmio~. It bM group. The ~ delivery. ~te 31.8% in we
not .been determined tt!hether amniolnfusiah the amniolnfus!on .g roup -~d :29":00A. tor controls.
improves the outcome -o f pregila:ncies With MSAF Ba~ed on the$e results, it was -concluded that
uptclate<J to flre ron1!Ction ofoligohych:a.n:mios. The anmioln.fu~ion sbould not be r.ec<>nunended for the
cvideilce does show a benefit of t~c us.e of prevention :0t M A$ in .CUni.eat settings With
:amnioinfusion in pregruu1ies :c::om.plicllted :by stan:da..\il pe~m . sutv.illlat1~" th~ authors
MS.Q'together wi~ - oiigohydramriios - {Hofut~yr. -noted th.tl.t th~ ~s:ulta of:this $tudy can orily .be
2~~). ' gen~ !() -~mnar tlihical settings (Fraser, et
al.., '200.$). .

. P.QINT~ Td'REMEMBER'.'.'

:: .. . EiectrOnic ~f~tal.monlto:y:ser:ves~s lhe,pnmary,,mod~.ot':inkpartum as~$$m-tnt.:of.-fetal. toc)dit!on.-

. - ,..; " NoimaletCt{t)nic'fehlfrnonitol'ing in(SlePtes.anoimal baseiinerate, variability,\ptesel"'ce ofaecele.f:ation' ::
-.~ . :~~:.ab~~~of~riY~d.~le~tlon::::,_, .
. .. : .: o;~~~~s ~~l~~lc ;t,~~~ ~?r.itotm~.lS recomm~nd~ f?.r w.omen with adver$e risks .faclors a~
.
I
. ~:Y.!11tt!lJ~!lQiJ!m.l1i.!IJi~tatiQo_findiags.. . . . . . .
tntenrtittentat~$~!tation- .1$ recorfimenoedfor thorewomenWho naVe uncOtripn~te<t pre9oaricy. 'f

A lOw normal b<;lse.Jine :fetal heart t~te .(l<)G-t09) in the absence of other changes m.qybe due to fetal
head CQmpression from an_occiput p.Os_terior or transverse position, especially dl!rii'lg the second
. s~ge -of labor.
Causes of fs~Lbtadycardia -are:
1. -Hypoxiq and acid~sls

2. Complete.heart block
3. _Drug~ ( . Be~ adrenergic blockers)
4. Hypothermia
Fetal tachycardia in the absence of periodic changes does not signify hypoxic fetus. The mo?t common
cause \s maternal'feY,er from aborticr.ammionitis. Other non.hypOxic causes are be.ta~mimetic drugs
(Terbutaline); parasympathetic .blockers (Atrophine)
Fetal scalp sampling is performed only in selected cases of deliveriesin which fetal heart rate tracing
.or .other conditions.:raise,some cbncem regarding fetal status but- not enou9_h .to mandate immediate
delivery..
Am hie-infusion is a method of intrapartum fetal resuscitation considered .for .patients with variable
decelerations, oligohydramnios or meconium - stained amniotic fluid.

Scanned 8y: C
 CHAPT-ER 27: INTRAPARTUM ASSESSMENT .
l. National Instit\.l.te of Child Health and Hu:nan
Development Research Planning Workshop. Electronic
fetal heart rate monitorin,g:researc;.h guiqellnes for
interpretation. Am .J Cbstet Gynecol 1997;1 77; 185-
190.
2. Cibils LA. Clinical significance of fetal heart rate pattem
during l;ibor.- .ll;arly decelenuion. Am .J Obstet %Ynecol
-1~ 1~~: 3:2~~9"3. . Cochrane Database of systematic Revi~ 1996. ci2oos
. 3. Low JA, Victory R, Derrick EJ, Predictive value of
electror.ic fetal :m onitoring for intetpretation of
iiitrapartum fetal a,aph}'Xia with metabolic acido&ia.
Obstet Gynecoll999; 93; 285--291.
4. Ozden S, Demitcl F. Signiuamee for fetal outco:me of
poor prognostic features in fetal heart :rate_traces with
v~ble deteletations. Ard1 Gynecol Obst~t 1999; 2.62:
.141-149. . Goffinet F, e! a!. AJ;nnioi.rJu$ion for the pmrention of
5. _Modanlpu HDS, Fn:eDl;Ul ~. "Sinusoidalfetal heart rate
. patt~.Jts_definition -~md''tliniailaignifican.ce. Am J
Obstef-c:JYneco11982; 142! 1033-.1038.
6. ~MD, Langer o. Samudoff A. Xenakis EM Field
Nl'. "Electronic fetal ~~ ~t'!l x:eassurin;? Acta
Obstet Gy.necal Scand 1999; 18: 15-21.
7- .~7-:;~ WI'+Jr. W~ P. Sinusoi.dalfetal heart
rete patw:n during tabpt. Ani J Perinatolt99t; a: 197..
202 , ,;-~_:r.::,- .. ..
8. Krebs liB, Petrt:f.RE:,.Dunn U.lntmpartwn fetal heart
rate tnonitoP..ng.. -N:ypica} ~Ie deCelerations. Am J
~t0yneCQ11983; 145:297-305. -
9. -~~_Qff 4 ~gqQ, Bez-kus..M, Fidd N, Xertak:is E,
IQdge'way.L. Is f~~ heart n:.te variability ~ good predictor
of fetal outcdome? Acta Obstet Gyriecol Scand 1994;
73:39-44. .
10. WilU,ems KP, Galerneau :F. I nterpretation of fetal heart
mte pattern in the prt-dietion ofneonatal academia. Am
J Obste~ Gynecol 2WJ; 188: 820-823.
11. RCOG Evidence-based Clinical Guideline No.8. The Use
of Electronic Fetal Monitoring. COG Pres!l2001.
banned 8y:
.. 435
~-
12. SOGC Clinical Practice Guideline No. ll2. Fetal Health
Surveillance in Labor. JOGC March 2002.
13. ACOG Practice Bulletin No.70. Interpretation of feb:ll
heart rate monitoring. Obstet Gynecol200Si 186; 1453-
. 1461.
14. H o fmeyr- -O J . Prophylactic versus therapeutic
a:nnioinfusion for oligohydramnios in labour. The
The Cochrane ~llaboration. Chichester, UK: John Wiley
&Scns,Ud. .
1'5. Hofmeyr GJ. Amnioinfusi-vn for umbilical col'd .
cocprea;si.on in labour. The
Coclu"ane Da~ -o f
Systematic Reviews 1993. 02005 The -Cochrane
Collaboration. Chichester, UK: John Wiley & Sons, Ud.
16. _FraserWD, HofineyrJ, Lede.R, FaronG,Akxander S,
the meconium aspiration syndrome. N Engl j M(d 2005;
353.(9): 909.
. .
17. Parer: JT ~cillary ~ethods .andin utero lreatment. In:
Handbook ofF~ H.ea.""t Rate Monitoririg..2nd ed. Pp.
11-9-~2. Philadelp~ W.B.SaUildere, 1997. .. , ..
19. Garite TJ, DUdy GA, MCNamaraH, et~-A>~W~ter . _
controlled trial offetal~ ozimeby.~'l:thi;in~
man~ent of.nonreassuring fetal heart tate patterns.
Am J Obstet Gyneeol. 2000; 183.: 1049-1058. . _
20. ~t -~_, ~~_.f'f.,_.~ ~ f.~~~t~~I?.~~J9r fe_t,al
-~=~~J:~~~~;%;~~~
Chkh~ster, UK: John Wiley & Sorus, Ud.
21. Paz Y~ S olt I, Zimmer E. Vari&b!es as~ted with
!lleconium aspiration syndrome in labon1 with thick
meconium. EurJ O.bst.et Gynecol R.eprod Biol200 1: 94:
27-30.
22. MeyO.anli MM, Dilbaz B, Caliskan E Dilbaz S Haberal
': Risk Factors for meconium aspJation syndrome in
infants born through thick meconium. Int J Gynecol
Obstet 2001; 72: 9-15.
. ,_: I
j
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 .!

~ ...

.t.

; ..
! '

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 28
..... ..

OBSTETRIC ANESTHESIA

Epidural .for Labor and Delivery

Regional Techniques Other than Epid.u~! for Labor and Vaginal Delivery

Other Anesthesia Techniques for Labor and Delivery

Anesthesia for CGsarean Section

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 . I

438 SECTION IV: CLINICAL APPROACH TO tABOR I DELIVERY . t

JNTRODUCTION of bearing..down ability due to accompanying:

motor block. Too ijtUe, and the parturient will
In the Phillppines, the goal i~ to achieve a forcefully push down to end her painful agony.
.:moth~r and baby-friendly obstetric anesthesia. Either way is a compromised situation. It is best
The objective is to help prevent and or minimize to s tart using the minimum effective concentr.Uirin
the morbidity and mortality during childbirth by of the local &'""lcsthetic agent to produce sensory .
.means of a safe and proper anesthesia care. This block only and then progress to administering the ~
.is in .s upport of safe motherhood being espoused optimum local anesthetic concentration but stilt' .
. by the obstetricians. without motor block. In this manner; the .
partUrient be<;omes in control of her labor and
. Obstetric @e,s th,ew',i,n th~ bo~ntty i$ also d~eey beea\l$.e~h:= ean ~,.down {lroperly,.a nd
11
~ownas Ure MQtli~:d.Btlby.;Ftiei1dl;i Obstetric li~equq:tely > without re~ling . the p:ain.
An~th~" .(MSFOA}. .W)Ue~v.er teclm.ique
O
or
A(lmil'llsteri;n~on;ly
pthnu~ effe.otj.ve .
the tnin~nium tip to the
co~centta:iion of .the local
dp;g is: ~te<Lf<)r la.bo& : ~ d~!Wetj, it shq'4ld
be &ood 'and &are fotbOih the mother tU'"td het bS:by. anesthetic -agerit should ~ot interfere with the
. Irf(lther words, the use of genetal anesthesia is natural progress of labor. I( an abdbminal delivery
~raged while the us.e orr.egionaJ anesthe~ia is eventually CQntemplated due to a failed labor,
is e ncc>ureged. Thi$ way, .the .Parturi!!nt is one should look for an uniecognized obstetric
~scious, eoheient, coo~rat;ive;comfo$ble and indication rather than attributing it to the epidUral .
~n :control dur,ing per labor .a1;1d Q.elivery. technique, especfu.lly when iUs .properly done.
Ft,tttllermore, the oppoftun:ity Jor bon<liD.g and
latch-on b ecomes ' very ..po~sil,>le .. rtght,on . the .
.... d~lWeryOJ!o~gtabl~;lt<i$:~n1a.J'ka:bl~<for.>the- .. pidu4rt~ethes1 for..l..abor and.V~~ Delivery_... .... . _
. obstetri~ ~e$t1ieSJ0lO~St~ tO GO bonding and . . s tMe of .. . .
. :la.,.;;"'-on. . u~ the$C are the first two steps o.(
beca -e. .J>a1 Pathways Conee~tration of MD
~. Labor. of~tion LoCal Ao,esthetic
.me baby~frienQly' Ulitlative in. ht:"eastfeeding. ~_,.__,__,.._,...._.:..._...,.__,..;..,....;.....,__...;.........,,_....,---'~-.-.:..;.,.~
Firsts~~ .tlO:"J..l ..~ 1;}.2So/o . ExplB,iil'.
. :This cha,ptentttemp~tQ .p%'9Vide the student~ Bupivacaine Supi>ori.
- .:c l -obStetrlC:.anesthesia' a~ple 'Jnde~.tanding:of-
; '0 .20%
. .an~thesia 'diliirig dilld.bfrth ~and" S6me pr-actkal . Ropivac,aine
A::PP!o.aehes for the apeathe$iotogis.ts and ..
>db$td:(icians alike Pro<:edu.re~ ~s suggested are Second S2-S4 < 0 .20o/o Coach
-iii~ded -to serve as guidelines consistent with 'no~Ll Ropivacai,ne
. :~t local pra~tice and knowledge of maternal
<0.25%
~~ (eta} physiblogy.
Bupivacaine
:epll)URAL BLOcK .FOR LAJ30R AND VAGINAL
. l>~LIVERY
.' ouring the flrst stage, the pain of lal>Qt' is
. 'To better u:nders~nd ~nd appreciate the transmitted 'Qy the sensory innervation of the :.
. epnd,uct of anesthesia ,it\ Obstetrics, imagine a ut~rus that passes maiply through 11th and 12th . -
ll~ce,Bat (or a "see.. saw" bar .in a pla.ygr.o und) thoracic segments wi,th some involvement of the
w})e~ein (pain reUef .or ena:lgesia) during laqor two . ~djacent TlO and Ll segments. Pain :
occ\.lpies one end of the bar while the [ability to oftentim~s .becomes severe during the late first
;b eat down} by the parturient occupies t.~e other stage and seond stage of labor. Pain from : the .
... end of the bar. Th.e f\llcrum is the [{lo<;;a tanesthetic uterus is communicated via : the uterine pleXU$>'
.ag~t and its copcentrati.onH tp be u~ed during the pelvic {inferior hypogastric) ganglia. and:
lab:or .and d~livery. The manjpu,lation of the dru,g plexus> the hypogastric nerve> the superio,r::
<xi?centration determines the balance between a hypogastric plexus> the lumbar and lower
.. :~ti~actoty pain .relief an<l an ~dequate ability of thoracic ~ympathetic chain and the white ran:ii
:t'be parturient to '"push-down" during a communicans associated With the eleve.nth ari.d'
. eontractiqn. Using a high concentration of the drug twelve . nerves. From this sequence, the pain .
Will tilt th.e balance towards profound relief o r stimuli enter the spinal cord through the i>osterior .
actual absence of pain but with concomitant loss roots ofTll and Tl2.

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 CHAPTER 28: OBSTETRIC ANEStHESIA
When active true labor has taken place, control
of pain i~J indicated and initia ted when the
Parturleilt. complains of pain . and asks for relief
regardless of cerVical dilatation. If this is readily
Q.~ceptable in a g.r avi docardiac to avoid
deca.mpensation or in an asthmatic patient to
prevent a."). attack, then any pa rturient in pa in
deServes a similar treatment. The decision to start
epid~ analges.ia should be ma de indi-vidually
With each pa tient. Parturien-t should not be made
to wait until 4-Scm cerVical,dila tation is reached
before benefitthig from an obstef:ric epiduial. .
. :' ~ - .
The .key to:-an effective obstetric epidui'al is
the proper titration oftheconcentiation of the local
anesthetic agent . Initially, 7cc of 0 . 12.5 %
Bupivacaine or .0. ~% Ropiva caine is adniinistered
.aft-er ~ 3cc te.st do~ via the e,pidural c atheter
which is preferably inserted at L3-4 or
t2-3
. intervertebr~ space..If' this
a_mc;mnt sti.fflces, then -
the.sam.e is injected when .the first dose wears off.
If nqt. another lOCc volume eqQ.ivalent:to the.first
dy~ : shril;ll_d be injected wit:IJ. or W ithout. 25 meg
Ferifalije-Tlie next thin_g -to .do when patient i~
n oty.et :sa.tisfie4. as~utning the catheter is in the
c!:pi_4~.rah~ace, .is. to gradua lly increase the
cd~eentf.atio~ but not -to .exc.e ed 0.25% -ror
Bu~~e -and o;2% for Ropivacairle to avoid
tnotc?r:bl9dc. When.the rl~t balance is ~chieved,
suCh do's e is given s ubsequently in 5-lOcc p~r
. il).j~cijQp. This is tl:i~ ip..t~rwitt.ept method of
~~:fu!~~-~o~t.E.<:~-~~Y.~!~d~x)!~~~~,o.L~. mru~JQ.o .
F~...!.....:~!._t:xal!J...I?Jtn._..lli',.Ysm-~.:J~QnirQlle.d__epi dur.al
?-nestbeSta (PCEA}. wherein theJ >atient is allowed
to acb:njnister bccasiontilly the locai anes thetic-
agent but with Pr-edetermined limitation.
All the: while, the anesthesiologist should h ave
explained this ..:obs tetr1c e pidu ral" technique to
~e _ patient, taughtper how.to be in cbntiol and
continued to provide h er with p sychological or
emotional support )lntil delivery, Arid., maybe the
patient is also rp.ade to under stand the phra se
" p a inle s s d eli very" to .cor rec t a ny un due
Cxpel!ia.tt9ItS. - . .
. During the s~cond stage, labor is u su ally more
p ainful and the serisatiort shifts in location to also
inv~lve the sacrat 2, 3 and 4 segments. The ~e
.m inimum effec tive concentration o f loca l
anesthetic agent in lOoc fs ad~irtistere d per
e pid\,lral catheter ~t .this ~tage; When thepqtient's
c ervix becomes fu lly dila ted, so.rrteti mes a n
additional lOcc volume. is added .to block sacral the
Scanned By:
' 439
segments, a S1' heeded. The previously gi~ local
anesthetic in very low concentration yet liberal
volume during the first .~tage would have "bathe"
the sacr~l segments and tackled the issue of
Msacral-sparing".
Finally, it is impo.r tant for the doctors to coach
the parturient during the bearing-down period and
actual delivery. !>roper and effective bearing-down-
effort should be in synchrony with the uterine
contraction.
.REG~OMAL . TECHNiQ.U~~ OTaR. TllAN
EPIDUltALfORCO!fTROL OF LABOR PAm AND
VAGINAl. DELIVERY . . . .
' . .
. These other op:U ons ~e: Paracervical Block (for
L'1e fU'St st:age of la't~or), Pudendal Block (for ~ond
st;>.ge) and Saddle Block (~_nd etage)~
. :ro..complete thel~ list .of coiD.ti)~>niy 1~sed
techmque~: .loocal;lnftltratiop J,'C.~y J~~r~dj~. ~~L .
!'lowe'l(er, ..1ts an-alg~s.ic effect is limited ~to
episiotomy and epi~_on'h:c;.phy. . ~- ::_::::~:;~;~\
Paracervl~at Blpok ior th~ FJ.rat St~g~':. ~f
.La~or . . , ' :
. ... . ~, . .; .
. . . . ;:.-' ; :-.x.o.r :f'-::.'
P aracervica1 blc>G~ is .a s iJ,nple :B.n.<k~!i:5.ftive
pr~edu!e.. It b~ocks the uterine paii1. pa~~- at
the _PelV1c (infeno~ h)1>0ps~c) ganglia an,(l pl~s
!Op"tt<1 in. the utero~ligalfient .on b6ili-sides
of-t~re.-e-e~ :a:t~aoout:~t;.-_r.sc~unaerneaffi the
tn~cosa:-.or-me- laterar~~fcii-illces; Bu~:ifi~
seldom used becaus .of possible fetal bradycardia
d~e m aybe to placental J t ans"fer of anesthetic
a gent. -It m ay riot be a. sign of f~tal. asphyXia
becau se it is t.rat}sienf (onset m1o minutes for
a bo.ut 30 m in.ute s) a nd he~Qo rn is u s u a lly
vigorous at b.i rth.
Th e parturient is p~Ced ii-llithotomy position.
About 5 --lOcc o f 1% Lidocaine o r 0 ~ 25 %
Bupivacaine is inje.c ted' ii-1 the latetal fotni~es of
the vagiria at 3 & 9 or a t 4 & 8 o'clock position s o f
the cerVix and -carefully aspirating for blood with
the needle tip resti,ng on the uterosacTal ligament.
Agau ge 21 -23 spinal n eedleis u sed With its plastic
s h eath or a drinking plastic straw a s. i.riipt:ovised
guide ~d cut at the dis tal end to allow a l 7 1.5cm
protrus io n: of the n e edl'e. An Iowa 'ftjl nipet
introducer can provide a more s table h a:@. img. A
good a lte rn ativ e approach is t o . injt-tt the
an es thetic agent. under direct vis ualizaTion by
means of a vagin~ speculum.
C
 440 SECTION IV: CUNICALAPPROACHTO
. LABOR:I.'DELIVERY
. .. '

Pudendal Block fot the Second Stage of Labo.r and 4 segments or the p udepdal nerve: A true
saddle bloc~ is not readily achieved; Some end up
PUdendal blockis a simple and sa.fe peripheral a$ low .w inal anesthesia. It is indice.t~ for outlet
nerve that is ~ffective tor th second stage oflabor~ foreps delivecy:. Itis called as such to refer to the
episiotomy Cind ~piaiorrhaphy. It is CbSfeffective. area pf the body that touches the saddle when
It is easy to perform. Obstetricians and ridingon a horseback.
anesthesiologists alike ean .do it.
. . .. .
While .thc conduct of sad<;ile block is reserved
It is best tlon'e tian~vaginally with the use of.
for atu;sthesiolo.gists.,. pudenq.cll block can be
an towa triltnpet mtiodut:er~ lfit is. nt>t availab1e, perfe>rmed by any lice~sed physician.
~ itnprcmsed needle mttOO.ucer can be used, i.e~ Obstel:J:ieian:s a,~ cmcourag~ toJearn 'a nd to use
a .$tePJe p!as(ic drinking straw or the plasti~ the tech~'i:que .!or r~tativ~ patient satisfaction
sh~th. ofti spinai n~ 'With the distal end ut instead ~f sinlply relyiltg on the local 'infll.tralion
smdothly !() illlow i gauge. 21 ~~3 $pinal needle ~ techn.lflll:e, ~e. .i n U!lCGciplics,te~ vaginE!.l d~livery
protrUde ll.Scril. '(IJ.~e the. $terlle baf\dilge when rtfe.m il to ,:a:n obstetric ane~t.ltesiologist is
scissotsinetudtd in the set t>f.lnstru.ments for r.ot contemplated. ,ayso doing. it m.aY ~em mo.re
Va,gitw,
. -. . ~divety .
to cut the plasticintroducer.)
.
.. econorni~
-
. .

Fill-up.a10ec e;ylinge With l.O~ C>fUd~e ota$:i AtJa$:ra~s.JA t&c.H~IQu~s F oR

~~2% or BUpiVa.~e '0~5%, .pr .R,,"-.,ryiva~ 0~2% LUo:a AND l>&t!VEaY
wlieh' t;ho6-~i,n:g -~. irtjeczt..only .5~ . sid~. Or; Per a
...2.oe;~)yijn~~ ::vfi.t~ :2~ec~-:or-~tdocMn-~.' :r% 'ot Nitrou8,@rd4e .~tJ;l..,P,tygen I~~ou
Bu;pjVS.~e1t2$0$'t~ a~te~;lfke.,F- side:'
connect ,the ne~C:'Jti~ge;: by.: /LUet-:!&.ck; :t>o .. ~i~~~ :~e~ (tt 1Q.).~;~~ :;o~gen: in , so~6?%
not' td:iU .$Y:t'.ifige ~ ~ .injection. U~g See 'Pr conee.nttat:Wn~ ~ 4eliVt.t$"Via. .fa~..mnsle dun,ng
sidi! 'ls. :8\rlijcien~ eifedive :~d 1e-ss plrlnf~~ it;;r. . .paltt.f."Q<l Ut~lin,e .: ,e()ntttt,:ot}9ft.$.~ ... .In . p~~we~n
~j~on~. . . - c:Qn~lioll-.. : mtto~e-:o;tide. 1$>-'Shut :9ff .a,n4-the
~i,~les~put;e~gen:to avoid, diffusion.
. ' :.f~.#:Jpfthe.i~':~~l?m~~:ot. fof'Ufe~d'p~e,:- h~.,;Sinec;N2Q,f$,1V~i~4ges.i<?;1t;is.rughly
~s m4q1,#( @mt'~rli~,~~tl:oil. Use the :fl~~- reco~n(led that~teral~algesipreferably
harid mtadteana Jna~. fmgerltps to. iderii;ity :& e nat~~ti!: '@~ . a :~'~~t~V.~ b~ giv.etl .~s. iu .
:x1&ii1tscli@'s~liii:"WSe iior~ l tie..~~1!'Witli' ptt~e-dt~u))fr-t~.,~ttt'rj..o'h~r:a~e:. the~pafn.-and
_ ,.te.~~
th .""..;_ .~.-..:....
'ir". i.
,.~a ~. $~:~..
...:....,...~th-.,._-e.-n"::=u.o.
&.U
:.-..:..c..,.,:-,_, e-.-'L,.,.~L;J.
..;.
...
~ .,.."".-=......~v.-.a.:Qa:J._:h-anv.
.-.;.,.,
.-...,~~. .
,..., ..... ~.u
. .. . .. ~~ .
s~s~:r-emni~QnCe'JX>p'\llar .tedm,ique
.
it~ tip ~tit! ate:~. i-tiitde the' needle !htttut:er . . lost its_u~ ~~ ~ibs~ttie wpen re~on'aliUle#hesia
Glide the netdle. mtiiodu~er M~e~il the ngbt parti~la.tly ponttnpo\1~ epidural for lat>pr and
jp.dei .al}d ~ddle '(thg~ts. this way the :palpa~g deliv~ry gained,.~eceptanct in the countrY a's a
hand. .!$ beiWeen. the , li~ad ' .o! the fe~10 and the ~er and ell'ective teChnique. . . .
:sYrWge,~e ~cn1~e ~~ d~ti:il ~tan~ert,t;t'ally
,and )at~thlly~ ThiSvJhole U$Jg . pte'vents i11Jeo"tl,qn .~ u~ of ,inhtiliitlona;l(ig~nts for iabQr ;arid
into th~ fetal 'h ead J1nd other complications 'like Vilgi~:deEvei;'Y is notpopu}ar o~.<fesit1lble~ These
laceration to :adj~ept tiss.u es. Mter the needle halogenated,~ents have ether-like properties and
. introd~cer . is insetted JUS-t pos;teriot to or may be irritatili,'g tQ the airways when given a t
underneath th~ is.c hJal spine,.the nie.d le is pu~hed su.banesthetic PQSC! :during labor. .
. tioUgli the gui~e . to tlle. vagitlal $UCOSa U~til it
pie~s the saero$ptnou~ ligament. Aspirate firs.t Intr.av~n!'us Narcotic and sedati~~
before .ad~~n~stenng ea<;h ~c .or drug .to avoid Admh~lstntlon
to,qity from unwant~ intravenous.injection. Do
the reverse:~n~the .other side~ . . Th~ o~~ir.~bility of.~e piu-enteral useof opioid
and .s edative in labor .~d delivery is. up to the
Saddle '}jtoc:k (subarachnoid) for th~ second . extent of not causing:depression. to the m<;ither or
Stage .of Labor . the n~nate :nor dol.lding her sensorium .duripg
contraction~ as. to .a!fect . the synchrony. o( her
. Saddle block is a form 'Of subarachnoid bearing-ilo\m efforts~ The dose should be like that
anesthes ia whic h intended to block s acral 2,3 is ofa_p.:r emedita.tion in a surgical patient though it

Scanned 8y: C
 CHAPTER 28: OBSTETRiC ANESTHE-SIA 441

may be repeated at proper ip,terval. Some ANEStHESIA FO~ CESAREAN SECTION OR

parturients are abl~ to tolerate the experience ~DOMINAL DELlVE.RY

while the rest will request or even demand for other
techniques of analgesia. Cesarean section can be done .safely unde:a
spinal, epidural, or general anesthesia, -somet;imes,
The individual techniques ~ be combined in combination, as planned or unplfu-med. An
to achieve a desired -effect. example of aplanned technique is the combined
spinal-epidural as some Caucasia n
Non-pharJnacologh:: App~Q"aehes anesthesiologists have popula..--ized. The Filipino
anesthesioJogists will commonly use spinal
The commonly )cnown alternativ-e non- technique for CS because it is .economical, .
pharmacologic appro.~c}les .to pain management dependable and reliable technique. Unplanned
are: Lamaze, clinical hypnosis a.Il~ acupunctUre. combined technique - occurs when a patie~t
initially linder SJ>inal (subarachnoid or epidure.l
block) is intubated and put to .sleep ~u~ of
inadequate block . 'Or when ventilation is
Lamaze 'ha$ become popular among compromised.
propondlts loqilly. The Janiaze sessionsa ttended
by the parent-couple which may tast the d'Qration Subaraelu1old 131o~k tor Cesare~ Section
of ; p.regnailey. . p rovide them with the
understanding .o f p~gnal'lcy' and the -knowledge One way: of :~pm:o.piii~g .Sp~al for. :Ce~
onwhat to 'do dllring ~l>or :a nd delivery. Some Section is th~ following: . Th~ p~P.~~t ~o~- tile
rJ;gbly motiVated ~en.ts art: able to. tolerate contemplated .procedure is evaltlated~ p,#i~d .
thf! ~s a,nd dis<mf&rt of child birth. Others . with or without .p~tned,ication atuJ.:.~i>~~~~
:-equest Iot supplementary phannacologic (adequate byd.n):tion. usually 10-2~/~glJ!>'Ody
. approacl)~sAo really make .delivery a ~ppy weight td COrrect any .fluid deficit from t:!le,~e :Of
-eXpenence:' . NPO .an.d ~pl~ni'Sll -~tenance voll,Une .in::.o rder
.. :;_ .... .. l#,.. ;. ~ to safeguard tb.e:pa.tient from possU>}~;U:n.~te4
hy.potem~ion . frotn. a sympathetic tP~P~~kj,;:,t)~e
technique is ,fJtlly Q:plain~d .to the patJ~~t: to
Clinical hjr:pnosiS 'is the-use of. altered state of stc'Qre her inJ'clined consent.
consciousness ior tJlemJ)eutic purpoSes like in
pam-:ma.-nag-emen~dUI'rilffcliilabifffi.Treatmentin TliepanuneiifiifplaCea~pierem:sryon!ierngnt
Jiypn6sciliamesseiUie-p:ower~ortfie-mind-toneat raterar$l~blliiiJ>OsffionTo'do1he1ii>Jor-&ooa
the body- the subconsci'Ous mind' be~g a vast reasons. First. safety and con:venienc~ are
reser voir of unrecognized strengths and considered. The lV line can be placed on the left
knowledge .. :as shown in increases of beta- upper e~ty for her coPlfort with relative ease
_'e ndorphiris in _:petipneral bloPd. Howevesc, while it of movem,e nt/:u.:se Qf dominant -band p.oet-
work~ in many occasions, like other forms of operativdy (sin:ce. righthandedness>
.p sychotherapy, jt-n:Ught not work for everyone but lefthapdedness). Also, the IV .fluid can. be tun
the highly motiVauid. freely during the-procedure without w~ste of time
since the intravenous catheter is not on the
~tupuncture dep~nde:nt side especially during emergency
situation. Secondly~ aorto-caval compres~ion by
While it works in many other pain tl).e -gravid uterusandfetus can beprevented. After
mana,gement, acupuncture is not locally popular the .injection of about 15mg of 0.5% heavy
.in the control :ofla:bot pain and delivery. Even the Bupivacaine solhtion (3cc) or lQmg Tetrac:aine
local acupunctun.su are not keen on dwelling in Niphanoi<;l (2C9) with or without 0.2mg Morphine
childbirth. Wh~ther the acup\lnctur:e needle and Epinephrine 1;200,000 at the level L3-L4 or
insertion, as alleged, induces a lal;>ar contraction, L2-L3, using .preferably a gauge 26 pencil-point .
is something to th:in.k about. _s pinal needle to minimize post-spinal headache,

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442 SECTION IV: CLINICAL APPROACH TO LABOR I DELIVERY

a wedge can be placed on the right pelvisas soon t hm the proximal e:od of catheter at the hunbar .
-as the patient is pu_t in supine and slight pun~ture site to allow .a press~re gradient. In.the
Tre~del~bu.r:g or head-down position t{). Here, t he ~eantim.e, the back of the patient is t:!eaned,
hyperbaridty o f the lOcal anest.hetlc drug and the wiped dry and the catheter anchored with adheSive
po~itiOnL:"'lg of the ~tient p roVide.. ad~uate and -pla-ster. By this tin1e, if there is inadveD;ent
even spread of the block frbm T1 0 to T4 level as subarachnoid or intravenous insertion, then
desired. cer.ebrospinal fluid or :b lood respectively will ct>me..
out of the cathete:i." by gravity. The usual classic
Sub3rachn0id. 'block is'-th:e most :common and test dose is d one afterwards.
preferred techt).ique for Caes:irrean: 'Seetipn :in the
Philippmes.. the tec~que. is safe and effec~ve Sitnilar hemodynru,nic changes -and.outcomes
when done properly. It 1~ reliab~e, simpkand cost~: are ~ed although onset i s .slower inepidural
l~s.s.. than).n subax:a~oid block. To further. address
these concerns .appro.p rlately; the patient -should l
Epiclll'r81 Block .for ~t>a:rea~ Section . be adequately hydrat c;d and a wedge immediately
. . . applied. On the part of the provider, h is skill and
. Continu~ms epidUral. ~esthesia in -O bstetrics self-conndence in doing the bloc. should be.hQn:ed
_is celled "t~que-.p~exc~lleiice~. It is so flexible by, more :~rience. .
that.it"caninitiB..tly he u~~in. $e:eontrolof-laoor
pain-$ anc1 in .the ~ub:sequel}t ~pon)::ail~ous or . Gene,aJ. A!l.~st.hesia. for Cesarean S.~ctlon
force~- vagm.ru.delivezy .~fir just sen,so;Y .block.
But'iff:fue.~ plal;mcl;'ma~et :of..de~vety; ifaifst :<h 'J.d . When-properly>"conducted,:.~en~ral anesthesia .
.~.Secliori::is ..ec~tmpif,i~~n)ltepidur:-al:._:~, ..(GA};foi;.-cesar~~-section' (Q$}ii~,J~st aS:'sa.f~.-;:nd~. .
bl~k-~~p.tO<:ili~.'aa~i,l.at:'iW...hlg~~ia;arid.'.:rri6t6t';: effe6tiv-e as:- r egitinalt ~est};i:esia except: .for it~
b1o<::)(by' m~shig tii:y ~ncentrati\?n<ef:.:h~Joea.l higher ti;sk of. aspirati0n of .sto~ach contents,
e.neathetic.,agent; -o:S:% Bt:tpi'Va;~e '.?1S~2b~. ()r i:r\a1i!i:la to . underlyi,ng .tis~\les du:rfug. ~tubp.tion
l%~p~ts~2~ :::~t),\f!1~l~.pl~#re~t1imd aridothdr: problems of'ventila~on:. A ~ent ~
~nDtibati6n"of.:an.:epkiui~f~~tl_ielet-~iUI~WS~JOr.;its . labof'is .at risk DecaUSe of delayed.ga?tri.Cemptying
:rapid -u~ .,for surki-cai anestp:e,~ia:..:~~fi;<i(: no.t . time due to :horrnonal.and ..mechaillli effects of
ut:il#ed.for. iaoor ~algesia. : Wh'ti. .stit~$- has .,to pregnancy on the. GIT, the a.IPd~ty and pain of~bor
t.>e done. a.l;>O~t 20cc of L'1CI.o8ih'e :~%. :l.s used and fu~ use .pf.~aJ'.toi;ic :maJ.g~.$~cs; .
p'~krably;beCau$e-of~its:faster-6-Ilset:-:of~ctionand .. -- .. ..:. .. .
:fu-e-fullodQee-Shotlld:'~given~Wj.th.ou~~ce~S<Q:JT ..GA is inditated-.-.~ith-ecP1""stat cs 'for 'lion~
.delay)D'.e tay h pr~V.en.t'e.d 'Qy ..ea;:r.ty pat~eht reassuring fetal statu$, when .r~git>nalblock; is
preparatfon: 'to inclucie a:ctetplatt h'y.dt,a:tion. oontia:indicateQ. .or as per p,atien~ s c h,oke.
F~... post-operative pain can e e r(;iJev.ed by
.:Ropi:oiciciiiil.~ O..io/o ,O'r -B'upiva~~O}z5%.or loW:ei ~ He're is on~ way o f . per.for;mi.ng gen~ral
with..-o,t:~t:hDu~Morphine ~b ..02% :T~l:: :p:e~ep~durai ane:sthe~a for G.S with .th~Jollp~g.obj~~to
cathettr .~n~ : or twice a ..day as Part bf:a:ro:ulti- prevent. pulmonary a~pir.atipi:t, to avoid utetine
moohl:~ge5ic:.approach. at'ony, to prbVide ~tmoperative :analgesi~ that
extend-s to postoperative pain t:elief; and. still
.. The pa,.t;ient for.epiclural a.hes.th:~sia:is prepared maintain the mother-and-baby-friendly initiative.
jU$l :ti}ce ~ic '~pinal block ..for ces.ar~an 'sectio.ti..
Iuadverte.nt.Ubarachnoid o.r intrayenousirijection The p a tient is either given a preme,dication or
.Of a b~g :Volur(ie .of lO'cal an~sthetic 'agent may not. after .a good pre-anesthetic .evaluation. .. The
haJ5P.e.l'l, and s~oufd 'be av.o ided. To prevent this. patient is p r epped and draped while the
.Co~~tio.n. and :.to :P:rov.iqe a n:other 'manner of obstetrician is about ready Jo m.a ke .an_ in~sion..
testing the proper inserti~n of the .catheter into Pqor to a rapi.d inductio~-intubation sequence
the .epidura:I space, the following C?-n. be .do'ne: with Sellick's ma!feuver .(the cricoid ~go i s
i~ mediately.-after .the r emoval-of.fue:Tuohy needle. pressed against the 'body .of:.fu~ sixth c~rvical
through-the catheter) the'dis talend ofthis.tatheter v ertebra, to occlude the esophagus; thus '
is threaded .b ack to it;s brlginal plastic' pack to preventing- .regurgitation in the unconScious. and .
m~taio sterility: N6ct, the Lue r-lock connector paralyzed patient), n a rcotic anafges'tc is
is attached hut kept open. It is then placed lower administer ed to lower the concentration <{ the

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 CHAPTER 28: OBSTETRIC ANESTHESIA 443

'-'!- jnhalational agent (Sevoflurane or lsoflurane) 0.2mg may be given intramusCularly'"li'lthough it

required to put the patient to sleep. The moment
endotracheal intubation is secured', the
anesthesiologist signals the obstetrician to start
the !'t.bdornlfial iicision. Upon delivery of the baby,
additional dose of opioid (Fentanyl l-2mcgjkg)
with or without 40-60% Nitrous Oxide is given
every 15-30 mii1Uteg while the inhalational agent
is shut-off or administered in minimal
concentration. In this way, the risk of atony due
to the myometrial depression-effect of the
. inhalatiorial .anesthetic agent can be minimized
or prevented. Supple111ental sedative {Midazolam
-t.mg per dose) will add balance to the r..eurolept
anesthesia.
The uti!rus normally contracts after the
expulsi.on of the place.nta. Usualiy 10 IU
(maxhnum of 4.0 lU) OxytoCin is incorporated to a
, Urer of intravenous n uid to make sure that the
uterus 6onttacts to a fist-size and it is given by ably handled .by tlhstet:;ric aneslhe~aobgists:. The
drip to....avoid hypotension. Methylergtmovine
causes hypertension. Another drug, .T latiexamic
Acid 1-2grains is now added in the
armamentarium aside from the traditional
massaging of the uterus.
However, instances happen when uterine
atony persists and bleeding becomes profuse so
that others would give Oxytocin rv bolus to pbtain
immediate effect but slowly to avoid l}ypotension.
The benefit of intraoperative narcctic use extends
favox:a.bly ~.x:to the inunediate pc:>stoperative pericd
for patient's comfort and satisfaction.
In th:e country ~ay, about 700~ Of deliveries
are still dO'ne outside of hospitals. At most. only
30% of
parturle.nts benent from the professional
;.ervlces of competent ohstetricia:Jls.. One ~ig
difference is that some ofthe.n.ere refetred to .a nd
pursuit of safe motherhood goes o.P....... . " -'-,t :

POIIn''S TO REMEMBER

:-:Mother and bat>y-friendly obstetric anesthesia encourages the use of regional anestheS~ ..
..:~techniques to ~eep the -parturient in control during tabonmd delivery :and experience~~Q9~L; ..
--.::and.latch-<>n w1th hef r.ewbom. . .
., ... w ,...,r.~ :"

\i.~i;:;.. 4'

..... .
Obstetric anesthe5ia referrals help preventor minimize the morbidities or mo~Jities of childbirth.
Pursuit of safe motherhood 1s a teamwork.

~ Parturients. especiaily when -in labor, are . better assumed as having full stomach fur safety
considerations like anticipa-tion and prevention of aspiration .
.,
Parturient in labor deserves a safe and effective pain control. A property conducted analgesia or
anesthesia should be provided anytime during her active trua l~bor when she asks for it

SuGGESTED REAnrnGs Bimbach DJ. Labor Analgesia. p. 202. 56th Annual

-~
ACOG 2007 Compendium of Selected Publications Vol. II
Practice Bulletins. pp 649-663. The American College of
Obstetricians and Gynecologistl!. Washington 1 DC. ~007 .
Vol. I Committee Opinions and Policy, ACOG 2007
Compendium of Selected Publications Statements. pp 372
373.
Annual Refresher Course Lectures and 'Bil.Sic Science
Moor~ DC. Regional Block A Handbook fo r Use in the
Clinical Practice Q{ Medicine and-Surgery. Ed. 4, Springfield,
Illinois, Charles-C. Thomas, 1978.
Abouleish E. Pain Control in Obstetrics. Phil~delphia: J .B.
Lippincptt Co., 1977.
Refresher Course Lectures and Basic Science Reviews. ASA.
At!anta. 2005. .
Palmer- CM. Obstetric Emergencies (I.Od A.!1esthetic
Management. pp. 201. 56th Annual Refresher Course
Lectures and Basic Science Reviews. ASA. 2005.
Tsen LC. Anesthe~~ for cekrean Delivery. pp. 10 1. 56th
Reviews. American Society of Anesthesiologists. Atlanta.
2005. ~
:.:r
Wissler RN. OptimizingPost-Cesar.e an Analgesii pp. 403.
56th Annual Refresher Course Lectures and Ba.sic Science
Reviews. ASA. Atlanta. 2005. ...

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..

.... . .... ..
...

. f

-) ..

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 29

.THE NORMAL NEWBORN

JACINTO BLA.S V. MANTARING ill, MD, MSc
MA. ASUNCION A. SILVESTRE, MD
MA. ESTERLITA V. UY, MD
AMELIA R. FER~ANDEZ, MD
RACHELLE M. PEREZ, MD

. General Management of the Newborn

Neonatal Resuscitation
..
'-

Bonding and Initial Breastfeeding

Temperature Regulation in the Delivery Room

Physical Examination of the N~wbom

Estimation of Gestational Age

Subsequent Care of the Newborn

S.kin .and Cord Care .

Eye Pmphylaxis
Birth Doses of Immunizations
Health Maintenance Supervision, P\eservation and Promotion
Newborn Sc_!:eening
Hearing S,eieen

Discharge

Counseling

Sustained Breastfeeding
G9mpletion of Immunizations
Recognition of Danger Signs

Follow - up

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 .:446:. SECTION IV: CLINICAL APPROACH TO lABOR I DELIVERY
.
" :. ~

INTRODUCTION 1988to 2003. The.d:ecline. therefore inthe under-

5 m ortality rate W.as attributed mainly to the
T he neonatal period is defmed as the first four decline in deaths among those beyond the
weeks of life {28 days); an extended neonatal neonatal and .infant period. Tile neonatal mo~icy
.~ is used to inclUde the ~9ct. to the 59u. day of rate has remained practically unchanged over th~
li!C":.1 fie d~pendent existence of the J.. u.t ero fetus years. {Figure:29.1)
ce~ses abr.).lptly at birth and a 'r.emark?..ble
. :a4hlstment to an. extr;allterine. ~X:istence is I:q. the Philippines, an estimated 17 of every
:: . ,.e~teO. to take place in .t he newborn. It i~ thousand liVe births die within fhe 1st 28 dtl..ya of
., .. .tb.:etefo,r~ u:nd~rstandat>le ths..t this period is life, half:~urlbg the 1$1 ~ .days of.li.(e. Birth 13-~phyxli
, ~$~:oc:iate:4 ~i~h sig:h.tfi~~n~. inofbtdity ~nt!. a(:c6\l-11ts_ J9r ~ppr~~ateiy .~q% 9f all tlles~
'.,ql~ty , . ' . neo~tal ~$; ::Wl:Ule .an estimated300/o a.ii.se
> rro.~,~#iW~~qns:.of pre~$ bkth. Other ca~~s
. ~~ ~ppfr:ie H~j:h S.ta&stics..:has S:}lr->wn a:. ..ru,e '~V.ere,U:ifeetions {l?'?hi}; C()ngenital 'anom~es
progresSive deCline in mfai;ti: 'lnottality rate 6ver {9%);' rrilScellane:OUS causes (9o/o) and neo'na~
the;:Oast decades. Statistit:s show t;..liat the~ has tetanus {1%).~
: ~~.decreasip;Ktrend in childhood mor:Wity fu
..:~:.P-Mt 15 Year$.. The 'q_n,d~--riVe m..orta).ity ritie .The P :epar.tm!!Pt ()f l.i!!.aJth. The 'Philippip.:~-
. ~~Aiet~ from !?:2.. then :43 ttl 42 d.e afus per Child :SunTiv:aJ. Strategy. Part 1: Chl1d Health.
.- i;ooo:iiVe ~irfhs a~ .re_po.I:te~ irl.'the .199~ N.D.HS; Situ.ation 'ill the Philippines. July~J07. . .
.. -ih~ ':l-99.8 NElHS, .ap.d.t he200$.NDHS t:espeetiveiy. . . .
-.riifa:rlt-..~ott:a.Iit:y:tates-,froni;;~ethteesu..rveys:also J'he P:hilippines P.4s ~dcpted as part .of it~
. : ... :_~b.~w'a-~'rpr.Q.tmcte.d>'fd~~.irie-;- f'.'O'rri 134'..to~.3:1 :. to'29:. ' . rnillen:nium~d.e:Veli?p,ttiep,t;~.als(MDG's)initiat:ives:~-~~
.:~~llis. per. :l;OOQ,;_ijyc~"::'birt;hs) 1;t-Ne<>naW:~d. past~. . :todecr~~.:the un4er.,;~ve mortalityrate by,: two-.'
. ~~tiJ. a:t:o.th::idecllned'tneslbWesto.ver'the .past thirds .by tb,e yea,r .2oie. . Cpnsiderin,g that .a .
. .. :2ri<y'ears.Wifu. :a:redu~ti<)n of .19% anO. 11% fro .sigr..ifieit:pottlon:!>f:the..u..Tlder;.fiv:e ~ortalit'j ra:t~: . .
:

.,
.. 4, - '

... .. ..... : . ........

r.--"'"'!"'.......~------_...--------------=-----------....,. . .. :.
.. . _,,, ....... ~ ..

ao
70
60
. ;'
.so
40-
30
: .
20
10
0
1988 1:993 1998 .200:3 2006
.. Neonatal Monatlty li PostneonataiM~ortaU~
.. ~. n1ant Mortalltt. . x Child MoralltY.
* U-nder~tv e MortaJitt

Figure 2 9 .1. Trend in :childhood deaths., 1988 -20Q5.

Scanned 8y: ~
 CHAPTER 29: THE NORMAL NEWBORN
is ~ontributed to by .neonatal deaths, initiatives
to reduce the under-five mortality rate have to . functions of br-eathing, maintaining c~tion, .
focus on newborn progranis. This goal will only
be realized if neonatal morll!.Uty is significantly
reduced by the year 2015.
GENERAL MANAGEMENT Oli' THE NEWBORN
In order to improve newborn survival, an
essential newborn .p ackage has to be adopted to
address the most .co.:mnon causes cf mort.ality and
morbidlty. Thie package should include the
int~rventlons. that W()U)dh:npact most on newborn
~urvtral using e.v idence 'b ased interventions tl].at .
have b~ea documented to impact on newborn
survi~. Based on an ,e~senti_al neonatal health
care p ackage rec;onltn.ended :b y th(! WH03 and the
DOW. the authon- -$Ugge~t' the following package
for the Philippine .settirig: TheSe intelventions are
outJ.ined::in the.table below.
-~~!Z?ci>Essenlial.nevroo~ ~clcige of interventions to .. secondary
.ret:~uc:e ~evnaWlil<>rta:lilY.
ImmcdWccare ofthe n~m
Neonatal~tt/ nrermoreguJ.aWn
. Post~n,{pre-tran;sporl)stabilization
Withiri.-&n-hour
Latching on I broastf~g
Withln2h?urs
Cprdcare
Syepropf:t:ylaxis
VdaminK administration
Withh24 hours
HepatitisB~n
BCG vaccination
Prior to disch;rrge
Counse1i.'lg op sustaining breastjeeding
Education on danger sigris, pre.uer.tive care and f ollow up
W ithin a week
. NewbOrn (rne.tabolic) screen
Hearirtg screen
The o utcome of the ne.o nate depends on his
~-~i\.!tr to adapt to extra-uterine environment.
Scanned By:
' 447
Basically, the neonate will need to take''bVer the
nutrition and excretion. For most neo~, the
transition follows a smooth, progressive 'COUrse
with the infant stabilizing shortly after birth.
However, about 1.0% of births may requite .a ctive
intervention during this critical stage. The
management of the newborn requires a thorough
un derstanding of fetal physiology, the details of
wh~ch ate discussed in the preceding chapter.
:h'"EONATAL 'RESUSCITATION
When a, fetus or infant is de'Prlved of oJ;fgen,
an irlltial period or rapid breathmg ensues; failure
to ielie_v e hYPoxia will result in c,e ssation of
respiratory efforts. dec:tease in bearUate~d the
i.nfar.t goes L11.to prlmru:yapnea. Tactile ~Ulatian
with.correct pas~tionmg and g~tle suctioniD.g will
in,duCf! r.espL~tion in most cases of pritpary apn~
However_, if hypoxia asphyxia~;;;9<>.P.~ues,.
respiratorreffqrts .w illbecome ~pirtg;.-b~:r:ate
and blood pressure Will continue.to:f.(dfuntil.- the
last. gasp, and the infant .enters~ ,peri.~d ~f
apnea. Positive .P~ssut:e::.Yentil,ation
should be:.i ristituted unmediately. Th~.lo~ an
infant i~ ili seco~ttary apn~. the gf.~tet the
chan~ that brain damage ~ occur~-~~-..~~!
. .
.The fetus may go into primary and ~aary
-apne~--inA.lteFo-~~d--at-~birth, the ~- eoilElittoris
cannot-be distinguished-from-~ch other;-lt is"3afer
to assume secondary apnea when faCed .with an
apneic infant in the ~elivery . room and
resuscitation should be initiated immediately.
For effective resu~itation to take pta~. the
two factors that require serious cousjderation are
antiCipation and preparation. One needs to
anticipate the need for resuscitation and to
prepare both the equipment and personnel.
Delayed or inefficient resuscitative. effort's can
make the resuscitation more difficult and may
increase the risk ofbrain damage.5
Traditionally, resuscitation for infants used
100% oxygen as ga,s oource. .A multi-center trial
has suggested 't hat the use of room air may be
just as.effectiv~ itt securing the survivat-6hevere1y
asphyxiated neonates. This is ene~raging
particularly in home deliveries anq th~many of
d~livery U:nfts which are' ill equipped.
r-..
~
448 SeCTION IV: CLINICAL APPROACH TO LA8QR I oEUVERY
Steps in Successful Resuscitation
P;:eparoti.on and Anticipation
a
'f:o anticipate delivery of depress ed neonate,
it is important that the Tabor room is regularly
checked for impending deliveries associated with
h igh risk factors. {e.g. placenta previa,
premaiurity, maternal sed ation, PPROM, non-
reassuring fetal heart rate pattern, meccrJU.ir..-
stainingJ . .It is important that resuscitation
suppnes {including medications ) .and eq:aipment
(heat source, w~ .sheets, suction .devices) ru'e
:~v.a.ilable and.in proper workLllg cond.it:ioil before
M:Y delivery. The availability cif personnel to help
with the resusdta~on 'sh~uld 1?e check~d.. .
ASs:eS;sm.ent ofA'cJ-eqr:ecte R~piratior;s
The rate jmd 'd~pth of r espirations should
increase with taeti.ll! stimula tion. Infa nts who
:r~Pl-9-iP ,~p~eic de~pite s timulation -s~o uld
. imm~c:l.iately. -tie . ~iv~~ .pnsitive - 'pressure
venti41tion-with 'bag a:nd m ask.
Assessment :qf. Cqrdiac St~i.ts .
To assess the neart; .a "6~seconds heart rate"
is counted and multiplied by 10. A r a te less than
1.q0 beat~ ..per .m inute :is-an indicativeof-the nee d
fo:t," PoS~~ive- _pressure vent ilq..tipn ~ven :if the baby
.is not apneic.
As.,s.e.ssm:efl:t of Color .
.I mprovement in color is du.e to improverr+ent
of oxygenation. It is important t o differer.ti.a te
- - - -
Snanne4 8y:
between acrocyanosis and central cyanosis.
Acrocyanosis (peripheral cyanos is) is caused by a
combination of low :environmental tem~rature
and hypoperf~sion rather than hypoxemia:
Central cyanosis is ind icat ive of hypoxemia. This
is best evaluated by examining the lips, buccal
mucosa and nailbeds.
Sequen~ of .Steps -'in RestL.scitati.on
All babies,- regardless of.risk status ~ have
to undergo .iapid isse~ment.(ie. is th~! baby dear
Of .meconium ., _ bf~athing.or. crying, w h h good
:mus~}e tone, ~d.ter:m ,gestation?j, a.n:d the init:ial
steps 9f ie.suscitat io.n {ie. positioning, dtying,
cleRring. oft~e aiftv.w.., r~po~itiop.ing, stimula~on}.
In ~.0 .~.rcertt t>fbirths~ th~ a!'e th~ ,oniy st~ps
necessary . to 'ens~re surVival . of fhe n eonate.
Another. 10 petc.ent .(.)f.babi~s will :reqtiire..positive
pressuz:e-ve!).tllation, -and 1~ .per-cent Will require
. chest cc::npressions.
BONDING AND INITIAL 'BREASTFEEDlliG
After the initia l steps of resusc~tatiop.:, the
stable newborn is -0ped dry .and placed .on the
mo.t her's ch est for immediate bonding (within the
30 minut es to 1 hour after b irth). The mother is
en couraged to initiate breastfeed:i ng d~ring this
tim~.The suckling .of the,h ifant offers an additional
advantage of in~reased oxyt Ocin release promoting
uterine coh):raction and minimizing postpartum
bleeding. This initial quiet alert period after birth
pro vides a n. opportunity for eye-to-eye ' contact
between mother and baby , establishing positive
interaction early. on.
Early latch~ng.on, exclusive b reastfee.cling and
the -non-use of"bottles, padfie~s, artificial milk
subs titutes and glucose water- should be included
C
 CHAPTER 29: THE NORMAL NEWBORN - 449
....

iil the orders for routine newborn care. The mothers. Training $hould include l),_proper
attending pedi~trician may override the routine positioning and latching on; 2) -n~tritive suckling
order ifhefshe deems that the "individual newborn and swalloWing; 3) milk prOduction and release;
is medically unstable or he/she suspects the 4) frequency Qf feeding/ feeding cues; 5) expres.s ion
infa.''lt to have -a condition ' that .contraindicates of breast tniik and use of a pump .if indicate.;!;
feeding with human nillk. 6) how to as~ess if the infant is adequately
nourished; and 7) re.asohs -for contacting the
Breastfeeding support and education should cliniclit.n~
beprovided to the mothers so tlw.t they can tnake
informed dedsions about their babies' feeding and These skills' should be taught to prlmipartms
care, E~cl usive breastfeeding is de.fined as and m:altipart>us women and reviewed before the
proViding breast milk as the scle source of mother goes home.
nutrition. Exclusive-ly breastfed babies receive no
.ot.ller Uquids or solids by mouth. Whether delivered vagipally or via caesarean~
birth, babies sho~d be pul to the bre8.$t at least
_PostpartUm SUpport f.or Breastfe~ng 8 tc. 12 times in 24 hours: lnfant feeding cues
. (such a.sin:erease<f alertness or activity. nioutb.ing,
. A recent- study has shoWn the itnpa<:t of or rooting) may be used as indicators of the babv's
. htitiatio.n of brea.stfee~itlg within the l:St bo~r. readinesdo.r!eeding. Time li.lnits for br&Stf~g
<
This stlidy !rom rutal ~ Gb.atia. based on 10.~"947 on each side ':should be av.oided .Irift:Uits .~ay be
breastfe4 _singleton L'"'lfants; has shown that offered both breasts at each feeding but may be
:i nitiation ()f breastfeed:ing within the .1st hour of interested iii feeding from only one ::s ide -during
-b irth .redu~ed the infants' risk of de.a th by 20 - the early days. . "- ::.: ':;: .;;("; .
40%.~
6 . .. .. . . ,___ :

At birth or ~n there~er~ if baby .a n:mother No s upplenlental w~ter, gluco$e ' ~ater or .

:iJri! -a~iJiii stab.le, the newborn sho:Uld be plac(1
. F.tere~Plr~kin~~skitl Wit4 th~ niMher.. $~-'tO:.
-, ~~-:~O.:n~ct involves pla~g the n~ed b.a by
prone ~b.'~ the ;motl1er's bare ch~st. Mother infant
dyads should be given Ule opportunity .tp initiate
bieMtfeeding within one hour. uf bi.r th. Post-
_.c ae,sa:T.ean.,bi-rth...:babies....Should--Ulcewise-be
suJ,e'wised -on--b.reastfeedmg-.,as...oooti a$--pOssible
eith~t in. the d~liveiy Qr recovery rqmn. The
..:administratio.n ofVitalnin K, the birth dose of anti~
he~tit1a a and ptophylactic eye medications ~0
prev:e nt ophthalmia neonato.r uin shouid be
delayed for the f.irst hour after birth tp fillow
UJ )it:l'te:rrupted mother infan1 contact a nd
breastfeeding: 7
Breastfeeding mother-infant dyads should be
. encouraged to remain together throughout their
hos pital stay including at night (tooming-in). Skin-
to-'skin contact should be encouraged as much
as possible. Mothers should ..be encouraged to
utilize available breastfeeding resources -i ncluding
cl:a-$ses, . written material~. and. v ideo
.p resentations, as appropriate. If clinically
indicated, rnotne.rs- should b.e referred to a
lactaticJn consultant or 'specialist. . , should be a conscious effort to ensure:ffiat heat
The .hospital staff should be trained on how
to couu'sel and to dialogue with breastfeeding
-formula should be given unles-s sp~cU!c~lly -
ordered or bY lhe mothe~s doc)i:tDoented and
infor-m ed Teq\les~,:a Prlor to nt}iji~iJ:ih.alJy
~dicated supplem~ntation; mo~ft~:~~~~~~ ~be
mformed of the nsks of supplem~nting~' The
supplement sh<mld be fed to the baby ~y_cup if
possible .and sho1lld be no more than~ 10 to 15
< rna term oa-'6Y :9 :19~~1- Arternative..'.feein:n
--- - - ---- . .. - ...... ------ .......... --- - -- - _ g
methods such as .syringe or -spoQ.tl-f~eding: Uiay
be used; however, thes~ methods h.ave not be
shown , to be effective in lfreserving
breastfeediri.g:
TEMPERATURE REGULATI-ON !N THE
DEl-IVERY R OOM
Thermoregulation is an integra l part cif
neonata l resuscitation and stabilization. A
thermoneutral environment i~ the range of
environmental temperature in which the oxygen
demand and glucose utilization is at its . lowest.
This is the ideal .envir_o nmerital temperature for
the infant _so lhat energy can be used for growth
rather than .for combating cold stress. There
loss is minimiZed ~ince hypPthennia .o r _db)d stress
has very grave consequnces. COld stress results
in hypoglycemia, hypoxemia, metaboli~ . acidosis,

Scanned 8y: C
. 450 SEC110N.IV: 'CLINICAL APPROACH TO lABOR I .DEUVERY

hyp.o tension, re?piratory, distress, apnea,
. pulm~nary hyperte~~ion a.p:d even d~th.- Infants
at high risk of hypoth~r.mia are -the prete!"lll
infants, srilall for 'g<!st<!,tional age_ infants, qi.qcally
ill .infants and infants with skin ancj. ;s pii:ull d~fects.
Preter:m and SGA infants, ~side fn:>m large body
~urface area, also h~ve m.inimal glyGogen stores
in the liver. Sick infants h;:1.ve a high oXygen
demand and rJgh glueos u~tion. tate while
l.nfants. with lEj.t_ge abdoliii.il]il ~~ defects or
.. ruPtmcl'lumoosatal :Pleuwg~l~ have a larger
sunate area for heat loss.
. There ~ - four c.m~P.a:nlsm~ ..Qf.heat 1oss in a
newborn frir-ant: 1) Conduction.;,2) cbnv.ecti~n.
3)_ tvaporeijony and 4)..Raqlation... .
. .:
., co~udi<m:is'heat iossfiom. the baby:to:acold
.:rnxn-acei~dn con~tt.with~ nue i:!.the t.r?e.{lf.:~eat
lo~ wb:eti' the 'i."i:fant'Jies OU ,celt! Wet Jte:e Oi' a
w.et <tia~
maii).tain the pre-:-set skin . temperah).re of the
in!a.rtt. In the 200() Neonatal resuscita-tion
pro~. the r~o:rnuiendat;io:i:l for newbOrn iriiants
. <28 ~eeks . gestation is tO,' .p 4tce tileinf~t's body
insi4e a galion 'S~ zip .~ok bag. The.d<J~ed end
of the bag is cU. t to allow the h .e ad ~f the
infant to.-
pass through. When r-esuscitating a,n infau.t
ou~side of the u-sua~. resuscitation s.re.as ,
thermotegU.lation c an be. .mruntaLTled :with.o.ut the.
ben~.fi~ of a r~.diani warmer. J)r~plights,
swaddlli.lg, the .use of ;pla~tic wFaps ,and even skin-
toskin.contactwit:n, the. mother are ways to
maintam-a .iherm~ne)..ltra:l envkonmeni;.
PHYSICAL ~INA.TION OF THE NEwBORN
. .
Physical d-..amiriation oi the newborn should
be-9-one at least ~- th:nes du.tip.g the stay of the
.,patien:t.mtl:~e: p:~rs:~ry~ 'Ibegohl.{l(the.~tion
dlf!~. Q,epending -,pn~e ~e the. ~~on is
done.. : . . . .. .. . .. ..

Cbnv.~on:is:he?J::;loSs~frOn:l-;:,~~bY,:!to:~e:: : . AH).i,.ti.h:,.::e:~dal;e_xamination~s:dorre.fob:iisk ...

su:;rounding-,::BJr.Aifz:rentt'.or.;.:envir.on~entaL . assessment;- s~ifically; . :to assess .t he ahility::of
tempe:ra~.JJt!a,i:~Jost fr$'tl;rc;~~t-,to'tH!- air t~e ne.onl,l;:te. to adap,t. .to an extrauteriue
. <?C>ild.lt:i~ncilri>Omailce4~vew:ri?-9m.sor:,n~eS~ en~!mle.Q.~ q~ i.r:i'l:.potta.ti~~sb,o'u,ld.be placed .
.w.no -~xi$,i~d~.~-too.m:.-tem~~ .fio~ :25~ otr.tf!'\(i-qg; l+At6:,:t9.r : tfie:.pris:~'n~-~ .of signs of
:?&"C~:to ~~te:l;leat~~;U;l:.the~tS: ..''fhe :use ~op.~~mprQmi.~::8,J;IdJif~:tlliiatehing
'Of~ ~~tol':$:wi_ll'prt;y:qtt cov.~ve heat :a!lcm~i~~: ;tha;t :Witl ):;e.q1.1Jre.. more ,aggresstve
;lp5ses . . ., :.- . ~eo~at:al ' -r~suscit~tion !i.n:d e:mergency
. ., . . ih!.#VC!~fi:!>'ns, EmpP:asf~ o~ -~g no:te pf.,fue
.,Y:a,}JQtatioa.iS4eat..lnss~when~w:~ti'cti.it:A::!l:o- : ool~r-.-:-t~.~;vit?.l >SiEn~:wi~h--l;)Jo Q d~pre-s sure;
:v.:a:poJ:.-~g..~~esli~it:~ti<>":P:t --ittf~ts:"ar~ .. drle'd al);~Ultatlorr;t'Wtheh~.a;nd.;l1mg~'; a:is~S'S'ilrg-tn~
. th6~1,1ghlJ;-e.nd'wetliU~n.i~reylaed.witb.~dcy)mes, use: of a~c.~~spry :Ii:).us.6f~s~ .. the.. presn'c e of
irtte.z:estal,, .:s~:bcos~. 'st~ma,l ~~- shp.risternal
. , ..Radiation .is -h eatloss f.tomon~.:sond obJect to retr:actlbn~. :alar ..fl~g.._ grunt,ing' ahd paying
.f;Ui. "o~j~ the hllant is not' 'in con~et with. The attentio'l;'l 'tothe pulses,: aij.dpeflusion~ tforni~y,
infant'3 ~heat ~-be tnmsfen-e(\ l~ _:riearhy cold th~~ lnfant s'ho'Uld b e ~wiuce iri. theTu-st -f ifteen t<i'
w~s ,and WW,do:w pa.nes. The :d ouble w.alled . th.i:rtY . :~ . . " 'Of.'lue
lii.fuuteS . . .. tr~mors
. , \vifu . . , soontaneoU:s
~ .

:kicmbaf.o~ Will;~se the ihfant t{):a-!w_anninn~r startle:m_oveD;lenb;and ccyiilg. This is follow~\! by

. wan and not to th.~ cold outer \Va,U,, niir)..imizing a derease -~ motqr activity and even sleep for
hep.t loss by ra<lla,tjon. ~e.-nerl hour, fo~owed by a . second period of
reactiVity~
the surface ar~a of .the h.ead of an infant, . '
es~y that-ofthe pr.eterm h"'ifa:Ilt:lnay. _cover as . Onee the infant has been
stabilized
.
latched
t .
mu.t'h. as.one:.fourth of .t he ,to.tal boqy.surface. and I:Outine newborp .oare ...has ,bee.n rendre.d, a
..
~~~$g that thehead :i~ -:wipedodry..and c;Qvei-ed more thoro.u gh Qhyskal examination sho-uld be
with :a dry_,<;ap. will he~p pr~vent ~ea,~ loss. Linen do:ne to note .for: gr:o,ss. and .even. s.u.btle
and e ven .s olutions like. povidone i~ne used for a.b~ori:nalities .that should :b e addr~ssed
eo~ .car:e-shol,lld. Pe.<sfur:ed .iriwarining:.cabinets~ ' ,iml?lediately qr even on an outpa.tient l?asi~.
:s'wa.ddfuig will ~lso minimiZe heat loss. The Rout~ely, a cathet~r-.is passed through. the :nose
.niicrochlpin ~1Vo:C:Qntr.pll~dr:adiant warmers and to rule out (:hoanal atresia. Theini'ant- should be
:i.nc1,1bators .a~justs tempe~a,ture .t o be able examined fqr .a whit e. ~ye. and the. pr~sen'ce of the

Snanned &y: ~
 CHAPTER 2!3: THE NORMAL NEWBORN
red orange reOex. Th~ umbilical cord should be'
inspected. There should be two arteries and one
vein. A sinile umbilica,l artery is seen in about
0.5-1.0% of cases, 10-15% of which may have
associated cong enital anomalies, .particulatly of
the genito-urinary tract. A rectal thermometer
should be inserted to ascertain that the anus is
patent. The .g enitalia should beexamined ~efully
and proper gender assignment should be
completed. 'the parents showq. be informed of any
anomalle~.
The t..~d physical examination should be done
Upon discharge .to note the presence of any
findings which may not have been evident at birth.
'the Heart should be reexamined esjlecially for the
presence of a new murmur. The central nervous
system {CN$) shomd be reexamined for a -c~ge
in activity ot 8enooriutn. The head sQ"oul.d be
examined fot fullness of the fontanelle andgaping
sutures. The abdomen and gastrointestinal and
genitourinary systems a!'e reexamined for the
presence:.ot.:.:any missed masses. The frequency
and volu.nlt::ofstools and _adequ;;.cy 0 furille output
shoUld likev.ise be assessed. The skin should ~ first 12 hours is recbJD.Ulended. oesfu.tionil age
reexa.nllnecJ,.fqr jaundice, rashes, pyodermata.
Meitt:ling;tem~tuie. ~olor and signs.or at?no~
petfus1ori;,shotild also be assessed. The ~rineal
lmd perianal areas should likewise be examined
for tasbe.s that may need to be addressed prior to
discharge. The ct>rd shoW.d be reexamined fa
- the presen~ .~f diss:ha.rg!!. 9r.~Yi9.@J.G~ qfinf~qQ_p. lh~ . fgllow.ing: _ l) .the .devi!lo.:PmenLo!:.the..ilexors is
Ai!~f !!ii~11Y.:"t: :fu.~-~J>y .~h.Q:Yld. ~do.b..s.enre.d .pr. .the
mother questioned regarding abno rmalities in
feeding s.u ch as spitting, regurgitation, vomitillg
(especially if greenish) and ~Pdominal .
distention.
.
'
GestatiQnal age assessmen~ and anthropo.:
metric measurements are nec;:essaryactivities that
will enable the examiner to classify the neonate
according to norms that will allow prediction o(
m a turity status and give an estima te regarding
survival.
. Gestational age assessme nt by the obstetrician
is traditionally estimated based on the flrst day of
the lastnorinal mens trual period of the mother.
What is considered the go.ld standard in
gestational age assessmentis an early ultraso'-lnd
Scanned 8y:
'451
(8th to 12th week of gestation) to note the size of
the gestational sac.12 This is very precise, since
maternal nutrition; congenital anom1'llies or
maternal m~ical conditions do not .i nfluence the
size of the gestatiopal sac. The early ultrasound
is accurate to withi...'l 7 days ..
Once the infant is born, gestational age can
accurately be estimated by exa1nining the anterior
vascular capsule of the lel}s but this is impractical
and is considered to be o f little or no value.
One of the easiest and most practi methods
of esti:rii3.tion .of g~stational age is by phyi>ic81 end
neurologic ~ation. This ii;""JlO~Dle because
there is a predictable pattern of changes ~IT.ng
throughout gestation. the most popular scoring
system. Ior gestational age assessment to date is
the J:j~rd scor:eP
Prec-~si'(l;l .: require.s some experience_ and
consideration ofth:e infant's hi$tocy and condition
a:t the ..t:4ne . that :the .e:ulrXijAAtlOII ifi~'l:~ing;'dtine.
Exainination &fter.itiitW stab~tionot.within:fue
assessment bas a .n~.li'Om\lscular C~J.llp:>I).~nt.and
a physical as~essxnent :.coni'Pon.ent.:;. ..'fb.~se...are
described .below.J.,. . :'::.! ~ .:~.' :'::,;''
. :.\ ..:;~~: ~ _.:_ ~:~
;' ,-
The theoretical 'bases for . the parameters for
n~uromu~ asse,s$t;Xlen{of th~ neQnate!nclude
preceded..by::thedevelopment.of-the-exie"nsors and
2) muscular resistance in.creases as the
gestational age increases. This can be appreciated
when assessing the posture_, arm recoil. popliteal
~gle. and the heel to ear malleUvers. On the other
hand, whi\~ :muscu:tar resistance increases,
. fl~b(lity of the. tendons and joints also increases
as the infant-matur.~. this is seen in the square
window and the scad sign maneuvers.
The theoretical basis for the parameters u sed
fot the physical changes for the assessment of
gestational a ge is that durirlg the last trimester, .
the accretion rates for fat deposition is at a
maximum. The more mature the fetus; the more
fat qeposition. This is best appreCiated under the
s.k in. The physical parameters that make u se of
this principle include exanliriation of the .~, sole
creases, breast and genitalia. .~
~
452 SECTION N: CUNIOAL APP-ROACH TO lABOR I DELIVERY

Table 29.2. Neuromuscular 'ilSSe&Sm.ent of .g estational age.

Posture: With the -in!~t su,pine and quiet, -score .as follows: Score
.Arm-s a nd legs ended 0
Sllght or moderate flexion of hips and knees 1
Modtt&te to strong fi.e:l!ion of hips and knees 2
Legs flexed and abducted, .a nns slightly flexed 3
F-..ill flt;)cion of ann.s and legs 4.

Squar~ Window: F'lex the ha,nd at

th.~ wrist. Exert pr-c:ssur.e SWiicient to tet as m)lch flexion as
possible. 'the angle between the hypothenar el:ninence and the .a nteripr .aspect or the iorearm: 'i s
measured and :sco-red:
>90d~ -1
90dep'~8 0
60d.~ 1
. 4Sdegrees 2
30 d~qees. 3
o degrees 4

A:;n.1 Recoil: With the .itJ'ailt,'&~;>ine. Mly Dex

the forearm for 5 ~nds;.. ih'C;Jl fully cctend by:pulling -
. the !lands And. ~~e. S<:c:lre the t~ct!Qn: . . _ -
. Remain.s extenQ.ed, 180 d.egr~es, or -r~om lllPverof!.n t$ 0
: M~ il~r..l-1()..180 degr~ 1
-sxpaU.:am~~J:#lc:xi93;ll~- 140 degret;s ~
t-io:d~e -~an,~~~oo,1legi.eea; . .3-
. BfiSkl'tttU.n,to lUll :fleXion, ~90.t!~ 4

't'PJ>ll~~~: .Wi~:t4e~ .Upi,ne~-4-~e i>e.~ :iia,t~n ~e-:rxa~in.il)g:surrace~-the leg is ncied

o'n :the thi&hilnd the :t hlP:.:iullY.J'ItJted':v4ththe.u$e ot.Oi\e ~a. Y(rthit;})eooiher hluid the-leg i3 t hen . .
ext~nded ~d ~ -~gled $C6red:
l$0 .de.pees . -1
. .
~; ..
. . ' '\1)9 :,(~~ 0
. 1~.41~}i# . 1
.. - '1.20"'t1~~s-- 2 , '

" lQQll~ . 3.
90d~s 4
<9(Hiegrees 5

Searl Sign: .Will). the ~t supine, .t ake .t he infant's hand and draw it across ~the nee~ and as.fiir
.. aeross.i lic o~$ite Sb;~u1tt;~ M P.Q;>sil>le. ~~istan~.t~ the dbow is ~rp:Ussible by. ijfting it -across
th~ 009y. Storc;.a~ri;lin_g tO tl).,:.lo<::ation .ofth~clbow::
EibOw ~cltt$.:or:.n-eora l~el Qt (Jp.t>9$i~ $boulder -1
f;lbOwd-Ois$e5()ppo~te .l:lQtroo'~'~li.n~ o.
Elbow reah<opj>ositt anterior 8xilla..ryline 1
El~.at.niitU.ine 2
El~w :d oes not -~~h:IJiidll.ne 3
E!bow does not cross proximate axillary line 4

Keel to Ear. With the :infant S\\pine, hold the mfanrs foot with one hand and move-it as near to the
head :as' possible withOllt forcing it- Keep the ~ivis ilaton the examining surface
Heel .~s ~~ - ~ -1
H~l reaChes :.the -clun o
H~ .reaches the .n eck 1.. '
HeeHta~eS the Chest 2
Heel reaches ,the abdomen 3
Heel dQes nQt go :beyond the abdomen 4 .

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 CHAPTER 29: THE NORMAL NEWBORN '453

The neuromuscular and physical assessment scales are summarized as follows. --..~

.Neur.omuscular Maturity

Ani'l
recoil

Seart
slgn
.--fY
.=
.. :-- .
~-
- :.
.. .

. "Httel .- ~
to e:ir
<. :: . . . ~~ .: .,.j
<fu
...:-... :
Physical Maturity
. ..
~ - ~

Stick
. -;:y, .G~latinous, SupCrficial Crtu;:kfug, J>areh.ment, ~ery.
s~ooth, pink; peeling . pale areas; -deep
Skin maple, redJ visible veins cracked;
transparent . trattsiucent ,. .. - .. . . ... :snd/.ot.rash:.
~
_ ,rare-veins . : cracking; ~ed
... . few veins .no 'Veesel
.. ..

J,anu~o None Sparse Abundant Thinning Bald areas - Mostly bald J.bturt1y
Rating

flanW Heel-toe .Anterior Creases over .Score Wecl\s

> 50 .i:n.tn, Faint C.-ease.s
sui-face 40~$0 inm:~l
no crease red~~ks
transverse
crease orJy
anterior 2/3 entlr.e sole -10 20
<40mm: ....2
-5 22
Stippled Rai~d Full areola, 0 24
.Flat areola,
8reast Imperceptible Barely areola, areola, 5-lOtnm bud
perceptible no bud 5 26
1-2-mm bud 3-4mm "bud
' 1Q 2~
Li4sopen; Slightly Well curved Thick
Lids fused :F ormed and
.oirina'
curved pinna; 15 3G
F:ye/Eil.r loosely: -1
tightly: -2
pinna flat;
s tay folded soft; soft but fu-m, instant
.recoil
cartilage,
e ar stiff
---
20
- 32--
slow re~;oil ready recpil ..
:~5 34
Genitals ScrotUm flat, Scrotum Testes in Testes Testes down, Testes

30 3G
empty,
(male) smooth
. . famtru gae
upper canal,
rare rug11oe
descending,
few rugae
. good..rugae . pendulous
dee!> rugae
t-- -
~')
--
38
Genitals Clitoris Cl,itoris Clitoris Majora-a nd 10 "' ~- ~0
prominent, prominent, minora Majora larte, Majora cover
(female) .prominent, -clitoris and 45 ;5 ~ - 42
small enlarging equally min.o ra small
la:bia flat labia mic.or;:t minora prominent . minora so :. 44
. . . .
.. .. ..
: ..
' .

Scanned 8y: r-..

~
 454 SECTION IV: CLINICAL APPROACH TO lfi.BqR I DEUVERY

After gesi4tional age assessment has been Vitamin ~ Therapy

perfonned, patients are weighed, the lengths and
head circumferences are measured and neonates . The ~erican Academy of Pediatrics (AAP)
are the::1 classified into 1) Appropriate (AGA), 2) guidelines state that every neonate should receive
Small (SGA) or 3) Large (LGA) for gestational age a single parenteral dose ofO.S to LO Iilg of natural
using growth charts. An example of a grm.:rth chart vitamin K o;tide (phytonadionei within 1 hour of
that has been .developed in 1960 for this purpose birth to ait;l in the prevention of vitamin -K
is the Llibchenco chart whiCh was developed in dependent hemorrhagic diseas e of the newborn
the Uru~er$i"t;y of"C~oloraaa. To date, there are no {HDN). The rationale i~ that newborns ar~ bom
c}).arts amo.ng Filipinos that havebeen d~vcloped with low levels of Vi.t.an).in K; which is also not
for thi~ purpose. present in brea:s;ttnilk. lt leads to a deficiency in
vit~in K dependent blo.o d coagulation factors
putting the new.b.o.rns .at .risk of hem~~h~ge.
THE SUB'S~UENT CARE OF THE-l'c-mvBO~ . Without prophyl:rocis, .approximately 2% of the
infants will develop hemorrhagic disease of the
Skin oand Cord Care newborn. . About 29-30% actUally bleed .to death
and among those who survive, a large proportion
The:American AeademyofPedia.trics curre~tly will have tong tetm s eq\.l.elae. When a single dose
recotp:ine~ds dry .~kin care for the .healthy term o.f vitamin k has been used .as a neonatal
rtewbo'rns . . WitQ: . this techni:que, cleansing is . prophylMrr$ fue rate h as lowered to .1.4:.6.4 per
delayed un:(ir. :a.n .infant's .t etrtpera,.ture ha:s 109,000 b.irth~. 15
stabilize&,:, tb.ehr.fresh.water.-:'oi : .D.on,medicated;. .
. .. soapis,tised'fu~:reinoVe Mood:: an.d-meconhim:from : .It .is . pr"e's:erttly;. "i:<!CO"mil'l:~n~ed: . tcr ' USt' .
the Ja:ce."anct,.neaa:<'tlie';t~st:of~ the:~ infarits-;.skfu. intratjluscular. vita'min: .K Jor. preve ntion of both .
rriay beieft untou .c h.e d; leavingth~ ve~ix caseo~ clas.~ic ~C..late :H PN.; ~th the ~tetna:tive. of oral
m.:pla~e: .. .~: .. vit.a.nn. K :to .be.O:ffered.. to.Jainil.i,es refus ing the
. .;: . . . . . . . .. intramusc)ll.at f6tm....
. Povidone'''lodhle~is sl<:in ~disfu1ec{<pit should .....
he auowed:.t:o :.cfrY"';J oi'''3'0'-"'secon:Q.'s'>'oefore;;.! a_ny,. .Eye,-:hophy~,ax!s.

p~oc~ .and ~mpletely remove: with sterile

s:iline. orw.a.ter after th!! procedure to p _i:event tha"'tWithi:>PJ
.s~fenu~ . ~~~~~x\: ....":i?.?II.ie .Pii)?i~i!?~i~sb~~ aevelop:m .appr"QXiliiiTe1y.2"'S% O'f liifanis._b0ffi.. tci
tlii6ugh iiie skin and is kri.oWI?- to affett thyroid
f~nctio:p.-. The use of isopropy.l ileohol -is
di~uri,ged be.c ause i~ is les s .e ffective in reduc~g
bacterial cpJon~tion . and more da."'llagmg t c> the
newborn
. .~
skiri.
. .
'Bacte@ infecti9ns, which :often .have enteF
th.6. l )o9y vi~:the u _m bii.icus, a~o"unt'.for ia miliion
of d~aths every y.e~. 1-> A review d one by Zup.a rt
anq <J.anl~r.$hpws that keeping the umbilipti.cor:d
dry and de~n is sufficient .for he_althy, term
n~opates. Clea.."1.ing the cord with disinfectants,
however may. decr~ase the ris k serious. bacteri"al
iz;l:fections. Acceptable agents for cor:dcare inchi.de
d :~y cai:e, ' 70% .al c ohol, po_vidone iqdip.e ,
chlorhdine, .triple .dye and bacitracin. To date,
antis~P,tiC ~~~differs from center- t0 center but
be<;a.U.$ .ofthe lqwer COSt;s and ava,.ilability, 70%
al<;;ohol remajl}.s th!! ffi.ost. popularly employ~d
antiseptic..
preventive measures. it is estip:lated
gdt.r0co-c~c:rt ..neona tar con]iXncfivrt:Ts will
wou:..e n with gonorrhea,. a r.elativ~ly ,frequent
disease .and .-l argely a sy;nptomatic in . pregnant
women. 16. Yhere is a.huge worldwide ,potential for
blindness from neonata l conjunctiVitis ranging
from 1.6 .per-ce~t or :le~~ On tp.e :4J:$} to .2~ percent
among 'the $0 'II!-illion bi:t. bies boi-n ' annually
thro.u ghout the wbrlci. 17 The use of 1% sil:ver
nitra te drops as prophylaxis soon after birth has
reduced the "inclderice pf gonococcal ophthalmia
in fue.us to lets than 0~03 percent .of in'f311ts.
Erythromycin has been found to be effective .e ven .
for Chlamydia.
Immunizations
. Hepa titis B 'is .a woFldwide health problem. in
the Philippines , birth and early childhood
exposure .accounts for 70:-80 percent of.the <::hronic
hepati~$ B .infection. Unfortunately; 9.0 percent
j
. of: tt:e "infected newbom and 30. percent of t~e

Snanned &y: ~
 CHAPTER.29: TH~ORMAL NEWBORN ~55
------------- '------'-.-;_
.' --~~-------'----,.----- --

infected 1-5 year old children wt11 progress 'i~to a Hearing Screen
lifelong -disease.11 The administration .o f hepatitis
B vaccinatio.n with'in 24 h6urs from delivery The incidence of congenital bearing
coupled With the completion of tl)e :recommended impairment is 1-3 . per 1000. Higher rates of
series is 70-95 pe~:cent protective. Ft>r this reason, hearing impair~~mt arc found in high-risk
a!.l newborns should receive monovalent Hepatitis infants {2-4 per 100}. ln the Philippines, hearing
B vaccine soon after birth. impairment is the third leading cause of
disability. lt affikts 13 percent of all disabled
For those .oom to mother.s, who are HbsAg- persons. The diagnosis of .congenital hearing
positive, aside from Hepatitis B vacc:irie, infants. loss is often delayed. In one survey, the median
should receive hepatitis B irn.m:unoglobuUn as age at diagnosis was 13 months :fot infants with
well, within .12 hours of life. severe to profound bilateral sensorineural
hearing lpss and 17 months ,f er th()~ 'With n)ild
The BacilleCalmet.te .Guerin (BCG) vacclri~ is to moderate hearing lo~ses. c:hUdren with
a live vaccine pre~ trom attenuated str:ains of hearing loss experience delayed development in
Mycobacterium bovis. the administration b( BCG 1angu.age, learning and speech. Impairments
vaccine at birth is recoilll!lended by.the Expanded exi-St as e~Tly as age 3 yeats and has
P rcgram on Immunization of the \Vorld Health. consequences. throUghout life, leadiQg to lower
~ti9.n and is currenUyl'ero1Ilillended by the reading abilities, .p ctner school perfomiance, and
.IJV
..........H. nu~e
ot. . tem
unp . ...... ta:tiort
~ .
: .r v .
. of this ""'lic;y is. TV"V>r
l'.~
. :under- o r upemployment. Universal newbom --
1t b-as be~n .est!mated that 1.7 b.illioti pe<>.ple hearing screeni:Og reduces.the age at- which
worlclwide:are .infee.ted with Mycobacterium infants with ..heariil.g .los~ are ~d~~os~~d
. .: .,,.: '('""'B
tu:tierc.....V$19' ro, ~ :.). an~
"" .:u.~$
..: aCCQ~ts
- Or.
i: 3.J'n1UOI)
:t: treated. Studies-of Stat~de uruve~ ne~&m
.deaths~y.)9 'f"ne high. rate ofTB ir.!ection<pOSes b-earing screening p:togranfs in <th~ ;Us;;i~ave
a risk forCritical diseaees especially :;u:tiOng yo-ung found that the mean .age of. "id~ntifie~tiori:" of
clilldren{>"!BGG imm.unliatil>ns co~er an -overall hearing ~pai.rment has d ecreased from 12-13
:p rotective eff~et 9f 50%. . p..gru.ns.i: pulinonruy.'l'B, ~?nths.before hear;in~ sereei)hlgpro~~r~re
'its-'effecti~ertes~ has reaehed 'over ~0% vihile mtrod~ced to 3 to 6 xnuntha. Asa'flitect-t"esult,-
agaiQst diss eminated disease and menifl$itis, the IIlean age a.t which imants reeeive'he1(tjng
studiesshow a protective effeetas high as 86%. aids has- been reduced from 13-16 months'"to 5-
7 months.

Univ.e rsal Newborn s-creening has been DISCHARGE

re:;ommended by the Philippine Nevtbotn
Screening Program of the Depa:rttnent of Health. Timing o:f discharge ~h.ould take into
The Newborn sCreening Act of 2004 (RA N.o. 9288) .consideration the unique ch4racterlstics of each
is an act ptomtilgatin.g:a comptehnsive policy and mother-:in.fant dyad and should. include maternal
a nationalsystem{or cmsuting newborn screening. w11-befug tcgeth~r with the stability .o f the baby's
The newborn 8creenit)g progrannrlril:s to de tect . condition. Recall that the transition fr-om
and ma:n~ge inbQ~.etrors of metabolism to reduce intrauterin~ or extra uterine existence might be
the morbidity and mortality of. certain congenital .accompanied by cardiopulmonary problemsin the
disorders. ln o.t her countries almost 1.00 per-cent flrs.t 12 hours Of life. Furthermore, jaundice in the
of infants are covered for newborn screening. .Jn first 24 hours, which is considered pathologic, may
1996, the Philippines initiated screening efforts be ~s.sed. If early di$Charge (<24 hours of life) is
for 5 disorders: l) phenylketonuria, 2) congenital unavoidable, measures 'should be taken to h ave
adrenal hyperplasi!l, 3) galactosemia, 4) congenital an early foll<>w-up c>f both' mother and baby to
hypothyroidism, and 5) G6PD d-eficiency. The detect .onset. of significa.Jlt' problems.
implementationofthe newborn screenirigaims to
identify and save 30,000 newborns from mental the American Academy of Peiff:atrics
retardatjon or :death annually.20 Although .t he recQmtnends that the following mini.mum?t:riteria
incidence of these diseases is rel<1;tively low, the be met before any newborn is discharg~tr. It is
program ensures. a normal quality of'life among unlikely that .fulfillment of these criteda and
those detected to have the c;tbove c~nditions. conditions can be accomplished in <48 hours, If

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 !
45.6. SECTiON IV: CLiNICAL APPROACtf TO LABOR ~ DELIVERY

di~harge is considered be(ore 48 hour:s ; it should F!ifllily tnembers or other support persons,
be limited to infants who are of singleton birth including health care professionals such as ~e
between 38.and 42 w.eeks' ges tation, who :are. of family Pediatrician or his or .her desjgnees, who
birth weight liPPropriate for g~tational age, and are familiar With newbQrn care and knowledgea!Jle
who tneet other dis.C harge criteria as-follcws: about.1ac~tion and the recogniticm ofjaundice
and dehydration should be available to the tnother
1J The a:atepartum, intra.p artum, an d and her infant after discharge.
postpartum courses for mother and infant
are \incomplieated; .. Matern-al and infant blood test results should
2) Delivery is va~at. . be available and -should be reviewed. This should
3) The infant's Vital signs .are tlocumertted a~ in~lud~: 1) Matetnal syphilis and hepatitis B
being Within normal ta:I).ges and .stable fP! surface antigen status. 2) Cord cr infant blood-
the la$t 12 hours. preceding discharge, type and dir~ct Coombs test results, .if cliniea1ly
. inclnt\ing a re.$pit1lt()t:y rate bel()w .60 per indi~ted, .a.nd 3) Sc;:reening test are perlortned in ~
tninpte, a heart rote -of 100 to 16() beats per accordance with st~te regulations, inclu~jng
minute. 18 .and axiUacy tetnper.ature Gf screening :for human immunodeficiency virus
36.59 0 to 37 .4C '( 97 .7F'. to 99.~11 F)''.2o infection.
:measur~d pr~pe:rly in .~ o.pe!l .c rib w'i~h
appropriate Clothing.- . Aside fwm the abcve .di..."1.ical factors which
4) The infants has Ufinat~datld passed atleast have . to bereV}~wed, .fam:Uy, environmental, .and
1 stoolsponu.tneou:~ly. . social ris}(.Jaetots 1ikew..ise, ,hav.e..to .beas~~d.
5) Thed ntant. has , c$:>mpl.C:teq... at :least..-2 , The$e,rlsk$Iactors may L"lchide but ate.n otlimited .
.. 8UCCeSafl1:f';fe~~...::w.itb">d"QUttrenta-t!(m"~-- ~ to.:.; 1\) .J5iltreat~d::, parental "iSUb"Stance, :abuseor ':
th"at'tht'infant~is..a,ble:'to coqrdlnate;stic1tin;g,' po.lrltive-.w.he. toxl~;ology. t~su}:tsjn theJmo~er or
.swallQWln.g, .and'bteathit)g,w}ijle :fe~ir.i.g..- .. neW.bptn, . 2}-l:iistory .of .-ehtld abuse -or. neglect,.
6) . P:by.sjqaL e~aminati~n' . .rev~aJs ; . .nQ 3) Merld)lln~s~r.in a p.are~f va?.o .i~ in the home,.:
a bnotJilP:litres.: t;hat::r:e:q\lir,e i.:Co:n th).ued, . ,. 4)';I:ack of-,$QGi.ai.. su.pport;.:.p;;rii;iG.ularly:for .sm.&le;, .
1\o~pj~tion~~-, i . , : ..' .. fit~t,tUn:e-;nothers;-;S}!NcJix~.il.hom~; ()),JiiStory.of
7) .thet.erisrno<-:~e:nce:~t>ftexeessiye ;.pl~edfug "- untie~ted~domesJ.;icwiolence;;,pa:rticP.larly during~.. -
at 'the.Circum~~:~ite {ifcappllablelf~r at this. ,p r egnaney, and 7) Adnlescerit moth~rs.
. least-2-hour.s, .pax:ticruiit'iy if .t heaoove :.c6ndifions:appty:.. ...-.
'8) . :r-he -clin-i~a.J. . signiflcance of jaundice.; if
present bef~t~ di~charge, has betl When.theseqrotherriskfatt.o rsareidentifted,
detenni~~. and appro.priate IA~n!lg<;me.nt disc;:h,ar.ge sh;ou1d be dft.l~yed until they . are
andfor follow~up plans have been put in a
reso.l ved OT plan to safeguard the infant in is
.place, . plac e.
9,) T-h.~ :tnothers; knpwled:ge, ability, -<i_nd
conft4ence to provide .&.deq...ate cat for her Fo.llow.,up instruction.&. ar-e given a$ part of .
Want ~~ <ioew.ne11ted :b y the J~ot thai-she h~alth n1amtenance sgpervjsion, preseVation and .
has receive.d training and dema.nstrated ptorrtotii>h. They .prqvide 1nformation as to the
coiP.~teney x.:e~~ding; . timing of the child's first visit, .newbom care,
9 ..1) Br~$tfeed,W;g (t)lebr.e.a stfeeding mother ptqper .ii:nmul1iZation and n1,1trition. they also
.a hd infant ~hQuldb.e .a~es.~ed by traiMd . pr.ovide .an :.opportunity to disGover disabling
staff. regardin,g breastfeeding position, - disea~es that are amenable t .o suitable.
latch-Pn, .? nd t:!.dl:quaty of swallowing)_, . precautionary measure~ and .trea tment and
9.2, Appropriate .u rination and d efecation for~see pathologic. conditic;ms tha t the child may
frequenj::y for the inf~t. develop that may pose a significant threat at
9.3) Cord, skin, apdg en1.e are for infant, present or in .t he-future. the. followiJ1g should be
9.4) Ability to recogiuze ~igns of illness and included.as part .of routine dis charge counseling:
. coltl.ipon. ht(ant .p roblems, p~rticularly
jaundice, . Counseling on Sustained Brea.Sifeeding
. 9.5) J>i'Qper.i.n(ant..sa(etYJ;!g, proper us~ of a
car safety seat and s upine pqsitioning for Well-designed peer counseling prograt"!ls have A
sle~ping). . . b een <lemons tra ted to inc rease b reast(eeding

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 l

CHAPtER 29: THE NORMAL NevJaORN 457

initiation and duration for term infants, e:'!pecially
among low income women. 21 22 23 A recent meta-
analysis validates this hypothesis, that lay
support, including suppo'r t from peer coufiselors
was found to pr9long exclusive breastfeeding
atnong tenn infants . .This holds true as well for
preterm infants born in an institution and
admitted to a level HI Neonatal intensive Care Unit
(NIClT).
all times. The IMCI emphasizes the need for both
health' providers and care givers to recognize
danger signs. The recognition of d~gei' signs (eg.
Rapid respirations, convulsions, lethargy. inability
to feed} wold lead to health se~~g behavior
which would LTl tum lead to earlier interventiorts
and impioven1ent of ~utcome.
FOLLOW UP

Advise -on Complf;!tion of ImmunizatioilS
. Immunizations lead to eradication . and
reduced transmission ofdisease. Worldwide, there
are 30 millionchildren hom yearly, 130 million of
who do not receive the basic immunization or the
. 6 ' EFl vaccine~ (1neasle$, polio, tuberculosis,
diphtheria, pertussis, tet~us). Th,e .great majority
of these unreached children is at risk of d~veloping
dis.eas~- thai could h~e been prevented with
prow~ imr..O;~tiori. This has led to development
,of polic!e:s;that improve . access to. sustainable
. imm~tjon services.
Recognition of Danger Signs .
.:, ~~~ ~::;' ..
A-cxnn.prehensive approach-in managing health
"Care ~ari<l~mon childhood ilhiesses include
reduced ~irus~ opportunities for imm;u nization,
breastfeeding, nutritional counseling, vi.tamin and
. iron ~upplement and treatment of helmiplh
it:tf~ft!.gn, .:.A Q-P.tiD1HPJl gf .Bre ..is. pr.o.oled at
health..iacilities in community level to malce sure
that these 'services are readily available and
accessibte to every member of the community at
.On follow up at a pre-designated date and time,
maternal considerations such as interval history
and physical exainina~n should be addressed by
:t he mother's obstetrician. 'fhe :pediatrician,
however, should address inquiries directly related
to newbern care. Such inquiries and issues
include breastfeeding, growth, development and
personal bygiene.
Growth pa.r.arilet.ers of the ibfant iJlclude weight
gain, linear growth and head growth.. Growth, as
well. as cardiac, puimonary~l;"'-reilat.~~:~nd
, gastrointestimil -statu~ shouJd be assessec:bsiioply
. 'by talOn~ a detailed history and d~mg:,~ th~mJ:I&'l
physiCal e:/raminatk>n. These~ as wen aS" the
. nelirologic, developrnenta'l, behavioral .and
sensory .sta tus . should. l;>e. assesse4,- m.::.'.t~lar .....
inter'lals duringth,efrrst year in .hfgH_riski~tes
to ensure early identification ot'r:pxnbl~st,;md
referral for remedial care. Guideliries for
preventive pediatric . health m~ten~C- have
Q.~~n ,_Jmhl.i_
@e.d. by ..1h:c :..Philippine... Pediatric.
Society~ 4 to help guide .~pediatrieia.:ls regarding
importa_nt procedures as well as soeial issues that
should be addressed .a s the child grows.

POINTS TO REMEMBER

The n~onatal period is defined as the first four weeks of life (28 days); an extended neonatal
periOd is used to include tha 291h to the 591h day of life.

~ There has been a decreasing trend in childhood mortality in the past 15 years. Neonatal and
post neonatal deaths declined the slowest over the past 20 yeats with a reduction of 19% and
17% from 1988 to 2003.

The essential newborn package include the interVention s that would impact most on newborn.
surviva.l using evidence based interventions that have been documented to impact on newborn
survival.

Scanned 8y: C
458 SECTlON.N: CUNICAL.APPROACH TO lABOR I DELIVERY

All bdbies, regqrdless or risk status will have to undergo rapid assessment (ie. is the ~by clear or
mecQC)iUm; breathing Of crying, with good _m uscle tone, and terrn.gestation?), .and the initial steps of
.resvseitation (ie.
.
pb'sitioning, dryip.g,
. clearing of the airway, repositiOning,
. . stimulafion).

The principl~ and.details of'rieonatal resuscitation can be foond -in the gt.iidelines.of !he.Ameiican
Heart Associatk>h . whic~ ha v.e been .~dopted by. the Philippine Pediatric Society and the Philippine
Society oi NevibOm Medicine.s

rhe mo'ther is encouraged to initiate breastfaeding within .30 minutes to 1 hour of life. Initi ation of
breastfeeding within the 1st hout of birth reduced the infants' f.sk vf death by 20 - 40%. 1
' 0

t The~moreguiation is an integral part of neonatal r~suscitation and stabilization. A ._thermo(leutral

tenw~ture )s .the ideal temperature. fqr the infant .so that enefW ~n used fc'r gr~ r~t.'l'er ~n for
.:coniba'tihg c;old str~s;

Physical eM3"ffiinat!on of .the nE?,>o:b<im should be dohe 3t l_east three times quring the stay .o fthe patient
in the nu_rseor: t) at birth,' 2).cven ~e b;aby is rnore stable;. al}d 3) prior to aiscbarg_e.

Gestatipn~l >a_9e.a~eS$ment;aqd .~n.thrp~~metfk.rneasurerp,ents aren~ssaryactivities that will.en~

:the cxf;)miriet'to-.cl~ssifythe n eonat~ accof~l!'9 to norms lhatwill.allbW prediction of .filaturity status 2nd
~- :~J~f~ ~~ti~te;;~~afdi.f.!9 .~~89n~~:;:in&suTviv9l. . .
. ~.. . : .. .. . . . ~ . . .. .
:. ~~ . ~~o~kr~~rd;~e,,~Y-~. P~op~~.:vi~mf~., Kadministrationl newborn scree~ing and bearing scree'ning
. are: iryteryenti-9fl?'~t.t1a;e :repuce.im~rt,aiJtY)'md mofbidity ?mong :newborn::>. t::~epatit_is . B and BCG
:imr:tu1n~tibr)s . p,r~vMt.oi~~~e:la~e.rin .life $ucli as Tu.bercillosis:and .~utt chrori_ic liv.~(disease.

.~ .: )I_(Q.t69 :P(~ai:f9:~~~h9.u:l~ :~~~}Jnt6: .9~C1~i~ ~ration..i.he:.~ ni.q\.1~ ~a.racterlstics ~ ~i ~~.~h. n:otner~ fant .
'-a-_,a<r;;iid :si1Cu1CLhiclu;j~Jnatemal..wetl-b}ng togetlier With :tne;stability :of ..the -.baby's condition.

. Pre-Qischarg~ :co.u(lseJif\g onbr~$tf~din.g ., \X)mpl~tion Of i.mtnunizatio.ns and recognitiO[l of danger

. s1gns;.furthef-rdi:l.cesmorbidity-a.r:id mo~!ityrcrtes. : ... ~ ~
.. - . 1 : . -- - ; .. .. . - - - - -

On follow-up, the p$diatrician .~hould i'!~dre5s ir.quiiies dir:ectty related to newbo:n care. such inquiries
and issues l'r:~clude br.eastf~diilg, growth , development and :~nal hygiene.
J . .

s. .A.:mcrican Heart Associatio:::.. .NccnataU~csu3citarlOn

Program. 2006.
1. Natio11al Demog:raphicHcalth Survey. 2003.
6 . Edm'o~d ICL, et al. Delayed breastfeeding initiatio1i.
2: The Department of Health. Th~ PNlippinc Child .incrca~ :risk of neonatal mortality. Pciliatrics 2006;
Sun-iva! S~tegy. Part 1: ChildHealth Situation in 117(3): e380-e386.
, the Philipp~es. July ~00'7.
7. Protocol. Co mmi tt ee Academy of Brcastfeedi n g
3. WHOU.nicef Regional child s urvival strategy. Medicine. Cordc~ R; Howa_;d CR: Clinical Protocol 13:
Accelerated .and Sustairie'd Action towards MDG 4. Hospital G~i dclin c s for the U.se of Supplementary
WPRO Nonscrlat Publication. ViHO Regional Office for Feedings in the Healthy Term Breastfcd NeWbom.
the Wcstern. P~cific. 2006. www.pfmcd.org. Academy. of Breas.tfccding Mcmcine,
2002.
4. DOH - National Objectiy.~s for Health. 2005-.2010~
Department cfHca+th. Available at:www.doh.gov.ph/ . 8 .. Elreastfecding for Physicians. American Academy of
n oh. .2005. Ped,ia:tnc~s..' 2006 . ' . .

llnanned 8y: ~
- - - -- - - --
 CHAPTER 29: THE NORMAL NEWBORN
9. Ho~ CR, Howa,rd FM, Lanphear 8, et al. Randomized
clinical trial of pacifier use and bottle feeding or cup
feeding and their effect on breastfeeding. Pediatrics
2003; 111:511-518.
10. Howard CR, de Blieck EA, ten Hoopen CB, et al.
Physiologic stability of newborns during cup- <:.nd
bottlefeeding. Pediatrics 1999; 104: 1-7. .
11. Marinelli KA, Burke GS, Dodd VL. A qlmparison of the
safety:o f-cup !eedin.gs and bottie feedings in premature
infants whose mothers intend to breastfeed. J Perinatot
2001; 21: 350-355.
12. P'..antelli.G, ~ C, Colt;riA, l.Udovici G, Paita "Y,
OramelliniD. Ultrasoun~ dating..:cur~e analysis in the
assessment ofgeSta.tional age. C!.ht Exp Obs~t Gynectil
1994; 21(2):108~118. . 2004; 158: 89'/-902.
13. Ballard ,JL, .Khoury JC, Wedig K, Wang L, Eilers-
WalsmanBL, Upp R. New .B~d .Score, expanded to
include extremely pretnato.u-e Wants. J Pediatr-199.1;
1)9(3)~ 4J7~423. . .
14. Lakartidriihgen. Review of Utnbi.Ucal c crd care and
jlre1!et"~tion ofinfetions. 2002: 99(14): 1563-1556.
. .
.15. ~ 'R; Kliegman R. J~so.nH. Nelson Textbook
of~tric.s, 17th Edition.. 2004.
16. Recom.'~ '~ nd!).tions for prevention of neonata l
- oph~~ CanMed AsSJJC J 19 83; .1 29 (6): 5.5 4-555.
.. . '?1~!{~ . :-_ : " . . . .
Scanned By:
459
.,; ~
17. Consultation with the specialist. Eye prophy~s :in th~"
newborn: infa.'"lt. Pediatr Rev 1993; 14(111: 423.
18. Department of Health. Implementing Guidelines on
Hepatitis B Immunization for Infants. AO No 2006-
. 0015.
19. Chaoguan L. Long terta effects ofBCG vaccination on
T lymphocyte subpopulations in Asians.
20. Screening for Inborn Errors of Metabolism. Philippine
Pediatric Society Policy s~tements. 2004; 4 {4): 18-21.
21. Chapman DJ:, Dam.io G, YoungS, Perez..Escamilla R.
Effectiveness ofbreastfeedblg Peer Counseling an a low-
in~ome, predominantly Latina population: a
randomized, controlled trial Arch Pediatr AsolescMed
.
22. Grummer-Strawn LM, Rice SP, .Dugas K, Ctai-k LD,
BentonDav.is S . An evaluatiQn of ~teastfeeding
promotion through peer :conSe:ling in Mississippi WlC
clinics. Mate:rn: Child Health J 1997.; 1: 3~-42.
23. Schafer E, VogelMK, Viegas S, Hausafus_.C . V4mteer
peertounselorsinctease..brt-.-astfeeding du!ati<:~n'atnong
. rur allowipcome.women. Birth 1998; 2.5 : 101.100.
' - J", ~~ ~- f~ ~ "t~~
24. PPS Preventive Pediatric Handbook:. f'hilippine
Pediatric Society. 2008.
25. Edmond KL, et al. Delayed :breastfeedi,ng .W ti.ation
increases riskofneonat&l,mo.rtality. PedUi.trics~2"6b6; -
117(3): e380-e386 . .: -:':".! 'A
.-!.:J.
~
! .

...
~ .

.,

. :

Scanned 8y: r-.

~
 30

THE PUERPERIUM

:MILAGROS J. TIA-JOCSON, MD

Definition
Changes in the Reproductive Tract System
Involution of the Uterus
Involution ofP~acental Site
Endometrial Regeneration
!mag!ng Andings
Clin1cai.Aspects .
Fourth Stage of 'labor
Lochia
Mer Pain
Chang,esinthetower Reproductive Tract
Peri~eal Care

Changes in the Urinary Tract

Breast Changes ahd Lactation
Phases of M:lk Secretion,
Local Setting
Benefit to the Women
Breast Fever
Return of Ovulation and Menstruation
Changes in the Cardiovascular System
Changes in the Abdominal Wall
i
~
Other Issues i
Physical Activity !
Welght Loss .f
Postnatal Care
Early Oischarge 1
I
l
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 SECTION I'V: CLINICAL APPROACH TO lABOR /.DELIVERY
.; .;

...J.:
DEFINITION superficial layer becomes necrotic which is then
sh;mghed 4:t the lochia, while the ba~ litye~
Puerperium refers to the Pe~od \that.: s.tirts remains viable and is the source of the n'ew
imn:l:ediately aftc!:" the delivery of the placenta and endometrium. 'the process of regeneration in trus
f .tsts .:until 6 weeks after C.elivery 1 This is the are~ :o~urs rapidly so that within a week, it is
~e wben mqst physiologic changes that occurred covered by !lew epithel.iam. But full restoratiQn or'
. ; :~~g pregnancy will rerum to the prepregnancy . the entire endometrium, including the placental
-statel. site , is not achieved until during the third
week.3

... ; . . - ~
;i,~
. . .
~c;~utl~~ :pf.~e:Ute~ :~):.itO\~ : . . I . . . VJ~asotmd .s~4ies. of.t;heuterhs artC;r no$al
1
y _w,:;,:_~.:~::..~}( .A/ du. ~-v.
. . ....~
~.l~t~rf'tt~~-
. .. :Ull.Jl,.I.~;::;Y ru,er e vety.o uep acenta ..u:.... Vagina!.
. . './.Mf
. . j d,djv'#)' _ O~e:d fu_at:fu.e U:td'U3 waso
. . sh
.1
.:ften
. . ..
' ~..~t:e~s -~nh~:d~ tolii~lly, ...redq.~ing ..its.'~~ . . retr,ov~~:~:;~?- .t.h.e . ~vi.ty . em.p:Y~ ii:t ~ early..

...... ..r.-.;6~
Sl~"-CU.. . . . . t1 y SO th . t "''\... r-... A
a UJ.e Ul'l.t.:.!.US lS :fi0W 1ocat
. : ed P.u.erpenQlll
. . . n the. .m.1d .puerp.eno:rn, . . fh.nd
. ...an
_d_ ::
, ..slightly beiow the u.mhilicus.3 Thi-s toni~ deb~s :-:ere seen m the ;vhole caVIty; by _nay;_ ~>. ~ ..
c:On~clion cornpte;Ss~ the blOod ve~~ls ~thin ~e ~":,ty was en1pty ana. appeare~ s.-s a thin we,~ .
~- ..... , m . . . . ,.,..... . .
...U!,.J; h . ta .. ~ 4 line. nnother study showed . pos1tivc correlation ....
~yome . urp. .resp,. ~g m emos s1s, an... b tw . . .- 'h d . . d. .. ......
... "-"' . .. t . .. . 1. , . . . '2 e . een pan~J' an u.t~nne tameter With the.:..
~4s ..prev.en mg pop~partu:r..:. h,e.m.orr:hage. . . . *""-'~ .. . . . .. . . . . . ~ .. ' . . . .. .
Pr .. ed . cr . . uterus no ~c;u to ;> largenn the multiparous group
-~-~srve ;r uctien -~~ the \lt~~ stze further .. . .. . ... . ~ . . -. ., ,, . . '
. QCcui;Sso~tha:tbytbe..l~'t-o.tJ/lth.P9stpartumday co~par~d to the nulliparous group. Rout~ o.(..
. . :"'::r~.:~-,. ,.,...,...~:.
. 1c- u.~r~m-.v'bHe]>C1YI.ecaVltyan-.ca:rrno1onger" .
.;. ... - . .,. . . .d.. . '. deliv~ry wa:s, anothe:r;.fa:tor~that~affected..utenxs... .
.. .. .. .. . ., ~
'' .. '-.:: ~t....,~-o-~.~: bd: _ . ;~11-.. :B .. , k'.. : . . .:. 1:... . .size aft~ G.e_llvezy., wifu.t he uterus. noted to:be .
. ~Y"""~t=- a. omm. ~;r..:.. Y' 6 !'Wee. s.~Itregwus .. . . : . ._. - . . ':- . ~ . . .. .: :
' t' . -~::._ . . . , .r . ., .. . larger at one ana.
.. 1ts..nonp~
.$~- ~ ..""""' ,process o IDV.OJ.~tion _. ' .three
. months
. : after deliVqy. ..cy . .
. _.t.; tb....:.. .... . ..,:~~ :,.to .t .. :.:....:,.._, ... ' ....esar~section, wh.en~mm:\l'e<:ltoone following
~.:..1.~m. ""' Uu;.f:U~ re,~~#s . 'l sno.1~S1Ze .1s . . .... . ", .. ; :- '-...-,:. . ..
- ~,.. .:r-:,..,.,.,..t~-1-;.le ....;1..~_t : ;o.1o._ ~ ......:.,...,_. . ':;". "'~-.... <AIV\ delivecy7,.Reg\ilar ..or~as~ .feed:ing .Wa.s ;also
~ ,.............,..!UI.1;1., , <\;l.u:t: .'"".e. . ...."""".""s we~.o.uc~g. 1 u.~o;~v :aginal t d . th _.,
_ :: . .

. ar
.. .,.,..;.n,_.:.,.
.. b'-~,
t 'te:r.~ ~ ~d
.:th .,:.-.""~ f;k .. ,.~.. .......:.:,,,. assoc1ae W1. Sm.4Uer:utenattiu:eem
' eHv~'J ,p . u..e.~p~centa,wLU .now" .. d 1i 7
9nths'aftex: '>

.. ~i~:.$(};,gmnrs~al-~fue::iend'Of.;fue ,p~erp~rium;~, .. e very. ' , . ~.- .: ... .. . ... : . .. .
~~~ .~~M~\<\~~ q--~ ~ ~ l~t0-" CJ.ll:iical I~~es
1
...

.. --~fii'Uoii ol~P.liceD.W.:fiite "t-mrx"' ... . ... _... .. - :

>--~:-~--". : .... . .. """. .. ....
Aft~ the dcl:ivery :of.t h.e plqcenta, the vessels t{lllikr:J The "fourth ~tage. of labor" is defined ~ '.l lie.:
.:. . ~- $e .pl~~'l).tal sit~ .un:O.er:go thrembosis. and
hyill,iijia_tion. There i"s aliso in'filtration wjth
.~")locytes :arid :m .o nonu'Clear cells .:that e~end
. 'into::: the :endometr.ium irrd ~up~ffi'c:J.a:l
:n.iY<#netn:um. 'The thrombose,. .and hy:alinized
-v:elP.'~ .are ~venwa,Uy ~d:ed with tlie slough 0f
:tll..e pecrotic placent?l site. By the seventh. day,
.. r~~her.ation o f endometrial glai'].ds and .stroma
.~~g..from the margirts of the placental s!te and
'fr.~m ~th.e deddua ba~s-occur which .eventually
U:nd,n;nine -the ~ntire implantation site. The
: i~f:,u'Cted -and .necrotic superficial tissues are
gB);d).l3}ly .exfoliated and extr:uded out. Complete
.,eXtrusion of the placental site may last up to 6.
.. . .. wee;ks.3
-~~-~ ~ .-~fl!.t'1~ ~~gfJ~.9.f.: . ' .-. ~ .: . .. t
.first hour ,aft!!r"dill.y~ryofti';le .pla~nta. This-is-a: :. :
critic:alperlod 'becau~ it'is du,rjp.{(ili.i~ tim.e ithat .
the .risk cf sig:hificant :hetp.ortha,.ge is grca~t? .'
'Clo~e watch of.the pa1Jent spoU:ld:P e mairif:i!i'n.ea. .
by :ll'lor..itoring thv:ita:l :signs cv~r'.f 15 r4inutes .. or
more often if ~~essaty:. Tohe titerus . shou.i4:~'
palpated perii><i1ally :to en's~re ,that it is ;,y~n'
contracted, and mas:Sa:~e of' tJie -uterus iliro.ugh ..
the abdorp:~ wall shouldbe done if relaxatlpil..i s >
notedShe amount ~fvaginal bleeding should also . .
be monitored b,y inspect~z;1g the :p erineal area.' . .
Early .etettion of uterine: atony as mdicated..by. .:
the presence ofuteripe_ r:el?Jrn:tiori a:nd an incrtase .- :.-.
in vaginal bleedii).g is important so that immediate
.intervention can be applied. 1 ...

,
. ..: . .
. 'End~metrlal Regeneration Lochia
. ....
. .
Within the f irst 2 or
3 days postpartum, the Lochia refers to the vagtrJ_al .ciisch.arge tiiat : .' ..: .'
.r~~ainjng d/i<:.Iua splits .into 2 layers. The originate mai;1ly from the uterus durll:lg .the . ..
.

Seanned lly: C
 CHAPTER 30: THE PUERPERIUM 463

postpartum period. This consists...o f ecythrocytes, "myrtiform caruncles~ at. the vaginal ~tus2.
decidu$, epith.elial cells ;md ~cteria, and its This . appears a:s small elevations of the :mucous
appearance .andamount vary With time. It beglt1s . membrane encircling the vaginal orifice.'
as a flowofbloqd lastfugfor several'hours, rapidly ;
~shfug to a reddi$h brown di~ha..rge, which Perineal Care I

lasts fo_r 3.-4.liay.s (lochia rubta} . . It-then becomes

progressively paler.in.colot (lochia ~erosa) .After. .
10 days postpa~mf the dis~harge beco_m~s
yellowish white in CQlor , con~isti:I).g of leuk&cyt~s
and .reduced fluid content ( lochia elba). LOchia
may 'persist from 4 to aweeks.3 .
Some women may experience a sudde~ but
tra.&Sient in.crease in ~terin-e ble.ed,ing between. 7
~nd l4 days postpartum: This occurrence
ro~ponds t() the slough of eschar. over the site
.of placental atta,ch,me.nt. This episode is .sei.f -
limit ed :and does not r.equire any s.p ecific
t:r.eatmentl. However, if it doe~ not subside ,.\.ithin
a 'few hours, patient should be evaluated for
J>os~bte:~?ined placental tissue..
. .
A~r f.g_U,{L,
This refers .to. the intermittent, crampy.lower
al>do~E!!Jiain thatis expepep~ by,.the woman
.artet detiv~cy. Its duration. and intensity are
.
m.~~th ~ty. which .~rrela.tes with the
o.bset:w..tiorrtbat l:4e uterus in mulUpar.a contracts
]JlOTe vigorou$ly at intervala While that of the
primi~ ten,cls .to :remmn ton.icitlly .contracte4!
Cleansing of the .p erineal area using water a,nd
mild soap should be done from ;mierior to
posterior r~gion. To reduce swelling and discomfort
fro.m .t he epi~iotomy wound, ice packs may be
applied t o' the a:rea. Use. Of analgesics is also
helpful. lf perineal pain .i s severe or persistent,
the area should be examined carefully to rule out
hematoma or ~llulitis. In easeof foll.dh. degre e .
lacer:ations, stool softener should be prescribe~
for one week. 3
CHANGES IN 'T HE URINARY TRACT
The ~ary biaddt:"-.. i.nmiediately ~m
b,as ~ incre.as.e d capacity and is. relatively
insensit ive to intravesical fluid pres~1,.lre_;; ~uJ~ng
in tl;le . tendency 'to c;;verdistention;. 1n~iete.
emptyj,ng end incr eased resid'I.W, unpe.~:~~!;tay
be aggravated by.exposure to the.paralyzing..effect
of regional 'bloc~ .a nesthe.s ia !Uld i:ra~ W , the
urethra :a nd l;>,ladd~r .d\4-ing :delivery,;.'~;will
cause. hyperemia and edf!ma. 1 Th~~i i"S-1'hlso:
ac~mpanying. diw:eois du.rlilg the,.:: fi,rst;,~.as
a means ohidding the body of excess extucC:UUlar
fluid acquire4 .n9TclliaUY during pr.~- The

~r~~~~~r~~~~rt~~;1~~ ~~~~~= ~~
oxyto.in from the posterior .p ituitary gland.
. 8
.:~1?..l!~j:jng ..t_$j!Sl$'il..Df..the _utinary.,tfaCt-which.
is.~.dila,te.d.... dur~ng....pregnancy-.retuma- to -i-ts
pr:.e pregnt'!,nt measurement by the :~ week
Ant!lger.!es may be taken to provide. pain relief. po.s .tpattuni. A~i of th~se factors exppse the
postpartum woman to incr~Sed risk :.Or'1Uinary
LOWER REPRODUCTIVE TRACT . tract.infecti.on.~ To prevent bladder over.disteJ)tiop,
the patient should be :encouraged to vOid within
.T.he lower ute~~n~ segment contr:ac::;ts and a few.hours after delivery:
retracts, convertiri'g back into.the uterine isthmus
located betw~.en tl).e corpus and . tl)e in te:rnal BREAST CHANGES AND LACTATION
~rv:ical os. The cervix . also conq-acts and the
cervic~l opening narrows. The externai os, During pregna ncy, complex humoral and
h~w.ever. remains'widenvith bilateral depressions neural mechanisms iiwolving several.bonnones
at iatera} . positions .. due to .lacera tions incurred
(progesterone, estrogen, placentallactogen,
during delivery\ resulting in . a "fish-mouth" prolactirt, insulin and cortisol) prepare the breast
a.ppearance. 1 for lactaticm. There is growth and devel~ent of
. . . . . the lactiferou s. ducts and alveolar ~crotory
The vaginal canal forms a smooth~walled epithelium syste m . B.u t the two important
passage that progress,ively decreases in size while hormones that have important roles in breast milk .
the nigae reappear at .a bout the.t hird week.3 secretion are prolactin and o~ocin. .Filowing
~elivery with fall in progesterone and ~tiogen .
The hymen gets tom during vaginal delivery l~vels, prolactin h<:>rmone. which is secreted by
~nd the remains . cicatrize to become. the the pituitary gland, isable to stimulate unopposed

Scanned 8y: ~
464 SECTION IV: CLiNICAL APPROACH TO LABOR I DELIVERY

milk lactose forma:tion Although the level of complications shan be given to their mothers to
prolactin in the plasma.after delivery is lower than hold and care$s itnme.diately . after birth and:
during'pregnancy', .each act of sucklitlg triggersa th.tough the assistance of a hospital staff,oinitia:te
rise in levels. Oxytocin en the other hand, is breastfeeding in the delivery room {latching-on ). .
secreted by the neurohypohysis in pulsatile The infants ..shall then be r(>omedin with their
fashion and stimulate$ milk expression from . a mothers Within 30.minute~ to 1 hour iifter delivery
lactating br.east by e;.tttractjon of myoepithelial to promote and facilitate .brea~tfeedmg. Following
cells in the 8.lveoli arid small milk ducts. This "let Cesarean deliveriea, inother$ sht~.U ~ ,given tQ.ei r
do.wn" r.dleA is triggtm~d :b y su~klipg. whJch babies to hold a nd careSs as soon :as she wakes
stimulates further secretion ofnxytocin, Cry of.the up from anesthesi~. Well infants shall then be
infant also stimulates milk let down, while fiigbt roomed-in With their mother$ within three to four
or stress ~ inhibit it.3 hour~;~ a;fter birtb. a~.d breastfeeding is then
initiated ,.;th the assistance or the ~()spital 's taff.
Phase: .of Mllk .Seeretion Hc>wever., .eJdstence of conditions t hat .do not
permit :rootni ns-in .,__n d breastfeeding as
The quality of breast milk varies a s time determined by tht .attending physicians may
progresses ~ter delivery. exempt moth:ets and infants from the above
proVisions~ H
Cclosttutn~ the first milk secreted lasts for
five days. This ilS .tlUclc,yellowish in -color, and The advant~ge of practiCing latchiri.';i-o n
ha5 bigh.protein t~laclalbuinin. &4\ctoglobulirt imrnediatJy po-st'Parttim.is suppOrted by a recent
and '~sei~)y.: and li.l.b.i~'CO'ntent;J 4~'I;gel';fat . . .study . that.showed ' . that vezy early skin-ti;>:-skin
gtobule:s:~a.nd:~!lesS~WbOby.dl1tte~:MtibOdibFare.-.' 'cont!'lct enlul.nced:breastfeeding; during earlY"
:also.~present~; es~yl~llrtoglob_uijn;;A tfgM postpartum .perlod~12
which . p_rovide: :ilrotecti.on: '~gai'ri.'$'t :;-:ente.ric
~t.l)qg~s;,... ti fll$() ,CZ\Qn~s ~es like.li:pase :Seneiit . to:.~: !Woinen .
and 'lacl:aseo:w hlh. hetp:iJ1e.~> ..:. . . . ..
.. . :.:": ~. .' .. , ' : .. - ... . . . ....Mothef$;.lu$6 :ben~fitJrom 'breastfeedh'"lg, 'The
..M.a1:\ire.:nillktis:nlP1e.<~ter}o;rQ.nd :~ntam~ln,o~: ..,:, o:xytocirt;tb~ttifi~leasd;dq_Jing.IIiilk~let"'d&Wn<fu;
Ia:t :~d<ti\e.l~~~ .~n,~~U"atlon~' :.ru~t' lii -~tbe th~. ~~Jy PQ$~til ~do4 eau$.es incte~sed
qo}~-~tr.uii:ls, J!J.~~ls.~_#e!!jh. ~~ibP.:~i,ta~ At . . ~__ntrnctiol}_s :~'d. i!~~~~mUP.;i..!~mal~ ~!~~ . !9_~s.
PQlt\Ml~J!ll Yitamimr~P.t .,~~ It..h~lUU!P.e.:ti.al .ar~~tkooJng_mc:.t\l~Q a:3.s,oorn:t.~d. wim d.e creased
quality 61-cllanr;in~ :tts e<:>mp.6Sitionto l:tl~tch the incidence ot'.o-~atian , and brea~t canter. It
inJ'ant's . nutrl.tion&l -needs-~ Added advantag~ ~of promotes bitth ~pacing bY delaying.the return of
h~ w..ilk to the .. riewb()m b tha.t,~side .{to~ ovulat;ory - ~yde. Both oxytocin a,nd prolactin
p~oVid~nir the right bruanee. t)f i:lutri~nts '.tlnd protnote feeling of attachment arid relaxation. 10
iP1~unologh~ factors, it. abo ~ontaitrs growth Recent studies :also show that b~a:Stfeeaing ma y
fact.or$ that p:'otnote :cellular gr<iW:th: a.ttd attenu.ate unfavorable metabolic r:isk factor
difrercntia.Uon, )ead~g to m atl:ltationofthe organ cha.."1ge$..that~r with pr~gnancy, 'by reducing
systen1 ofUl.e t fewbQtn.l0 the ~:ri~ in ihe19W"'den$ity UP.oi?.rotei,rt.and fasting
. -. . .;. insul!:n leve1s;l3 However, it m ay r esult in bone
Local ~etting . demin~rali~tio.n . due to. ma,ternal transfer .of
calium to-the breastmiJk, which occurs even with
sm:ce prcper an.d adeqUate feeding is vitalfor calci um supplementation, . Fortunately,
physi~ and 'rP..entaldc:Velopment ofthe newborn~ reminetalization :Oceuts following weaning, and
. the Ph,ilippines Department of UeaJth strongly bone mineral density mass is expected to return
~dvoc;:a:t~ exclusive 'btea$tf~ding for the fin;t $ix to normal a ye.ar after cessation of lactation. 2
Ill.onth.li. In. lli)e with this, . the Republic .Act N.o. . Lactating women should therefore be advised to
7600, also known a-s The . Rooming . ;. Jn and continue calcium :supplementation even after
Breast;feeding .Act of 1992 was signed .into<la,w weaning; Res trleting .milk intakeidurlng l actation
which r equires that all private .and govetnment has..also.b een;correlated with inadequate .. protein
health buitituUons apopt .rooming-in , and and. micronutrient in~e with no difference in
breastfeeding practices_ This. law requires that all w.dght l oss, when compared to those who do not
well infants delivered vaginally without restrict milk intake.14 Hence, to maximize the

Scanned 8y: ~
 CHAPTER 30: THE PUERPERIUM
:tbenefit of breas~feeding, mothers shQuld be
encouraged to - <Jrink milk du.ting lactation.
According to tbe .U.S National Research Council,
the recommended daily caloric .requirement for
Iactatirlg women during the frrst 6 months is 2.,500
cal0li~s. 2-
The 2003 Philippine National Pcmographic
and Health Survey shows that 87% of children
born in the preceeding five yeats were breastfed.
F~cto.rs that wer~ ide.n tified tc influence the
likelihood of the child to be breMtfed were the
following: geographical location ( rural vs urban -
91% v:S' '82%}. economic status (poor~r v~
wealthier household - 93% vs 79%), education
(less vs ~ttt:r edue2.tea mother -. 95% vs 82%),
and birth attendant {traditional birth at~endant
vs h ealth professional ~ 93% vs 8$%)15
"- Breast Fever
.; .. , :. __ .
. . , Eleyation pfbody tetnwa.ture tna,Y aceompany
breast engorgeinent..QUfhtg the :fh:st 24 h9WS after
st~m .of lactation. This m.ay range from. 37.8 to
39 OC. a.nd -usuallY v,rill not last long~r tllan 1:6
hours.. Exo.e_ssive .Qr~a$t el)go-rgement -m ay be
treated'.by'-snpJ)ox:tin,g the breast With aJ:>ind~r or
bras$iere;cta:pplying ice bag an<l intake of
arialgesic~;fbfuer ca~ses of fever must also be
e.xcluded. 3
Postpartum ~omen who do not breastfeed
may experience ovu.lati3n as early as 4 weeks after
deliVery, with a mean period of 10 We~s. Lactating
mothers may delay their m.'Ulatiori for .. a mean
duration of 6 months 2 , although fr-equent
.breastfeediilg .f ur longer toW time each day can
furth'er delay orula:tion.
.fot more t],_an io<morit..'-ls;16
Menstruation will return in 70% of non-lactating
postpartum:wome[l l:lythe 1.2u..week~ter.delivery,
although the average time from delivery to the
first mensl:nlation is as early as 7 weeks.2
The delay in ovulation in lactating women is
attributed to the ~eir persistently elevated seru~
prolactin level which is believed to make the
ovaries unresponsive to FSH stimulation2 :
CHAirGES TN THE. CARDIOVASCULAR SYS'i'EM
I obesity. lmmedi.ateiy after delivery with uterin~ .
Immediately after delivery, plasma volume is
diminished by approxima tely 1 lit~r be cause of
Scanned 8y:
4.65
'b lood loss, but this would incr~ase by aoout the
same amount by the third po~tpartum -.day
becau$C of shift of extracel_h ilar fiuid in{9 the
vascular space. 2 By one w~ek pos~-tum, the .
blood volume returns to nearly its con~preg!)a..~t
level. Cardiac output remaina elevated lor two days
postpartum but gradually de~reases until reaching
-nonnallevel by the 2nd week;3
Blood coagulatioQ factors r emain elevated .for
variable perioqs during the pUerperium. In one
study, the gr.e atest level .o J c;:Qagulability w.as
observed to be present during the first 48 hours
postpartuml. Fibtin()ge~ .l~el remains .elevated-
during the_first week po&tpartl,lm3, after which
progressive decline i~ expected until eventually
ret:Uming to prepregnctr1t level
CHANGES IN THE .ABDOMINAL W.,ALL
. : ~ ':": .. ": .--: .; ~-: . "':' '
After delivery, the abdominal wall r~mains soft
~d flaccid. But a:fteJ," sever~. .we~s~,U~~ay
.retur.n to it~.prpr~cy. ap~ee~ -~~P.f;:for
the presen~e :ef stretc:!:-~ .mar}cs.., ~hieb..;is,-t!Q;w~
as silvery striae._..lf diste.n tion of the ~~~men
during:.pregpancy resulted in -mark~ ~~tion
t>fthe ~s -mQs~es,- p.ia~W,sls rCti.;way, ~ult
causing .themidline abdominal-wall-t o be:d "onned
only by peritoneum. attenuat-e.d~~J~cia,
subcutaneous fat and skin.3 This wili~Iool<ftlik~--a
ridge whiCh runs down the-.t nidqle of the Jll>domen.
-ln." UlQ$LCas~i.. :dia-$tasis i:ecti . heals:on.lts. own.
.Exercise may. a1so .i.tnprove: the.-conditiOtt:'7
OTHER lSSUES
Physbal Activity
Early ambulation :for those with uncomplicated
v agina! delivezy is encouragect. However. this has
to been .done gradually and the patient has to be
a:;;sh>te<l ;initially in ca se she. experiences some
.d izziness. Being out of bed within a few hours after
deliv:=ry has been associated with less bladdef
com.pfication and less ipcidence of
thromboembolic disea se. 3
Weight Loss
. Retenti~n o( wei~~t gain,ed d~~g pregnancy
i's an im-p ortant 'factor in feina.Ie overweight and
evacua~ion and blood -loss,. women generally lose
5 - 6 kg. Further loss of .body fluid thtu diuresi~ .
~
 .;..~ :.

.,

..,

. -: . ..

.. ......

.-.
..
.)

.... -.
....
:. ~.
.! .

Scanned 8y: C
 SECTION IV: CLINICAL APPROACH TO lABOR I DELIVERY 466

in. the subsequent days leads to another 2 - 3 kg
weight loss. 3 However, only 37% of women are able.
to return to their prepregnant weight six months
postpartum. Failure to lose weight .gained during
pregnancy . in six months is considered an
important predictor of future obesity. It has been
shown that those who retain postpartum weight
were 8.3 kg hea vier at lO~yr follow-up while those .
who were able to' lose them by the sixth month
postpartum were only 2. 4 kg heavier 18 To promote
weight reduction after childbirth, there is evidence
suggesting that exercise alone is not effective; to
cause significant weight. loss, this has to be
combined with diet. It is also reassuring to note
that this intervention of combined exercise and
diet during the postpartum period .has not been
shown to adversely affect breastfeeding
performance. 19
Postnatal Care
Providing .health care to the mother after
delivery is important to enable the identification
of complications arising from the delivery, and to
provide the mother with information on how to
take care of herself and the baby. For those who
deliver iri the hospital, it is assumed that they
routinely receive postnatal care. Since 66.47% of
.deliveries in our country occur in a home setting2 o,
providing postnatal cate to these women is even
more important. The P~ilippine Department of .
Health recommehds that mothers receive
postnatal check up within two days after delivery.
In the 2003 National Demographic and Health
Survey, it was noted that only 34o/~ of women
surveyed who delivered outside a health facility
had postnatal check up within . two. days
postpartum, wl)ile 17% .had check up from three
to six days postpart:q.m. 1s
Early Discharge
For those who deliver in .the hospital; there is
a growing tren4 towards discharging them early.
In a meta-analysis tl1at review~d studies on early
discharge from hospital for healthy .mothers and .
term infants, there was no eVidence shc:>wing that
early discharge was . associated with. adverse
outcome (i.e.' mfant or maternal readmission), and
that it had rio l.mpacton breastfeeding, 21 However,
one limita-tion of this study was the great
variability in the definition of early discharge
across the eighf trials included in
the review,
which rang~d from .6 to 72 hours after deiivery.

POINTS TO REMEMBER

Puerperium period refer$ to the first t? weeks after delivery.

. Complete involution of the uterus occurs by the 61h week postpartum.

Full endometrial regeneration is not achieved until the third week after delivery~

Factors that affect the process of involution include the following: parity, route of delivery and breast
feeding.

The risk of significant hemorrhage is greatest during the first hour postpartum, which is referred to as
the "fourth stage of labor".
. The vaginal discharge postpartum (lochia) progressively v~ries in its appec;~rance and arnount ( from
lochia rubra to lochia serosa then to lochia alba);

Following vaginal delivery, the external os of the cervix assumes a "fish-mouth" appearance.

The remains of the hymen cicatrize to form "myrtiform caruncles.

. . .)
Colustn.im is the first milk secreted which is thick and yellowish in color and has high protein.and
mineral oontent.

Mature
. m.ilk .is more watery and contains more fat
. and lactose concentration.
.

Scanned By: ~- -
 .
467 CHAPTE~ 30: THE PUERPERIUM

.. ,,

Republic Act No: 7600, also known as "The Rooming-In and Breastfeeding-Ac.t of 1992" requires all
. private and government health institutions to adop~ rooming-in . and breastfeeding practices'.

Ovu)ation can occur as early as 4 .we.eks after delivery for women who do not. breas"tfeed.

Presence .of stretch marks, known as silvery striae, may .be present on the ahdomir]al wall after delivery.

. Ep.rly.ambt,Jlation is as~ociated with less bladder c~mplication a~d thromboembolic disease.

Combined exercise ahd diet i.s important to promote weight reduction after.childbirth:
. .
There is a trend towards early discharge for: thos.e women who deliver in the hospital.

11. The Rooming-In and Breastfeeding'Act(R.A.7600) and

1. Sumpaico WW, Baja-Pan1ilio H (editor~). The
,puerperium. Chapter 24, Textbook of Obst.e trics, 2nd .
. erution,-Philippine.Association of Writers of the _Philippine
. Textbooks of Obstetrics ane\ Gynecology, Inc., 2002.
2. ()abeGG, NiebylJR,"SimpsonJL (editors): Postpartum
. Care. Chapter 2 1, Obstetrics~ Nqrmal and Problem .
.Pregnancies, 4th edition, Churchill Livin gston, 2002
3. Cunningham F.G, .Leveno K.J,. Bloom SL, Hauth J C,
G ilstrapill.LC;Wenstrom KD (editors): The Puerperjum,
Normal Labor and DeliverY., Chapt~r 17,30, Williams
Obstetrics, 22nd ed!-tion, McGraw- Hill, 2005
4. Mulic-LutvicaA, Bekuretsion M, Bakos 0, Axelsson 0 ..
. mtrasop.ic evaluation of the uterus and uterine cavity
after nonnf}.l.,yagio.a t .de.liv.ery. Ultrasound Obstet
(}~ecql..~QQ!; ~~(SJ.: 4.9.1-4.9Jt .
5 .. Al-Bdour AN, A~ash HF, Al-Husb1J.il NA.
Ultrasonography of the uterus after normal ~aginal
delivery..S~~di Med J 2004; 2?(1): 41-44.
6 . 61ayemi0, OmlgbodunM, ObajimiMO, ,OdukogbeAA,
.Agl,lD.loye AM, Ai.makhu CO, Qkuniola.MA. '()ltrasound
Its Implementing Rules and Regulations. DOH, Phil
2004.
12. Moore.ER, Anderson GC. Randomized C(lntrolled triai
.of v.e ry early mother-infant skin-to skin contact and
breastfeeding statUs. J MidWifery Womens Health ,.
2007; 52(2):1~ 6-1'25 .
13 .. Gunderson .EP, Lewis CE, Wei GS, Whitm er RA,
Quise.nberiy CP, Sidney S . Lactation and changes in
matem'al metabolicris~ factors: Obstet Gynecol2007;
109 (3): 729-738 . .
l4. Mannion CA, Gray-D~riald K, John.son-Down L, Koski
KG. Lac.tating women r estricting milk are low o~lect :
. nutrients. JAm Coli Nutr 2007; 26(2): l49- 15_t.:J
1s. Philippine NatiOiYal oemographic ana Health sUrvey ;- t
2003. NSO; USAID; ORC'Mac.r6, 'Oct 20()4.. . i.
I
'
16. Hov,.i.e l:'W, McNeilly AS. Breastfeeding and.postpartum
'
l
ovulation. IPPF Med Bull 1982; 16(2): 1-3 . !
!
17 . Marx J Rosen~'s Emergency Medicine: Concept's and 1-f
. . Clinical. Practic.e , 6th ed. St. Louis, Mo: Mosby 2006 .
. I. ~

a~ssment of theefe'ct of parity on postpartum uterine

18. Rooney.BL, Schau berger CW. Excess pregnancy weight
.involution. J Obstet Gynecol2002 ! 22(4): 38 1-384. I ,
gain. and long-tenn obesity:one decade.later. Obstet o I

. . Gynecol 2002; 100(2): 245-52. :~

7. Negishi H, Kishida T, Yamada H, Hir:ayama E, Mikuni
M, Fujumoto S. Changes in uterine size after vaginal
Jielivery and cesarean section determined by vaginal
sonography in the puerperium. Arch. Gynecol Obstet
- 1999; 263 (~ - 2):13- 1 6.
8. Holdcroft A., Snidvongs S, Cason A, Dore CJ, Berkey
KJ. Pain and uterine ~on tractions during breast feeding
.in the immediate post-p~m period increase with
parity. Pain 2003;104_ (3): 598-596 . .. .
19. Amorim AR,'Linne Y1v1 , Lourenco PMC. Diet or exercise;
or b ot.l;l, for weight reduction in women after.childbirth
..
( Revie,v). The Cochrane Collaboration, The Coc~rane
Library.20.07, Issue 3.
20. Philippine Fi~ld Health Service Information System
Annual2004 Report, Nati.onal Epidemiologicai Center,
DOH. .

9. DorlaDd's Medi.cal Dictionary. 21.' BrownS, Small R, Fa ber B 1 Krastev A, Davis P, Early
postnatal discharge from hospital' fo r healthy mothers
10. ACOG Educational Bulletin. Breastfeeding: Maternal and. and term inf.:mts (Review). The Cochra11e Collaboration.
Infant Aspects, Num~r 258; 2006 Compendium, ACOG The Cochrane Library .2007 , Issue 3 .

Scanned 8y: ~
 Hemorrhages in Pregnancy

31 Abortion (Miscarriage)
" Loss
32 Recurrent Pregnancy

33 Ectopic Pregnancy .
~~ - ~ .

_34 Abnormalities of the Placenta,

.. ._.;_..-....._. . Fetal" Membranes and Amniotic
'

.: ?:'-' ::.:'-~Fluid <

:ss~ Gestational Trophoblastic

_.:. '\ .:. bfs.eas~ . >

36 Placenta Previa

37 Abruptio Placenta

38 Disseminated Intravascular
.Coagulation in Obstytrics

- . . ...
~

"'=:-

'. :~ .. . .

Scanned 8y: ~
. ... .
.'

.. j

Seanned lly: C
 31-
ABORTION
(MISCARRIA.GE)
ZA!DA NOBLEJAS-GAMILLA, MD

Definition

Incidence

Pathophysiology

etiology
Fetal Factors
Maternal Factor~
Drugs,SubStance, and Envir.onrnental Factors

Categories of Spontaneous Abortions

Threatened Abortion
Inevitable- Abortion
lneomplete,;A.bortion
Misse-dAtroltlon
Recurrent Abortion
Anfiphospolipid Antibody Syndrome
\ Thrombophilia
i

Tre~tment

Complications
Septic Abortion I Shock

lleanned 8y: ~
. < 472 . ,
SECTION V: HEMORRHAGES IN PREGNANCY

DEFINITION ca:ses of abortions with a mortality rate of .0,82

.. . . percent for spontaneous abortions and .1:43
. . Abortion is the expulsion of the proquct of percent for induced -abortion. In 2006, theie were".
.. eoi:lception or termination of pregnancy before the 72,96q.cases reported but with the same 'mortalitY.
..~ ri.od. of viability. Conventionally, it is prior to rate. In 2007, .ad~line of.reported abo.x:tiori.ci.Sc:s:
. ..:.20 .weeks ges tational age or at les-s than 500 with 45,751 V.rith no reported deaths Hom
. .- :~s birthweight :~egarded as Level C evidence spontaneous a bortion a;ri~ 0.55 pe.rcetii 'for .
.- : by~.the R9ya_l College of Obst~ric"ian~ an.d. j.ndusro aborti9n. 3 In tlle aval.l.able dati. ~"tlgh
;_'"0-iP.:ecologists (RCO:O), the recommended.i:ne~ica,.l th~DOH publiShed l)y the .~uttmach~r Ins.titu(~; .
.. -;:ie~ fo loss unde,r 24 weeks is 'miscarriage'~ 1 it :wa.s .reported that annually the numher :of .
'..::.Th~:~vep:~ cfw~ou.."ldh.~s :<:!1?-i\:q.,gd<;l :the cl.W-cal ,:Vom(:Il, .~9$p~~-~ ro'x: ~pori~eo~trs .ab.Orli9~ ..
..~... _imP.r~~~i<?;i . ?f .a,ho:r~h>n s_o . :~h:a,.~ <P.:e:w numbei:cili6iC92a...TYd Tor. li-,~.duced abortioli a:n .
. :. 'i~z:Q.m~diljion~ .like _pregilancy :or. u~own e;tfuta.#i:i&.:~. . . :' ' .. :- :
,~~
" 1~-t:ibji,iui:d irit:i;itul.nne:p:-e~gi{~cY:i>f ti,nS:~itain
' .;~: :~bility are j)osru'lafud:r . . : -Ap~roxin1~t~l~ -o~e :in'.:iou:r ~:o~e~,.W:i~i.
experir.nce a -rillscarriage_in her llfetime -'With IS
:., . ~.'th,e E\.\ropean Society for Human percent to 20 percent of ;::lih.ic"aJly recogniUd
: : :~rpduction Spec~a1 Interest Group for erly "pregnancy "dmgnosed. ~~ abnohxl,al in th~:f@it "9r ..
. :--. .ffig.niuicy has.publi;::hed a revis~d nomenClature eady ~-on() :tfimes ter. f.~~~ :~P; percdritto o;i
: : ::: ~~~~nee Level IV). perc~nt of ;pr~ancy loss "Yili "be :c;o:u~iderea .if .
. . . .. ~ly -Otchlt ..Pr"egll.a.rlcy are incihide~L-4 ... . -. '
. .. ' ' .
. .. . : .~ . . .
: < "> . . PATl;IOP.llH5IPWG-:Y' . . . -~
. : . Apptc::d.mately-15 'percentof:cli.nidilly:evident' . .. . .
... . ~ - :P.r:1~ci,~ ~d .6 0 percen.t of ch~l;Ilicauy eVident .P regi:\aney wastage:catU:a.k;'phi.te at" {P;iy ~e :.
~ . p~ci2s end-i::l -spontan~ousabo:rtii:}ns. Eighty after :ifupi1~#~ oLfue 1J~tb.CY.Et. In m:os.t;c;_a~es.
. : ~'Pti~D:~.of:.~.w~~~us :abortions: occurs prior.to oC~It.i.cm._";theri;:.is::hcin:<.?trl;lf\.g~ ;:m.. the d~uas :_
. ... }2,:Weeks .ofgestii..fu>n:'l. ba.~s;foTiowea :t?Y _ti~.ue. -ri~CIP:sJ..s, rp.e: -~~t.:-~. .
. . .. . :~me:~hafl.i.sxp:s-.i;es~nsib1e -;f9.r4~bortion; are:. not,. : .:.
. . . Cliromosomcil. anomalies :cause at least" ha.lf.Of always ap~~.itird mQ$tl}dieath.oflhe ".eriibcycf
.. . . : ~~;fi"bO.rti~~s .. Th~risk ofspontiuleous -~~-(tfon . or 't~tu_s pt;ec~4: !'!:'iq:,>jJfS't~h). ;p.f :"the p~~d_u'rit~:~of: .
. . :--:fu'ctea-se~--Y,ith:'p~ity: a-s .well :a-s-~materrtar -and cori~"ptio:ri .. 'T.lr:e-:d#'?~cih"<{d-eorttt:'ptu~ . a:crs _.as--a::,._.
. .: :_~~ai7'a:ge: clin:iciilly: reco-gn.iz:ed" spon;t.ane-:-ou:s {of"eigrCoody; st:!m:W.~$ig''ttte71Pe-c:ontracffcin:s;::..
, . .i\~tu9r.. occUr-s in 12 .percent of-women of ab.out dila~tion of thc cer:Vi,~'aric): ~oJ;ilplete or :pam.a.1
~ ' ::~1.6 -y~s o1d to as mu~h as 26 percent io. women C:xpul~i>n of.the products qfc:OnCptio;J. . .r:n.:$1y
. ...o_idetthan 40 years. i:he 'inddence of 13-bortion is m.i~~ge, tb.~ pr~es:s often leads to q>:'p,~~te
. : : .;,~~-.increased if a woman conceives. within 3 expu.ls)oti b ut .ftO+n . 6-1:4 \veeks some .p_Ia;cehthl . .
.". : . i:rionth;s..of a term birth. tissuC:S are .-oft.'en retained. . .
.
.. ... .. .
-~
....
. .
. .'. .In tire 2005 nationwide statistics o.f POOS .H.a,lf .of the cases of ;ea,r.ly s_pon t<t.nepus:_.
.;a~iteq hospitals, there were 5?,~08 reported miscarriage has an empty sac. Chromosomal .

Definition

. B~em.ical pregnancy los$/ Pregnancy not located on scan

..Pi-einancy
.... . of Unknov;:n location
.. .
~nj.pty sac I Blighted ovum Sac with absent or m.i.nimal structures
...
. 'Fetal loss/Early embryonic d.e mise Previous CRLme3..SUI"iment.with subSequent loss of fe tal. heart activi~ ..
.,
. . ~pregnancy los:i Con.fu:med empty sac or sac With fetus but_.no heart activity
: .
. Late pregnancy loss Loss of fetal heart activity at 12 weeks

---
Scanned By: C
 CHAPTER 31: ABORTION (MISCARRIAGE)
abnormality occurs in 50 ... 60 percent of
spontaneous miscarriage. ExpU :tsion of
abnormal zygotes may .occur very ~arly in
ges~tion so that pr:egn~cy is undiagnosed or
later in the -trrst trlmestt;r that it :p resents as
anembrjonic pregnancy ot bUghte.d ovum.
Second trimester abortion is ies.s :c ommon at 1-
2 percent :and fetu.s oftentimes normal and
presentatipr.:~ labor like.'S
E'l'IOLCGY
. .
Early . ~pontaneous aborlio.n exhibits
develo_p.: mental abnormallty C>f the .zygote.
Hi!!torically, this was de$crlbed b)r H ertig and
SheJ.don in 1;943 as blighted o~" .Poland.e..!..~
des-crf~d the s.a me problem in the context of
riiotplio16gica1 di&Organizatitm.
B. ~loidy
.-. Thj..~--.~~ an . abnormal chromosomal number
i,nd ': tJ~i-)~1 0 st com.m on genetic a)>norJP,~ty.
~ono,~.W.YX orTurnei'ssypdromeis the'Sinf1;le
:J~~~t)~Yi)ti 0n . ~euplcidy accoul}ting for 20
~petcerif"ofth,e_se gestations. Autosomal trisomies
.account for h~. of tha an~uploid los.~e;s Wjth
Trlsotl1y . i 6 ~~ the UlQ~.t CPllll,JlOtl. Pdiyp1()idy
usuiillYa$.1riploitly. hrfQ'\,tnd"ili-~u--~;:~~~Y
are..'li:S~tecl'with ' olignu;d o'\iiiin and pa.-tial
hydatidiform mole.'
Th~remaining half of early abortuses present
witQ ~ormcil chroz:noSO;t tlal COUlplesnents.
MendeUari factors resulting 1n anatotnic d~f~cls
may. play a role and often tes\llts in late fetal
losses.
MATERNAL .FACTORS
A. Systemic Disease
1. Infe~tions: Organisms like Trepone ma
pallidum, Gillamydia tracbomaqs, .N eisseria
. gonQrrhea, Streptococcus agalactia, herpes
simpleX: viru.s , cytomegalovinis. and, Listeria
mo-nocytogenes have b.een impliated in
~pontaneous abortions. Tb~:Y .however .do n<;>t
conf1m1 a causal iell~:tionship. 6
Scanned 8y:
. 473
2. Endocrine Diseases: Hyperthyroidism and
poorly controlled Diabetes mellitus may be
associated with spontaneou!i abortions. The
.implication of progesterone deficiency ten:ped
as luteal phase defect has been suggested as
a caus~ of abortion .. However, this was
thought of more as.a consequ.en~ tather than
a cause. 6
3. Uterine D~fects: Congenital anomelies that
distort or reduce the size of the uurlne cavity
may Pe associated with 25-59 percent risk . of
spontaneous miscarriage. J..cq~ enomalies
like submucous myoma may &1$0 likely to
cause abortion.
4~ Malnutrition and o~sity
. Only' v~xy severe malnutrition predi$pe~ to
abortlo.n. .
ObeSe women are at a.n in,cteaseQ. :rlsk for
pregnancy complieation;s. At least three
.coh:ort .~tudies .suggest that obesity ),s an
'in'dependent-risk .facto-r for spoJi~eous
abortion AJUong women who un~~Q.9#~ty
treatment.7 . . . - . } . ,:
5; imlnunologic Facu;rs ._-~>. ~- ,, ,. .
IP ~N4:~~~... ' I' ~ . ... ~ i
Blood :group. jnco~paiibllity . due:b:)I:J\a0, .RH
nas . been asspciated .with sp~nt~I),~pus
abortions. S~milar maternal and;,p;ite{ttai
hu~ leukocyte antigen ~ . ~tus tnay
~~E..~~ .!Af!.w.~U>.llincqf.abnttiQab}..,t:a;.lsing
~.!:1-ffi.~j._~nt .m aternalimmunoJpgic.recognition
of the fetus~2
B. Breast .C ancer ,.
There has been confusion ov~r the ~lationsbip
between breast -cancer and abortion. In a
collaboratiye re-an~ysis ,made in' 16 CQ:ut}tries of
8J,OOOwomeri With breast cancer, they have found
out ~hat a history of i_n duced or spontaneous
abortion is not .associated With breast cancer. 8
DRUGS: SUBST/ujCE AND ENVIRONMENTAL
FACTORS
Radiation, antineoplastic drugs, anesthetic .
ga s, alcoholanci nicot;ine have_.been s}loWil to be
erobrypto~c 12 . Caffeine especially thosetM"omen
who 'consume more ~a,n 5 ~cups daily ~tesh,old
increases the risk for abortion. 6 .E~pri~uie to
certain pesticides specia1Jy organoph9sphAtes and
~
 SECT! ON V: tfEMORRHAGES..tN PREGNANCY

org-anoch~orines may . increase the risk for Inevitable Abortion

spontaneous aborliori.:9
For wo;r:D.:en who smoke more than 14 cigarettes
. <;tday the risk is about twofold.
~Ftequentalcohol U:s e during the fitst eight
weeks result in both spnntaneo\ls abortion and
fetai ,maiformatio,::.s.
. Gross. rupture of the bag of waters in the
of
pres ence cervical :dilatation without passage of
prOducts .o f conception or the 'fetus often signals
that abOrtlon is certain. Oftentimes, this e':ent is
followed l?Y II!-Ore 'P leeding and. e~ulsion of the
prod-uct 'of conceptioiL Tn!atr:rient at this. point is
uterine eV'acuation. ,..

Incomplete Abortion

.. When part of the .Placenta qr p<>rtio~s oi the

pr~ucts <>f eonceptio.n is expelled .in the pr.esence
of an o.p e:n cerviX and bleeding, it is termed
.incomplete. Curettage with use of sharp c'urette
Theclinical P.iagnosts of threatened abortion and evac!)..atS,'ori of retained produc.t s With a
l'S rirade "*ith 'tb. :pres~nc~ of 'b!oogy vil;ginal ~?-,rru.t:tl vacu1,u;n. a.~pir~t~on; at.~ st:atn!ard
diSc.~~ oci~se{l.cetNix. :n!cl:\1-te.r<..n-e ,~ai.arg~m:ent p.rocedill'e.
. . .
s ln.the
' trl=;atrilent.
. Use of oxytOcin
.
or
mthc'~t'~i:>fpr.egr-Jmcy. Th~ cha.o~cter:of':fue o;ltytoxic are h~piul wlten there is more"bleegmg
pain . inayipe .rnytli't~i~, ctainP.Y; or J:r.~.ay be appire$ted.
.:perSisten:t~~;.b~~p~~.pth~~ll~~oiis .for, the .
-paui~roiy.~;.aVili~:'#itenot,<;n:~ny,ga,~~,ar.ea.~. EctQpic ,pt:egp:~cy~ m,,ay~~ill~:be ~onsidered~...
cft.hef.~~-Q:a~.iln'Us{;.~~!:purea:.:oiiblikeo;-icer:vir,:;al. '.:: specWlywh~n the.patholcigyo'.f:thee~lled ti:?sue
ta3ion8, ectdpic: pre:gh,ariey. :.bvarl8;il'::p atb.'ology' . .. r~ys ..~eci,du;:l..'':v.rithout cP.oriohi~ Villi. .
utdJ.nepa~orogy)U..fu~ traCt and:f: P~.b1$:s. . . . . . . .. .. ' : . .
.. .:.:. . :. . "Miu~a -Abbitlon ~
. i'h.~thn.~.'~Wm~tf~.qtrite:<:oil:iirio~with ~ne. . . . . . . . _. . . .
. o~t :o~;~o~7~~.uo/.e:.~wdni~!(i~tl~.~~~ag4lal....;, : .... W?~.~.tq.#,'~! i~h~jpoypn,.~/fe,tq.Lde.fui~..but~o .
~:p.o.ttJ:~g:!or::li~.a,:Vi~~t : .l:ftee~rrg :d\\:r:wg . :eafly eX:pUl,sJori Of ~the pr<X:iu:Ct of" concep:Qop. . an,.P.
~t::y.:A&>u! ~wtof the;.~ .~9ffism~~..il.h9.rt . Inst~d:ttietJ~~r.e_te:titi.Qli.fo_t.:a.:~edts..<~r: m.or.e,J.t
.-,@'d~tb.cl~iW:)l.t.:mct~rislc.oEpiet~:On.:birth, is.. ml~~:'a:bQ:ction.. ..Due :.to:.the. ~cj:v.eitt. of.~ly
low'biifuwci_ght and Perinatal de<:~.th. . . dil,\gi'l6si~ 'of .ik:nri,3e.' mth' .tlJ.e uitr-aS()I;l.Il.d ~ t}:u~
. . reten.tion 1;ntiy . trot reac-h Cl. weeks. . Tpe
Treatnient consist 9'f J:xxirest althougl). .it di:>es. charad;existi~features at'e a do~ cerViX, .i D.iiiimal
n .o t .~t4r the eourse
~f' the thteaten~d aJi;rtion. or. absent va@'lal.bleedihg, ut~n,is :inq)mpatible
Use .of acetamin.ophen-based analgesia is with age oi g,e;;t~tlob.. on. a .bac.kgro~!1d of
re'Zol$lended.fdr ~:telj.eL dfsa,J'Peara,nc~ of ~i~ns ~nd ~yi~1pto,II1s of
-pttgn8f1cy. . .
Hemoglobin ~d:h~tocrit mttst be' d~~c~~d
:if .t here :is '~ntinuqus :b leedbg. MMagement will be dilatation and curettage.
In s0.me cases, the .preoperative place~ent of
Work u ps -spetially.if .bleeding coD;tinuously lam,inaria to dilate the ce::vi.x helps in the
shbul~ inciuc)e. vaginal scnography, HCG levels evacuation.
to. a: .eeitafu :progres:S in viability.
Habitual Abortion. or Recurrent Pregnancy
.. Loss

Women who a.re 0 negative .sh9uld probably Rec:<l.rrent pregna:'nty loss '(also ca lled
.r:eceiv,e .~.rt.an:.~i:,.D .iri:uimnoglobiilln .b~'at1Se more recurn!n.t abOrtion) .i.susually define as three or
.'than 10 percent .of such women have signifi~t more loss.es in .a i-'o w. About 15 ~rcent of women
.fetomatetn~ hetnor:rh,a ge. 'in 1J:le reprod,u~ti<v:~ life
willlo~e o~e pregna.~cy, ~
J

Scanned 8y: C
 CHAPTER 31: ABORTION (MISCARRIAGE) ' 475

percent will~ ~ose two, and 0 . 34 percent
theoretically may lose three or more. Most
miscarriages will occur within 12 weeks of
conception.
The cause of recurre:nt pregnancy loss is
difficult to assess. The .s ame causes for
: :>pontaneous .abortion may be the eti\>logy for
,::eoutret;lt p~ghancy loss.
lrnmwwlogic Factors
Low molecular weight heparin is reci>mmended
for patients with recurrent pregnancy lo~s ot early
fetal demise associated with thrombop.h ilia. io
Incompetent Cervix
An incompetent cervix is cl)e,ra:cterized by
relatively painless vaginal bleedi.Ug and cervical
dilatation occulTing. in the secO.nd trimester or .
early third trimester. This is accompanied by
ballooning of the membranes into the vagina.

Oae theQty of recurr~rtt pregnancy loss is that
.theniotl-mix.rimune'S}'stemmountsaccllm~ted
~~ ~st th .fetus, :that anh'bodies deVelop
in all the suE:Ce$Sful pregnancies to block.this
r.esponse . and. :that -without thes.e . blocking
. ~cl~. &bortions always occur.10
Treatment of this clinical entity .i s surgical
of
consistingof reinforcement' the weak cervix by
suturing around the cervix calledcetcl&ge (Figures
31.2 & 31.3) .

. Aritip'l iospbolipid antibodies .con:;ist of

.anticar,diolipin antibodies and lupu$ anticoagulant
wherelnbne or the other is pre.sent i ,'fl 5 percent
to 15 perce~t of women Witi recu.rrent pregnancy
Joss ..Rec)lrient pregnaneylos8 and late fetal death
. may..;o cc\lr' b,caU:se of placental infarction:or
.im~ .uoph()bJast f unction.
,: ~ ;..- .;.~. #

tne diagnosis .o f antiphospholipid .a ntibody

syndrome requires at leas t. one clinical criteriop,
(arte~, vtmotis, or small vesseJ tlu'omlx>sis in any
organfi:is'su:-et plmr.:~:t le'tfst one labo-ratory
Cfitefion(positive. cardiblipin arilioody, lupUs
anticoagulant. or B2 Glycoprotein 1 arttibodies on
two or more occ,asjons at l~:3t:6 weeks apart.

Riek i$ alsO increased for . p a tients with

antiphospholipid. antibodie.s : 6 percent to 24
percent ofpatients with S~E are positive for iupus
anticoagulant and 40 percent are positive for
anticardiolipin antibodies. 10 Treatment for these
patients include low tr..olecular weight heparin,
aspirin 80mg, apd prednisone.

Thrombophilia

Patients with inherited thrombophilia may

have recurrent pregnancy loss due to
coagulopathy. .

The most common inherited thrombophilic

disorder are t he factor v Leiden mutation and the .
prothr.ombin G20210A mutation. Figure 31. 1. Types of abortion.

Scanned By: C
476 ~~CTION V: HEMORRHAGES ltf.PREGNANCY

septic shock. Endoh:Jxiri.s are releas9. from the

gram negative bacteria after the death of the cell
and the lipid portions of the endotoxins elicit a
variety of biological responses Among the early
effects are th.e enhanced coagulation and
.fibiinolysis which may even:tually 'lead. to .biC.

Seps is :fr:om abortion is u~ual1y caused by

.... pathogenic organisms .of th~ bOwels. -and vaginal
.f lora. on,.ly about one fourth o.f .the cases have
positive bl\)od cultures. . The. tn.os.t ~oJ])inon
p,aeyt~gens are th.e a:Iiaerobes co:tnposed <?f tb.e
,pe.ptostreptococ:c:;u:s. backroide.S, an4 clOstridium
a.cepunting fpr-oa percent ott he ~~ 1"Qe rest
are :caus.ed l?Y' e.co.Ji, pseudoinona, atl.d beta
bemolytic.stre~us. CliniCal.-tea~ ii:iPude
-fever -~ :chitls,/and folil Sm.elli.n.g cetvical.di.sclW:ge..
Gr:e.:m .stain~ :culture -.of vagituil s6tretions and-
blood, ches~ .X-'.t:0Y.; ~d .abQ,oPil,nal ~-ray _to nile
ol,l.t .~QI:atW~ .sh~Ul~: :be <ib4dn~d. . Treat:r.e:rrt
incl~des in~venous antibiotic~. -curettage, and
hy:ife~~m.Y ~ ~me u...JJ:esj)QnSiye cases.

..SEPTtC:ABORtiON. . .,.. .. '

. . . :.. \. ...: . . ..A$1A~-~ftb$;lJIC. ~eqte::-t.e~ill..~taih.tre can also
,.. .,-- . . .. . : .
-A'(;9~pi-~.tj~t>O!)'sac::C~arid~~~~f~tl;-e~ll oceurW.:~. tev~-roftits 6r bS.ct~. ~~oek. Th~
:wan,~~g~~~n~~e~~fP.l.~l?~s~toi:: -~t!cipa:y~~:~!)x!ly..l~t~~en!J.O&~..iri.e asesof:.
b~ -~~-~- l~~ai 'fator. in ;p~-O,d'ii~ffi-g the se_p~;~lJp~Qn <lb~..ate.thecascadj:ngeffects Ofthe
pathPP,P,t$1010gic ,~erange:rne~ ~ ..a.S~ With ~14fectjoti~ :P:rqCe:ss
... - .. ..:- . .

-~ 3L).. Comparative an.aly~i.s .ofthe.diffcrent ~ of:aoorik>n.

. . . ' .. . - . -. .. ..
-.Ot!ler
.. :~4~
+'FHT . ikdR.~
. Th~
. . . ~ -~...
: ~ .: \ ;... -f': ....~. vr~
. ;: = .. :-- .:~ .; .. ..= .
.'

-~
bxyt~iil
. ~ .: ' . ... . . . .r.~,.e.
+!- . .<f. :. ,' Ai- . .. _ ..
.~rnparib k .; . . ..:.. ,fHT . :.
...., .. : . :!
.
..

+1.~ . .. ::- fucorilpatible ~ Nt>t .A1milt

tpp.~ed . signs af
,..:
...--....,.,_,
..
\

~
r@mpwl>re : , N?t .. -.fHT ~inr
. -. - ~- ..; , _ ........ . i . . ~ .. ~ I)... &.rid, .
. . J:b_b:lb; al +I + . eom~ibt:e .. :rm ~ flP'. correct
~ll- . ~~ . Shortened prob&bf
dellVery incomp<:tem eause
.wvix Cercl:a&C.
- ,.. .Completion.
oirrtti.ze .

Scanned By: C
 CHAPTER 31 : ABORTION (MISCARRIAGE) .. 477
:,;

POINTS TO REM~MBER
. .
Abortion is the expulsion of the product of conception or termination of pregnancy before the period of
viability.

Ultrasound has chang.ed the clinical picture and presentation of abortion.

'Eighty.percent of spontaneous abortions occur prior to 12 weeks of gestation.

Exact mechanisms responsible for al;>Grtion are not al\roys apparent but many factors ara cited.

Fetal factors include abnormal zygete deveopment, and ane.upk)idy. whiie maternal factors include
syst~mic dlsea se like infections, endocrine disease, utsline defects, malnutrition and ob~sity,
immnulogic .facto(S and :drugs, substance and environmental factors.

Different cat~ories include threatened inevitable, incomplete, missed and recurrent pregnancy loss
(habitual abOrtion).

Differences among them :ar0..Jn the amount of vaginal bleeding, cervical dilatation,and with absence
_or;presence of"ftHT.

... ~~fl~geme.nt are .referrable to the patienrs status at the time of assessment

antipho~photi,pid cauSei~are' 1
Tha entities -o f .antibody syndrome , thrombophili<;l , and immunologic
ed in the cau.sation of habitual abortion.
_:impJ.i_ . I
. :~i~ptic abOftio:n is u"sually associated with unsafe abortion and as such, merits"a closer<~;o~~ihe- '. J
..: '~'tunieal manifestations. __:iif::~ .!~ o,.

~CES . 6 . Cunningham, e.t al. Abortion. Wi.l.liam's Obstetdcs, 22;.~

1. Royal College of Obstetricians and Gynecologists:
GUideline no . .23. The management ofearJY pregnancy
loss. London: RCOO.October 2006,
2. Uzelac P, Garmel S. Early pregnancy risks. Current
Diagnosis and Treabnent, lOtta Edition. 2007; 259-260.
3. Annual ReP9rt, 2005-2007, POGS
Edition 2005; 234 .
1. ACOG, number 315 Corependium 2007.
8. LCe.R. Rreast cancer and abortion. SOGC Joirtt
Committee Opinion no. l58 SOGC 2005.
9. Frazier LM. Reproductive disorders associated with
pesticide exposure. Agromed.icine 2007.

4. Creinin, Swartz, Guido, Pymar. Early pregnancy failure- 10. Kiwi R. Recurrent pregnancy loss: Evaluation and
current management concepts.CME -r eview article discussion of Ole c auses and man9.8ement: Clev Clin
2002; 105. J Med 2006; 73(10 ): 916-917.

. 5. Bas kett T. Miscarriage. Essential Mana gement of

Obstetric Emergencies 2004; 25-26.
~.

Scanned 8y: ~
. ... ..

Scanned 8y: ~
 32

RECURRENT PREGNANCY LOSS

ANA MARIER. MADAMBA-BURGOS, MD

What are Antiphospholipid Antibodies?

Lupus Anticoagulant
Anticardiolipin Antibodies
. Anti 82 Glycoprotein I
Other Antiphospholipid Antibodies

Prevalence of Ant!phosphOiipid Antibodies

Mechanism of Ant:phospholipidantibody Mediated Injury
Causes of Antiphospholipid Syndrome
Pathological Findings in Pregnancies with Antiphospholipid Syndrome
Diagnostic Criteria for Antiphospholipid Syndrome
Overview of Clinical .Criteria for APS
Oy~_ryi.~!'i of Y!bg_rat~ Grit.e6~. fo~ APS
Aim.s..-and.Umitations ..
Which Antiphcspholipid Antibocly -is Associated With Morbidity?
Thrombotic Risk .
, Pregnancy toss and Other Complications
Treatment of Antiphospholipid Syndrome
Who to Treat
How to Treat
Controversies in Management
Risk of Thrombosis In Jnfertile Patients with APS
Maiemal and Fetal Monitoring
Preconceptionai/Antenatal Counseling
Fetal Monitoring
Plan and Mode of Delivery
Outcome of Fetuses
Points to Remember
References

Scanned 8y: ~
 480 SECTION V: HEMORRHAGES 1N PREGNANCY

I~TR.ODUCTION but presented with tJ1rombosis and this formed

the basis for the anticardiopin antibody test.
The Antiphospholipid Syndrome (APS) is an Almost 50 years ruter the introduction o( the reagin 0

autobnlimne condition defined by the presence assay the existence of the lupus anticoagulant tha(
of characteristic clinical features of ue:?..ous or interfered with in vitro coagulation tests was
tvterial thrombo$is, orpregr..ancy complications1 like observed predominantly in patients with SLE!.
~entspontaneous~caniagesandfetaflosses (Systemic Lupus Erythematosus). Despitethe fact
as~ated With elevated levels of any one of the that the antiphospholipid syndrome is mainly
following circulati.."lg antiphospholipid antibodies, known for "its correlation betw.een
:1up,11s anticoa,g~l~nt (J.A), . antic~rd.ioli,pin . anti phospholipid antibodies .a nd thrombosis,
antlbodie~ (aCJ.,)' OJ' anti-1}2 -glycopro.teih l . prgnancy.loS$wasthe'fu-st<;:linicalm~estatiori
.an~ T6dey .t.hl.s .syndrome i$ known .to .be. that was r-eported to be .a ssefated with lupus
,.-tsj$tem.icand .rnay 9if:ct -alm,ost ever}' .o~an f;lnd :anticoagul~t. i'he first ca$,e~of a ~irculating
~issU~'.in :the bp4y..In-the gene~ p(>pulatio.n.-!tis anticoagQl~nt ~tssociate4 Wit}l. .fhr.on;ibosi$ ~d
..,- the most co mri;ion acquired cause . of pregnancy loss wa~ described. 5 In 19.75.,' ari
hypetcoagulability . 1 . For women, the association between intrauterine fetal death and
an#phospholipid syridrt>me is of major health circulating anti~thtomboplastin was reported.',-In
;_, ~.., .c;O~. sinceapptoXimately70%-90%ofaffected 1.980, various reportswere published relatin~-th~.:
f~~~:. :>irdUviduals are females, and particularly presence of circulating . antipho3pholipid
!t;\~.repro(Juctive ag women . 2 Currently, antibodies with fetalloss.7.8.If:.was in thi3,eiiod
~'. ;..-,. antiphospholipid antibody syndrome is associated that fetal al!.d eoil;>rym1.icloss was fmally included
~~~-U~ With :recurr~nt ..embryonic.. loss,-.as ..welt as..fetal . as a ma,iotclinical featUre of the antiphospholipid
~: ,: -~ -~ -'d~in uteri><~tihe l:O~ week-of.pregnaney.as . .synd_rome. .
~..~"'Wr:1i~;aa other. mot'bidities_,,throu,ghout;.p~gnancy~ ..:
. Ff).l'~e. obs.tetrlcian, l.ts.i.mportance-l ies notin.its : Antiph9spholipid . ap,tibod:i es are .. ~
:'" ~nce .but-m its implicationsforthe iri;dividudl heter.o ge,n ous . gro~p .of art tihodies origjnally .
--~andberba:byand itssfutt:tsas a potentially.. tho\lght tp r~ad directly .. agairist neg~ti;'V~ly.
_. ,~fe cause.o ( pr<fgnancy loss.At-should fo~ . charged_:.Ph.csp_holipid;..bind~ng_ .:p.r:oteiris, . :lik~
l)t\t( ;bf.the:. w~rlc?upxou. patien.ts~ .px:esenti.I!K::With;,. :.:.. p'ho s pfl.atidylglycerol, : ph o spha tidylinosi tol,l. ...
- ~fetal loss. pbo~phatitfyl~eritfe, pQ.:psph~tidylchoij~~T.
_;~~L____. . ... _. ... ... ... .. ... ~:~r.:9JQJ.iP111~. . __9.r_ .P.!I2.~~1!~1!.id-:_~_?..~ !~i9~g....
. .. WJIA~~-~J.r..HQSP.UQL~lP Mi.TXBOP.lts.? ~trn~!Yt~Jh !ti~ I!9.~_}9).Q~:.!h~:LtWJiP!:19~pholipid:~.
antibodies recogniZe phisma protein~ that biil:d to
_1}le antipho~pholipid antibodies, .Parti.ct\larly phosph~lipids rather than recogriizin:g- .
. the lul'us anticoagulant and anticar<liolipin pnospltolipids themselves. Th~se plasma protein
-J~ll~es have been associated with a varietY df . co-.fact.o rs eM l?e ~2 Glycoprotein-I, .prothro~bin
:. J:Ilt~jcal conditions that include thrombosh, and ~ne,Ons. In or4er -to exert their effects~ the
:ti~'tolmm\.me thrombocytopenia and fetal loss. antiph.Qspbolip~d anJibo<ly 'bin<;! to these P,i'Qt~,iOs.
. : ~;e$:$ frequently but never the less im.p ortant, and form a complex: .t hat , will increa$ ~he
ro,~iUcal complications like heart valve lesi'ons.,. a.rttiphospholipid antibOdy's affinity to m~mQrab,e
a dienal insufficiency a nd ava scular n e.c ro.s is of phospho1ipids;9 It is now established tha:t 132.
, bO!\~. have .been associated with anti phospholipid gly.ccprotein I i s con'sideted to be. tfie: #lost
:ah:ti.bOdie$.3 Sitnilaily, aside from fetal loss, these importa nt antigen for a illiphos pholipid .
.. ax\tlbodies have also been associated with oth~r antibodie.s } 0 ..
ob,$tetric compUcations like severe pre-eclampsia,
fc.t al growth restriction, preterm delivery, placental There are antiphos,pholipid auto antibodies
i,tliiufficiency and placental abruption. described for each pho-spholipids in the cell~
membrane and these a re detected by..
. . Antiphospholipid a ntibodies were fir s t immuno assay techniques. Not all of them. . are
described by Wassermann, et aL in 1906 jn. his- believed to cause.thedisease syndrome. Curre~t .
~ttidy of patients with a positive .serologic tests consensu s criteria consider three types. .of.'
.1.or WI>hilis.4 ln l94l, it became eVident that some antiphospholipid auto antibodies that at~ strongly:
. .patient who tested positive for reagin {antibodies associa ted with the syndrome and thus fonri. i>art
.p roduced by syphilis) diq not suffer (rom syphilis -o f cr:lteria for the diagnosis of the antiphospholipid

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 32

RECURRENT PREGNANCY LOSS

ANA MARIE R. MADAMBA-BURGOS, MD

What are Antiphospholipid Antibodies?

Lupus Anticoagu!ant
Anticardiolipin Antibodies
Anti 82 Glycoprotein I
Other Antiphosphofipid Al_ltibodles

Prevalence of Ant!phospholipid Antibodies

Mechanism of Ailtlphospholipid~antibody Mediated Injury
Causes of Antiphospholipid Syndrome
P~thological Findings in Pregnancies with Antiphospholipld Syndrome
Diagnostic Criteria .for AntiphospholipkJ Syndrome
Overview of Clinical -Criteria for APS
Overview of Laboratory CriteriaforAPS
Aims :and-Limitations
Which Antiphcspholipid Antibody is Associated with Morbidity?
Thrombotic Risk .
, Pregnancy Loss and Other Complications
Treatment of Antiphospholipid Syndrome
Who to Treat
How to Treat
Controversies in Management
Risk of Thrombosis in Infertile Patients with APS
Maternal and Fetal Monitoring
Preconceptionai/Antenatal Counseling
Fetal Monitoring
Plan and Mode of Delivery
Outcome of Fetuses
Points to Remember
References

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 SECTION V: HEMORRHAGES !N PREGNANCY

. ::I~~ODUCTION but presented with thro111bosis and this fanned

the basis fpr the anticarqiopip. antibody. test.
;The Antiphospholipid Syndrome (APS) is an Almost 50 years after the introduction o(the reagin
.autojjni:il.une -condition defined by the presence . assay the existence of the lupus anticoagulant tha.t,
of characteristic clinical features of ve:<ous or interfered with in vitro coagulation t~st~ was
.a fterial thrombo$is, or pregnancy complications, like ob served predominantly in patients with SLE.
ret;ttrtent $yon.tarl.eous :rnfsccirriages andfeta( tosses (Systemic Lupus Erythematosus). Despite the fac~
asscciated -with elevated levels of any one of the that the antiphospholipid ~yndrome is mainly
r6lloWing circulati.."lg ~tiphospholipid.anti.bodies; known for its correlation between ..
~ 1:UP;1J.S a~tico~g~l~nt (J;.,A), _ ant~c~rd.ioliJ?in :antiphospholipid antibodies .and thrombo:sis,
,antibo:die~ '{aJ,}' :a .r anti-J~2 .glycopr.otef~ .I : JJr~bianc,Y.los,S was thefrtst9~cal.mWilit<s'tatiori
. antibodies: '!'6daj. _.W s .Sy'ndroine .is :knC?Wn..to .be_ that was reporte~ t~ be _asso~fated with -lupus
.,_,. sj#<;m.ic"-an<l;-.niaY e.jf*~t: .alrnpst. ever)' .organ ~d -;al\tko~~la,t:J.t. The fir.~t. ca~e~fa c;in::l,.rlating.
Jissu~ m.:t l bgqy. .1ti- the .geneqil':pPpulation;it is . ,a:nticoagu.i~nt '8.ss&ciate4 With thron:tbosis ~d
..<me mvst c6mmon acquited cause . o.f pregnancy loss via:s des.cribed. 5 In 1975,'ari
.. 'eypercbagu~abi1ity. 1 . For women, the a~sociation between intrauterine fetal death. and ..
~t'jpnospholipid syndrome is of major health circulaiting anti.:thr9mboplastin was reported,6,th .
-rR:-,,._ :.,~.~~ since approXimately 70%:-90%'0~affected 1980, various r.eportswere published relating the.:
~:~~::;:1nd}Vlduals are females, and particularly presence .ot .circulathJ.g. ap.tiphosphoii.pid , .
..
-~r~:~ ~epr~ductive age . women. '2 Currently, antibodies with. fetallass. 7,.s1t.was in thl~.>' peiiod
E~r~i:~-~~jihospholip,~d-m:tibod~ syndrome i's ~ssociated th~t fe~ a:q.~ :~~pzyocl<;:.l~~s was ~any i nclt~~c:d .
t~~f~'t~Wl~-:tecum~;J.~~emor.yomc.los~,,..as .we1l..as .. .fetal . .as a n;taJotClimca1 feature of the antipho ~pholi~:nd
(,~-~; "''~tldn -utero.<pa~r:the .1:o:n. w.eek-of:pregrnmcy:-as.- . .synd_rome. . . . . . .. . .
.'"--~~wen;,a.a. other. -mo.r:pidities.~tb.r.oughouct;.pr~gnalilcy~., ._:.
:,.-}'dhe. ob~tetrlclari, .it.s.'4n.pot't~rice-lies .not-~its : Antiph<;>.spholipid ap._i;i~o:dies are.. 8.;
:""~ce,but-i.n its implica.tionsfor-the'iri;dividttdl . heter{)ge.n pus .gro!lp .of a~tif;?.~dies originy.
~.-~end her baby .and if:s status<is.apoteritially... tho~g~-~- tp: react directly.. agliiiH;t neg~ti;ve_lj
. ,';~fe cause.!,{ pr~gnmcy. .loss;J'f.should> fo~ . . charged,_:phc~p_holipid;.:bind~n:g: ~I?r:otein:s! ..:lik'e
-~;;of,.the::-wqrk?up,ofr, patien.ts;,pr:esent;ir1.g::;w_itht.,. ::.. . pho sph.a~id:Y lglyc,e.r.pl, ~-ph o s;ph~ tidylinb.si t'ol~) . .. .
. ~g'feta1loss. phc>s,p hat.i<,iylseril}e, pl').ospliatidylchoHi;ie., :
' :. :~.... c:ard-f:o!iplrt, o r phosph(:rlipid-e0nta,~i;ling
......;\T.iifiiT~A:RE
. . ANTiPHOSPHOL1PlD
. . ANTiBoDIEs?
. st:nxctures: -!tis now knowntha.t- $1-tipho s:pholipi(f:
antibodies recogniZe plasma protein~ that b~d- to
. _.r_he ~tiP.ho~pholipid antiboQ.ies, .PartiGW.a.dy _p:hosph()l'ipids rather tli~n r.ecognizi~J?/
-:- ::th>-1\\pus a.D.tkoagula.n t and an:ticardiolipin p!losp~olipids themsely~s. Th~se plasma protein
-~~es .h ave ;been assoda,ted with:a variet,Y of . co~fa:ct.ors <;:an be ])~2' Glycop_rot:e~.-1, :prothrompiil
.=~ :ttl.~fiical conditions that -.include lhrornbos'is., and ifune,Qns. rnc)r.der :to exerf their effe4ts., :fue
: ._:~~l~hbm1.me thrombocytopeniaand :fetal loss, antiph_ospl;w lipjd' anJ,ibody 'binc;i to -these pro:t:.e:ms
'Ls:s frequently but n ever the less important, a nd form a .complex .t ha t ,wiil increa~~: ~he'.
:ro;~cal complkations like. heart valve lesions, antiphospholip.id antibOdy's affmity m~roo,rahe to
a~ insUfficiency and avascular ne.cro.sis of phospho'lipids: 9 It is now cst'a:blished th~t ~~ -
. ,-bop.'t_have been-associated with antiphospho~~P~~ g~ycc_protein I is con'sideted to be. tile: iost.
:an:tipod.ies.3 Similarly, aside from fetallqss,"these i~portant antigen for a:titipho ;>p h:~lipid ..
. . ~tibodies have also been associated with oth;er antipodie_s) 0 .,

Qqstctric complications like s.e vere pre-eclarnp~i<~.,

.. .';fe~ growth restriction, preterm delivery, placental Ther e .a re antiphos_p holipid auto antibo\lies
i,tl.-&ti!fi~ehcy and placental abruption. described Cor each phosphol-ipids in the ie.lf
memb:rane and these are detected by._ :
'Antip'hospholipid antibodies were first immunoassay techniques. Not' all of them. are
described by Wassermann, et al:. in 1906 .i n hi$. believed -to cause.the' dis~ase syndr_ome. Curr~:p.t . ...
...~tUdy of patients with a i:>o.s itive :serologic tests co nsensu s criteria consider .three types .of."
..for eypbllis.~ In 1911:, it be~ame eVident that some anti phospholipid auto ~tibodies that an~ strongly:.= .:.
:patient who tested 'posit~ve for r eagi'n .{antibodies associated with the syndrome and thus forni 'part
.produced by syphilis) di4 not suffer (rom syphilis of o:Iteria for the diagnosis ofthe antiphospho\ipid

Scanned 8y: ~
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 CHAPTER 32: ~ECURRENT PREGNANCY LOSS ., 481

syndrome: the lupu~ anticoagulant (LA), the
anticatdiolipin antil;>odies (aCL), and the ant,i-P2
glycoprotein I antibody. 11 These antibodies are
related, and can be positive together or present
alone to cause disease. They .a re independently
associated with the clinical feature.s of the
:antiphospholipid syndr-ome and the presence of
any one of these antibodies is adequate for the
la.horatory diagnosis of the antiphospholipid
syndrome.
Lupus AJ'lticoagulant (LA)
...-;
'l'helup\ls. anticoagulant wa:s .fir.st discovered
with SLE but it is present iti many b)dividuals with
SL~. The name. ~ticoagulant is also a misnomer
since LA is associa:ted with thrombosis arid not
a.ntieoagulation iri vivo.
The antiphospholipid a ntibodies detected by
t;upus anticoagulan\:- (LA) are heterogenous non-
. sp~'cifi-tjm:munoglopuij.ns that have . different
. .reactivities to plas ma proteins like an:neJdn V or
prolli:iOfubin or 132-glycoprotein l, that bind to
anionic 'Or he~agonal phas~ phospholipids.
Recently, it appears that .J32-glycoprotein 1 is the
m~"~etantigen, and LA antibQdie.s that are
. cau~e4'l)y~ ant1-p2.:glycoprotein I . appear to
. coHeUi~"be1ier. witli. throrlib.osis""compared to
. ih~se'li~'antfbodieS" that ~e no.t caus~d by .anti-
p~ : glyeoproteiri I. Patients at hi.gh risk; for
thromboSis have been observed to ~ve circulating
.glycoprotein
~4~~~. <>11 ~~~!r. pla~_l!lP-..!Ji<i.f r~~~~e J~--
1 and cause LA. The combination of
these two te.sts may be Jl.lOl"e predict.i ve of
. thr.oin,l;>osis~ 1., .
lupus anti~~agulants, and 4) the pres-ence of
specific factor inhibitors like fac~or VIII or fu.ctor
V inhibitor must be excluded. Tnese tests should
be p~rformed without. heparin since th~se can
prolong activated Partial Thromboplastin Time.
Multiple laboratory a ssays (qualitative
rests) are required to detect these inhibitors.
A single assay will identify only 60-70 percent
of lupus anticoagulant a n tibodies in positive
patients. For this reason more than o ne test
for LA is recommended. Consensus guidelines
recommend screening for LA with two or more
phosphclipid-dependent coagulation tests like the
Kaolin Clotting Time (KCT), dilute Russel Viper
Venom Time .( dRVVT), or activated Partial
ThrombOplastin Time {aPTT): jJ only two tests are
used, a.P'IT, and dRVV'f are tecominended. 3 lfthese
two tests are negative L'1en, l..,A can be excluded.
However, one positive test suffices for LA positivity.
LA is .often associated with .-autoimm.une
disease,. If pcsiti-o:e, it indicates a greater<~ for
thromboemboli-c c omplications-.: as:,./W'f!ll .as
re.c urrent pregnancy loss, transveisemyelO,'p;lthy,
and nonbacteri_!U .L'Lro.mb<ltic endoe@'diti-s.t
Antics.rdio~pin. ~tfcodi~s , .. ~ ... ~ .
. . .-:.,. ."':'...... ;.:...f,(~,,"
... ..f}'f; .
:~ ~
J.ike lupus .anticoagulants; ahticatJ:h'9lipin
antibodies react to _ negatively .c hat:ged
phospf-olipids, in this particula.r case. ~~o~W..1.
Th!!Y~.?h~, ~~g~4".1! !! P!.a~m.~- P!:Q!~.ill ;c;p~f.~t.Q.r. ..Uke
132 glyco"protein I, prothrombin, or a.nnexin V to
i:>otehtlate their thrombogenic effect.

.These antibodies are determ~rted by

In the laboratory, however, its presence is . c.o nventi<mal imml,lnoassay.~ usin.~ -purified
detected by qualitative oagulation tests by their cardiolipin in t})e phospholipids inatrix .
. .ch'ara.~teristic paradoxical "interferente with
Anticardiolipin antibodie~ h~ve considerable inter-
phospholfpid-<lependeht coagulaticl'!. reactions by laboratory . variability an~ because of limited
prolongtmv_ the clotting time. Different accuracy and reliability, (;Onsensus guidelines
phospholipid-de.pendent co(;l.gulation tests are recommend semi:..quantitative reporting .ofresu1ts.
u 's ed and.t he:antiphospholipid:antibodies.detected A standard positive ~era _h as been developed by
by the lupus anticoagulant interfere with the the Antiphospholipid st.and.a rdization Laboratory
assemblyofthe ptothrombin complei:. These tests in Atlahta and this has helped the reliability of
have to fulfill the criteria or the International different laboratories in calibrating !ll1d allowing .
Society of Thrombosis an:d Hemostasis for semi-quantization of the different antibody isotype
standardization of tests for the lupus levels expressed as GPL t1riits (Immunoglobulin
anticoagulant 12 which are the following: .. G [IgG) binding). MPL units (immunoglo\)uHn M
l) Prolongation of a phospholipid screenmg test, [IgM)- binding) and APL units A (IgA] biffdmg). 516
2) The addition of normal platelet-free,plMma does Positivity depends on the t iter level, .:ffi'gh {>80
not correct the p rolongation of.clotting, 3) but units), medium (20-80 units) and I@ (10-20
corrects only after addition of . excess units). Medium to high titers are most specific (40
phospholipids which confirms the presence of the units) for disease.

Scanned 8y:
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~
 482 SECTION V: HEMORRHAGi::s 1N PREGNANCY .

Low lev~ls of I.gG an::d lgM. :anticardiolipin pos.:itiv~ .test {Ev.ide~ce ~evel 1). Am~ng the
antibodi~s are sometimes found in healthy .proposed .mechanisms by which anti--7~2 GPl
individ~als or may result .from infe~Uon and non- enhance thrombosis are the following:2t
..specific binding in the -general obstetric
popul~tion. 17
1. ~ti'-Jl2 .0Pl an~ibod,ies complexes interfere
with .e:ndt>genous .a nticoagulant
Low po.sitiv.e ant:icardi()'lipin ,aptibodies IgG or mecA.anisms su-c~!l . as crystalli~atipn. ofthe
I'gM .a re -of.q_t;t~'Stionable s igcifi:cance. Irt. contrast, -~AS anticoa~lant shielQ., fibri~o.lysis
, sevetal s:t1,1di~ have. sh'-wD. .a correlation l?etWeen is :triggered via -a.nnexin 1\2 and m!!diated by
inq-t;asmg. ~ters of A'CA -and ,ditor.der r~lat~d tc plasmin, the protein C and S mech;:mism
antiphospJ;lqlipid an'tl"bcdis. 17 ln fact, cliniCal tissue fac~qr pathw'.ay inhibitor -'
.fea-ture;; are seen .e ven in low titers anti lgM
i~cype.l~.
2. An~.-:~2. GPl ~mp,1exe~ can tri~e!' s!gn9-ling
. . e\'elit:$ on~ll.s 'su't:h ~s'leU:~ocytesin the blood,
~~-:~~Gly.eoprotei=:l I en<:Iofuelium. platelets and tro:ph9blasts that
:', .:. din 1ead to th. expression Df pro-thrpmix:ltic
. 13.2-GJyc.p.picit~in I, . als.o. known as . ana pro:-adhesiv.e phcil.otypes_ .
. ;:tf,\Ohpo'pi"Ptl$1.a~ f$.the ;ma)or:~tigen rewgnll;ed
ey antipllr>$ph()~pid:attt.q~tibq(Ues. IUs a natu.$1.
. in:hll;;itor. .cl i:hr:om~oSis si~ceit Jnhit-~s .th~ . 3~ Alfti-:tl'@ G.i>.I .:a ntibo dies can a-ct'lv-ate
~nv:ersicn pf :Pr.oth'romp,in to thrombin~ and the
com:pltnettt. and trl:gger :~n infla,m~a;tory
.acti,va;tiori <Qftlie,ilttrinslc ..cas.ca4e and p-;otein C :rea.Ct:fut). on .t he vasq)Xla:r- Mdjor:trbphoq4i,stic
S~. .
'1,u.tiY:a~ion~ ....l<
t:-. ts: 'fil ..:eo~iaet~F::'. that ..allo.w.s.....
anf:ip$b'sphpl;iP.ids' -~.~a .'to:negatively .'cthi'Q':g
ph~P.}io~:p'i~s~dt?,?~~tiat;e~!th~thri:mit)Og~riic o 't her ..:.,Anttphe)lpb:_ollpld~.:Ant;lliodles
eff~ :lt <is Jo~~~-:t~(l#thelia}. eells~ :pl'~cei:rt~.. .. . . . . . .... . .
. cep.tra,f.l,fet;V,Q\,l's.~~\~lt.$ Md heP.;:tt:pcyte~ .b,ut. . . . : . .~~es .~gainst. other :p.h~spnl:>lip~ds ;:that
its)~:uijor..S<>~ :of:~~ilie~~:fs:;th~:liver::~...:,:: . .affec,t:::pt~gn.:an~y _h;av; .~t;n):-'!J.~e~:.~stuP.ied~ . .
. . ,: :.,. . . . . .- . .' . . . Ariu~es - ~$~t.; phQsph)1:tiqy1~tira.n9lafu.lne.. '
. . A~~thG~t~;,.t;~~~-1i2~:.1i:~~p:tzotein:: v:rt>t~:, . a.. . t~r$~. ~ :pi.to~~hifi4yt~~i:t:ne jA:~~). phos;ph,a:ti~
lietey-ogeMu:s.;gn>~p--~t:~JJ#~.4'ies.J.i.i:patients -With
dy~cholipe {a:PC}, pl&.9~p;h9-;ti:dylglycerol (a:J?.~},
lli~iilitiD5.ru~(~mi!aevi1o_' thromb<>si's .!>tilers . . ::P~q~P.ll:att~Y,lffio.~i'tO.l. (aPt}, ,p,hos 'hathi1i(a:dd.
.a<?-liit'ii~~~~-~ ;f\2:~&>Pr&~T?i$ n.;~ l~Al":'~v~. be'fii~id~~tm~a :ii~irigJ>sta.!i'd~dkii
. e.p;it,6p.e domai+;r~ W:hl~} the ~ttphospholip'i:d en::rm,~~:4 i~i:l~:~sprbent a.ss.ays (~LISA) .
. .ar:t tib0dis can. tatge,t., .lfu.tib<$:es tl).:3-t tecogr..iZe Using- Co'-'f~'cto.tproteln~.~ 1.1;1. patie~ts wi,th
. d9.m,~.l ;of ~~~g!yeop.r.ptein .I had . ~ histoty of rec}u:i'en~ early pregn~cy los$, aPS:a~ci"aPE;are
't:h:rqinlsis: w~e -tho~ m'.d~tt!-~ Vwereseen .in fr~.q..uent . 'sin9e. the_y 'I'e'p.T ~ se'nt . th:os'e
.P~ttents .witbou~:.throl.l1lX:>~i~~ Ret:~n:t .eviO.enc~ anl.pb.;9;$p.h~~5pi'~ antib9dbs .-'th.at .?ifect~.cell
:~u-gg~s;ts ':that. :ii.. s'ttb<s.e.t 6:! :r;fBL .:a:ntibO'dl~.~ ~~Yj~i6i1.':4t}~g ~ip.~cy9:g~n.s.is.anct $ e. nwma1.
a.~t m$ :~~-~ri-ik)?f'rtfuofrioo~l.s:and '{unctiji o.~ the:tt<.n )h9blast. T;he :.toies '.Of .oth.et
epi~llsl;ii tt:e<$-f9:\~ a;.p. .epitbp~ lh: do~aui I ~f antij?'h:~~ph~H:pids an~ those a'gal~st .cci[~ttci.i
p2GPI that-':cpr:!;si~~s :af .G1y4o~Al~lt43 . .It has been . p_roteins are)ess cle.ar. SGJme s.t\lclieshav.e showh.
:s:ugg~:s'ted th.a:t .. .the :a.J{ti~b94Y.;..:medi~teti th~a~;a;p.~e4oroihJt~~e of aP<&,.:a:PO;, aPA-and;tJ>J
dim:~t;i.Zati<m.:!i;U.d p. eP..~a:i.ll.eriza:ion 9f -~2GPI ~c &~el;i mwomen With:. r.~urrent spontan~us.
i.O.~s the~~ of.~tio.QtiY-:P2:0PI .i.in:mU:ne a't?ortfoJ;lS. wpil~ .a.ntibod1~s against eofacto~
compiexes for ihe .pathoge.nic . e-ffects of ~PL prot~.in~ prothrombin andannexin V have beert
. apti,Pod.i'~~_.l'J ' .. . rep()rt~ tp .be plQt'e significant in reprodu_ctive
f~~~ thai?- ~CL aJ.one.
'An curr:ent':avatlable .data in~m~ate .t hat
a4ti~~- ctiie'cte4 :~owa:rds J3.2, gly~pr~~ein: r-..are :Most of. fu,e.aPL are.of the lgG andJgM ~!>ocypes
a m~or. Ca.use-ot tlie. thro.m!'tic.coinpUca;'.tl,ons ;but,._ about l"O:percent-are IgA.. It e.ppears thatthe
~seeri ;in. ~t~phos.pholipiQ. .syn~roil1.:~. tn.3-10 . IgG ..isot;we i s rri.o re :coir\mon :ir1 recurrent ..
. ~rcent o{ AP$ patien~s .~2 . GPl .!Xlay ~ the only pr.egriru;1cy los ~.' . .

Scanned 8y: ~
 .._

CHAPTER 32: RECURRENT PREGNANCY lOSS 483

PREVALENC.E OF ANTIPHOSpHOLIPlD Table 32;1. Types of p atients having antiphsopholipid

ANTmODIES antibodies27 .

I. Antipbo$phclipid syndrome.
About 1-5 perce.n t of the general population A. "Primary" - in the ab3ence .o f SL!;:
is l;>elieved to have the Antiphospholipid B. '"Sec(,ndary" - in patienls wifu SLE
syndrome. Ten pel'ceht of healthy .individuals
have .&ntiphospholipid antibodies but thelr . n. Antibodies stimu!ated by infections.
persistcn.c e ls :rare (<2%) . Anticatdiolipin A, NO known association with -throm~a e.g. syphilis ,
Lyme disease, CMV, Epstein-Barr. virus
antibocli,es are found JD.o.re freque_n tly in elderly B. Possible Elssociation with thrombosis_e.g. varic[!lla,
pers.oti~ where e.h ro.riic disease is more Htv. hepatitis C
preval~nt. 23 About 30-'50 pe:rent .o f patients With
.SLE hav.e antiphosphollpid antibodies b ut only m. Drug-induced antiphospholipid antibodie$.
10 percent have- at)Upho~pho'}ipi<;t lSyridJ'ome. If ..A. Chlotprc!J).~e
they develop .thrombosis and/ orpre-gnancy Io.ss, B. Other piienothia.zines
they art .eonslderecl to have secondary
c. cardiac dnlgspr.oca.itupnide, quinidine,
propranQ1ot,hydralazine
s.ntlphospllolipid srndrorn.e~i Patients that .h ave D . Others- ir..terferon a, quinine, amox;ici!lin
the .antiphospholipl.q syndrome bl,lt do not have
associated autdi:in.ill\ine conditions 'llke 'S l,$, IV. AntlphosJ?h<>lipid antibodie$prevalent in the genenu .
l.lav~ ~.pdiii,acy .a ntip.hospholipid .s ynd;t-9Jl1e. population.
Re$1.llts fro~ the tnuiticent~ Euro-Phosphotipid
pr_oje~t . showed that ~bout 53 percent are
:pnma;ty"\~iwe 41 . percent .are secbn~ c ases . . ~ .
of 1\Ps~2'-; : , . :~ .:.:. :~~t-;:~ .
MEcllAmSM:o;F ANTIPllCSPHO.t~ ; :t'f ;:[. .
. _.'there iS a fein~e pred<>~nanee, pamcUlarly ANT.mODY MEDIA'tED -m JURY . ' ..::-,;.-,,~}4_~ ~,.
iil e_~ ec,I;l~ ~s. It ls nibr:e ~otnmou in y.o\mg
.riUaalC'Jateaadults. f!ojVeve~, ;it is .a.lso ~ in .Despite -e.Xtensive research, the :path9g~P,etic
chil~terl':kn'd eiderly ad-u'l't~ ..-'the "cU~se bas . mechanistil. of' the '.~tiphas-photlpi<l~~Wdies
bee~ :61c&hrtered in child:re:n as young as :.g l acks clarity. It is known that ~#p)iq~l.ipid
month.s . arttibOdies are associated With throm00Si~<tbrif"6m
an
be se.e n' tr.rough pc~sible anatomical.Jtreas
APS 'Pl~Y c.on:t ribute .to an in.cr.ea:;.e d atthough somear.terlal..and v~nous sites :tire more
fre:q_'U:ehey_ .of.. _c.e rebJ:al...vascular ..aciden.ts.. or. .trequeritfy.affected~thati-others-:-AHhe'-preser,;t-tim.e
myocardiat infarctions. particularly in yo\lrtg unfortunately, there is poor cotrelation between
individuals. Sti'Qkes may develop $econdary' to serological m;;rrk:ers . and cliniCal .m:anifestatiop.s.
an in situ thrombi or embolization from a valVUlar Thi$' r esults mai."liy from :t he.'lack of reliability of
lesion of sterile endocarditis also seen in APS. tbe cuq-ent assays for det~tin,g the jni.sence of
The .c atdiac valve dis.e ase may be severe eno.u gh these antibodies. A stUdy recently found that the
to tequire valve 'repiacem:ent. Recurri~g presence of the anti-132 glycoprotein I that iriduces
.pulmortary_ embolism or lhto'1ll~o.sis .also seep 0!" reacts with lupus antico'a gulant, pa:r-tkulady
in APS can le'ad to worse:ning pulmonary the one that has an affinity for domain I, is
hypertension. Spontaneous pregnancy .losses uniformly associated with thrombosis. 28 Other
are common par tic.u larly in the second and third . proposed mechanisms-for thrombosis tha t m ay or
trimester but .it can occur anytime durin.g may not d;pend .o n P2 glycoprotein I 'expla,in the
pregnancy. 1 ~u6 different cHnical manifestations associated with
these antibodies at the placental l'evc;P8 :
,.
Antiphospholipid antibOdies are :a lso seen in
patients with i nfec'tions such as HN, varicella. and 1. These antibodies activate the endothelial cell
they may develop in patients "On chlorJ>romazine and mbnocytes leading to a prothtombotic
(Table 32.1).21 It. is significantly .ass9(:iated with state, characterized by the exprel.~m of
thrombosis in 4-21 percent, a11d ~:s the titers adhesion molecules and tissue fac~o.;_:S. For
.increases the risk,of throtnbosi$ -furthet iricreases the~e f~ctors to .caus.e .. thro'if.};bos i s,
suggesting ~ cause 'and effect relationship :bil:t the anUphosphblipid antib0dyP2 glycop'fd'tein 1
exact mechanism recains to pe elucidated. . complexes will have to interact with cell-

Scanned By: ~
484 SECTION V: :HEMOR~HAGI;~ JN PREGNANCY
surface receptors such as anne:x;in II that
induces a signaling cascade for thrombosis.
2. After exp<>sure to antiphcspholipid antibodies,
platelets are now J)rone to t!.ggregate.
Prostacycline (PG1 2} inhibits platelet
aggregation but requires .a racl)ido.n ic acid
release to do this. However ~2 glycoprotein 1
di.n:)ers that are bound to antiphospholipid
antibodies on platelets, wm
now interaCt with
theapo'lipoprotttin E receptor .2, triggering the
activation and release of tl-..tomboxan~ that will
disturb the balance t~f tiles~ prostaglandins
facilitating . platelet aggr~gation and
vasoconstriction . impe<Un; blood supply to
fetus and ~aricing procoagulant activity.
3. Thr~rrtb0$js in~~ plactnta and oth.er vascular
beds is in<;luecd by antipho$pholipid.:.medhtted
interference With the anneidn AS anticoagqlant
shield .. Aimexiil AS is expressed in high levels
in the placental trophoblast, covering the
. pb,o~sp,li~:llpid...:sq.r ffac.e s;:. oL trpphobi~sts .
: shieldi:~S r ftrim :~oag~lation r.eaG~i(.)ns. - antiphospbolipidantib6<;liesb ut d(,)not neces sarily
Antipltospholipid antit>c:>dies -.i inpair bi:itlt
. in.trins~q ~(;1 e:xqmsic fibrinolysis.
. . . .. ...
4 . :~~Jcil:l; ieffe<:t:= ~~~tet~.elikii\;3~(IJ:?.$Fis: an -:. .. .pet~;ent;, A:utc>inlmune;t:btoriioo.=.Y.t~peru~ l>uiJ)tira
-~~~Pffl~~~qcy~.~Q~i.e "; U\a~ ~e,;t.h~c:~~' 30:P.e~t;:p~~tic;ar+Jiri~s'm.~g ~tcent~32
.. i>1aeerit~):.an4 !etill ae~\optl:lc;n~:,~p..ijicrea~s
me~ocyte Ul,lnlber. ,: Jra~ent$ .wi~ ..APS
li~e loW ~IL-3 .tev~ts. ~Ftrr:theiiiirire.;. ;~th~t~ .
pro1iUJ~mm;i:tOiY~:an:a p-rbWomooticc.YtolQife~
.like .tumor-necrosis faetor-ct (rNF-<i) ~.e tU~
~evate~ In :ritro ,tudi~s of l>n.tien.ts with .Al>S
~ted Wi~ low.dose.aspiritl show-~ inerease
iri..leritrotrleiie.fonilatlon that' .e nhanee.s ..f~
pto<lu~tio.11~~ CiproflOXl:!.oin treatment in .,mi~
.ha~ also :be~n . iinown to incr~a$e Ilr3 and
. m~oeyte :tm.>4uction. 3 o
5. Antipho~pliolipid ahtjbQdies al~o alter the
O)aturation and invasiven~s s of. the
t;ropho,blast cells in vitro. sugge~ting that tl):e~e
antibo<lles ~n .c ause def~ctiv.e placentation
and induce p.lac~ntal apoptosis.
Antiphospholip'ids cause dysregulation of, the
complement activation a.I)..d interaction of the
anUQodies tha,t exp~se .phosphatidyisedne
.during trophoblast ~ncytium formation
whieh will affeCt placental structure and
foinlatioJl. They also ;inteljere ~yjth .{~sqgenic
~ipids that are Tesponsible for tile .fusion
mechanism that transform cytotrophoblast to
Scanned By:
syncytiotrophoblast and amnion development.
This can also be manifested as decreased
secretion of hCG.31
6. However, other clinical features such as heart
val-le abnormalities, thrombocytopenia and
livedo .r eticularis cannot be explained by
thrombosis alone and sugg~st multiple
pathogenetic mechanisms. Ep1ergil)g e;.?~~ce
Irom murine models of APS sugges:t that
antiphpsphPlipid-mediated actlvation of
complement..c.auses infi~.matory-mediated
ti$su.e dariu~.ge ' which is. crucial for
.c omplications .in pregnancy.~ ' i
CAUSES :OF .ANTIPHOSPHOLIPID SYNDROME
The . cause .of ~tiphbspholipid synclrome is
unkno~. The . ~ch fpr pt)sslble triggen .h as
unco.vert;d a wide :a."7ay Q.f.,~~~~ed auto.~une
or rheuma:tic.dU;;eases, infections and div~s. These
associatiQns. Will 'ho.ftilly proVide a clue to the
.etiology.ot.AP!:tSin~ qulte:a.nl:ll:JlP.er:of-thern have-.
m~ifest the ~4rome. ~ples .a,re SLE that
ar.e ..'pos~vi:. fQr afL.:in 25.50.: ~rcent.. Sjog;en.
syndq>!h~ .iJ.:t 4~' pe~t. .rh.;uxnatoid .artl:i:rlps 33 :
As in tnMY other autoilp,mune diseases, a
rombina.t!ort.of eu.Vir.onment.al and genetic factors
have oeeni>roposed; Receril'"il~tii .i'iidi~te' That
irtfeetio11sagent.s, as an environmental factor, may
play.a role mthe etiolog1 of ,APS.
In!ecti!)us -cause
. Vario'U~ ii:Uections like HIV.(l7%), pneumonia
(14%),. I;l~p:;tti.ti,$ C v~~ .( q%), skin in,fections
(1$%)_ and urirt~ tract infection (1.0%) have been
impH_cated in increasing antipbospholipid
antiboqies;33 .E ven l'Ielicobacter pylori h as be~n
asso~i{lted with AJ>S, causing intrauterine fetal
growth retardation 34 and. increased risk of
reproductive disorders. 35 Certa in microbial
path9g~~s like H. :pylori are known to .have a
homologo-us epitope on phospholipid-binding
protein :with P2Gtycoprote'in I. About 34. percent
or' patien.ts ixl.fected w.ith ti. pylori :were .positive
for anti- ~2-~lycop.rotein I due to their high
hon10logy.::of ~et .-epitopes; ~2-gylcopro~ein I is . .
immunognic in vivo. In experimental $;n,imal
s tudies, when mice are injected with p2-
C
 CHAPTER 32: RECURRENT PREGNANCY tOSS
gylcoprotein I, a significant increa,se in anti-P2
glycoprotein I autoantibodies is produced which
is associated with fetal. r.esorption,
thrornJ:x>cytopenia and prolonged activated JXll"tial
thromboplastin time (aPTT}, characteristic of
experimental Al>S. In ether studies where mice
were vaccinated with Haemophilus influenza or
Neisseria gonorrhea that have epitopes
homologO\ts to 13:2-gylccprotein ..I -e pitopes.,
pathologic anti-f32~gylcoprotein I autoruttibo<lie.s
were produced that also induced ~e clinical
picture _of APS in mice sugges$lg thi3 a.s a
mechainsm by which ooo:ieinfections cartptovoke
the production o'fantjphospholfpid antibodH~s and
..the disease syndroti1e ma,.nifestation.. Jn h'.lmans,
.:\iarlcella infection lias peen associated With APS.
uowverthere a....:e some infectious ageri,ts like HIV,
hepatitis A, hepatitis B I;Uld hepalitis C that.are
alw assOclatecfwith an in~ase in the prewletice
of an~~cardiolipin antibodie$ fuat ~;ite n~l. P2-
. ~~po]>rotf:~ dependent and so do not ptoducii the
sjjldromC:Ratber~ it is those in:fectianstllat raise
a~ti.pocit~~ : that can recognhr.e 'epitopes .on
phospho'fipids binding proteins, like f32-
glycoprotein AI, :that will manifest (tbru:actetjstic~
~Lthe _a.~.ti_P.l,i(rspholipid syndrome. Molecular
riiiij)'irj between ,-p2 glycoprotein l i!nd h.terial
M~ :~~ito pes llP:pears to be the prlncipal . small ~ssd &.rm:ilbOsis~other :than. :supei:ficlaii~en(jus ..
niecliarus ni'that-links infection t<.> APS.;J6 .
PATHOLOGICAL FlNDlNGS IN PQGNANCIES
Wll'H i:..P.S . be pre~e~t W}~~ut ~jg;:tincant evidence of in1lanimation in
The uteri of patients with APS show abnortnal
spiral arteries with narrowing of the arterioles,
thickening of th,e intima, acute atherosis and
fibrinoid necrosis.
similarly, the placenta sh<Yw$ extensiv.e
placental necrosis, due to infarction and
thrombosis showing villous congestion and
hemorrhage, early trophoblastic necrosis,
~rivillous fibrin deposition, fib:rosis in infarcted
areas and decrea.s ed vasculo-syncytial
membranes. These histological 'findmgs however
are not specific for APS and are seen in conditions
associated with placental insufficiency. Recently,
immunohistochemical ~echniques have .shown
increased deposition of laminin an~ collagen in
placentas from patients with.. AP~ ~ompared to
non- APS; These finc:iings may aid in _a xnore
specific .pathologi~~l - diagnosis oJ APS .Other
studies of the placental be<:! in pregnancies
complicated. by APS . have underscored the
. Stanned 8y:
'485 .
importance .o f inflammatory rQecharusms~ ,R ather
than showing vasculopathy. atherosis and
endothelial .cell activation alone. APS placentae
were distinguished fro-xn controls by clustering of
inflammatory cells around blood vessels and by
macropha,ge infiltrates.
DIAGNOSTIC CRITERIA FOR
ANTIPHOSPHOLIPID SYNDROM~
. .
The currently a~e_pted diagnos:tic :crlteria for
antipho.s pholipid syndrome is derived from the
con~ensus sta~~ent updated workshop -of tbe
Antiphosphbiipid Syndrome .Working in Sydney
in 20'0~H . prC:$ented hi T"'ble. 32.2. Th-e
antiphospholipi!f syndrome is present ii in lea8t
n
one ( ~linical aud one ( 1t laboratory criteria .are
met.
Tbl!!! 32.~. Diagnostic crit~ria' for antipl:lospbolipid
~;tultol)le. . ..... ~ ~._~;>;~. ~
f. :
.. :: .. t-:. . ,.
~ ~ \~)
. - .:{~ .::
Vase,~ Thi'oml>9&is
1.
One or more di>cil.mented episode ofruterud/:'Veni)u:s ot
. UlfombOsls-.in any 'tissqe :Qr organ. ~~bq~~ ;~,t be
confirnled b1 objective validated criteria sudi M:Mru~r CT
scan. For histopathologic ronfirmatiou, thtombo~ould
theve~!~~!
a. Three or ~ore unexp}.ained ccnsecutive spon-taneous
abortions before the 10~ week ,o f gestation, With
maternal anatomic or hormonal :abnormalities and
maternal and patentat chromosomal abilorm.~ities
excluded.
b. One or more unexpjained death of a morphologically
nonnal fetus at or beyond the 10..,. week .o f gestation,
with . normal fetal morp_l}ology documented by
ultrasound or by direct eXamination of the fetus, o r
c. One or more premature births of a morphologically
normal neonate before the 3411o wek of gestation
because i) eclampsia or severe preeclampsia defined
according .to standard definitions, or ii) recognized
features of pl.acental ins ufficiency
LABORATORY C~TERIA
1. Anucaidio~piriAntibodies (ACA/ aCL) oflgG ~{or IiM
i::otyj>e in$trtlm ol" plasma, p-r esent in inedi1:i~ to high
titers ~i.e>40 GPL:or 40 MPL or >99.,.percenttr~) on two
. or' more occasions at least 12 weeks apart, measured
by standardized E:LISA..
~
4as SECTION V: HEMORRHAGES JN PREGNANCY

2. Lupus Anticoagulant (LA} pr~sent in plasm~ on twoor Table 32;4. Non-criteria p reanancy con'ipl.ic.a.tions
. more occaSions a~.least 12 weeks.a.part, i,ie~edusing associated with APS.
phospholipj9-& dependent. ~ag-.llation teSt.s like those
rnentione;! he~ow: a.~cording to the guidelines .o f t;he Early and l!lte abortions
I:rtemetioil.al Svci~t;y 9fThrornbosl~:t:arid Haetnostasis Blighted ova .
(Scientific :subcommittee on LACs/phospiwli:pids - Intrauterine gro~ .r estriction
dependent antibodies): +~2 bccasions atleast 12 -weeks Oligohy:ir:mtnios
apart . Pre--eclampsia .
HELLP syndrome
Kaolin.Q otting1'irile {KC1.1. "' P~cen~i.nfarcti0 n. .
Dil1.ttt< Russel Viper Venom Tim,e..{DRV'VT)
Acfi'?ated Parili!J.TbromboplaStin Tune (aP;tl)
.-BJl~/or
' Ov.ervi~w oO..a boratory Detection ,of AP$
3. . .Apti~~:a giycaprotem-1 ~body<>figG e:na~\!'isatype
msctUm oq>l&Sma fm titer ~99da percen~). present l,~.bor~lpry t~sting f or an.tipho~ph~lipid
.
Ui two. ;more OC"...asions.. st leait 12 'we&$ :apart, antibodies ..is complitatM 1)e6atts.e of un~ty
~easurecl. J)y :a ste.n~a:'-d 'ELlSA, aceottUng to
of :~e .antigeniC targe.L TWo -cypes .9 f testihg are
x~m-mended proced_ures.
curr~p.tly bdflg u~~. fir~th~. ilm,n\i.D.Oa:ssa~ that
deteruline ~e tit~r:s bf antiboale~, or 'SecOndly,
tp~gulati.~n tests th at i ndirec tly test the :roi-
p:rese;nce. of the ,ari:tlp(xijA.)3eio.w.{table $2-5) 'is a
. t,' list of tests .u Sed fo,r. ~ete6tli:).g.'~tiphospholipid
.A ~ty ..p!.~ther .medi2,].,candj,t;ion~s.i~~.<oft~n . ~~~~.~.s.t"l . . ..
~in:~J.ifients-Wiilian:t;_pliosiihoUPl?';antH:Xxlies
ye~ do :not.fortn~part- 9fthe offiClal~ciitnatfor' the .. ..
diagnosis of the syndr-ome . 'Th,~:ar.e 9,11~ non~ Ta'!ile'.32:s,:r eSt:S :for thediagoo~ of the .aiitlP,l;iocoj}h~li_pid
:Q iter:ia ~~ C?'f ar~tiph(;~sph9lipid.:Syn<b;oil;i~and syndrom~.
t 2r..;, d 3n4:rr 'f"',._.._ -.:.,..: .. . . ~-
...-..JI : " ' b
~ ~~ m...~a , es..-.1.:.c.,.p,~: ,. . '7-;. ,:. "'"~e _
.. -
. .7
_,.....:..

. . ...-..o..:..:-.-"-"-~~....__-~~~~..,...,._
......

.pli#t~~canna.tbe.tixpltzine4!1Y a.thro.t.n.bo1ic: .: .. ~~P.as~Yf . . : .: . . . ..; : . . .

pathd'o'f7icai ptoceS.S ::alone,anc{'s'u .ggest otiter Blo:oSlc?.J~;po$_1~e-~lqg~.<>t~~I!>r..~ :'
.,~~.~- the dis.~e. ' Anticardiolip~ ~tibodies tco-fMtor depel;l.tknt.assay)
.: ' . . A>;lti~~2QP1 an?bodies ..-
~!!Ph~M!ilirll!~~.liD_g"M9.i<;.~
Table 32.~~ Non-Criteria cliniCal .niat:Jiiestations of the An~prothroinbin antibodies
.an1:Wbospholiptd syndrome.
COa~ation ttsts
. Uve(l,o retkularls Dl:liite RU~l Viper vehbth :tun'e{D~VV'J.l with
ton:f'irlii'lftqcy t~S'ts:ii.Pt'r (ac.tiva:ted.p ~
.~v~qpathy tlJ.i:6i nooplastin time):
~.idente ofl.ti:hil?itot \;Vith #illdngst.U~
. . ~'tiA, 'fi1U1Sv.I:se ll'lyelitis.C b,orea, .Multi-.~rct - pap!; .pf'.aFL-se.n;.itiv6 ~d-ins.e'?-s:itive.a.P.fr .
,9emeritia reagent!! .
~platel'et nO:utr.e.li:zation .ptbcedu:re
Tljl'c:1!il~bpcrua

Ptilij:ron'aiy'h:ype~e!:lsio n Kaolin clotting.time (KC1.l

. Tissue th:rotiJ.boplasjm irihibitipnte.:;t
Nsp~pathy . H<?c~gonal ph~ arr.aY. t~.~t
Texta:zjn/~~ test

A recentlydescribe:!: ~0ndition.associate'dWi:th
~ntiphospholi:pid antil;>o.dles, :called . t he
catas~ophlc antiphosp~olipid syndrome; .
in some .inqiVidual.s ,\vho d~7-~elop=:pro,gres-sie
thro~b.d~~ an~ ml.ilticirgan.failure.:~a.o.thers have
.a: sev~re pos~par.tum illpe ~s. :consisting of
. cqrdiopulmon a!}r f ailur e arid fever. aswell as ~ena:i.
insufficiency and multiple thrombosis. 39
. . / . .
M m s .and: Limitations of the Criteria
occurs
The. criteria for clefini.ng' the syndte>roe afe
actually designed. to proJide a . Urilfonil basis 1n
se'leeting .grs)Ups of p a tients for clinical and
.,
r esearch. studies. Although they h ave 'he1ped
clarify the diagnosis in t'his comple.."'{ disorder and

Scanned 8y: ~
 .CHAPTER 32: RECURRENT PRE.~ NANCY LOSS 487

the va)idity of these criteria ha~ been proven27 it antipho.s .p holipid antibodies are any , less
is not designed to .guide the clinical diagnosis for important than persistent antibodies. "Certain
treatment of APS. There may be other ris.k factors cases do notfall into the classical APS criteria yet-
for thrombosis that are present in a ddition to they manifest the full clinical .features of Ai>S. The
.a rttiphospholipid antibodies and this crit~ria do probl~m lies in the lack of standardization of many
not JlCCelisarily exclude other causes 'of tests particularly the antip2 glycoprotein I assay
thr-otn.\x)$i$. in. different centers. Further evaluation of t.hese
cases .h ave been suggested and presented in the
The sellsitivities and specificities of the Fig-u.re below. 40
different antiphos phoHpid antibody tests are .
variable. A smgle negative test ~annot nile out
the .diagnosis in a paUent. It is generally
recommended that a panel of tests be done to
exclude the diagnosis: Patien~ who t~st positive
for ~ -~ . of the major assays - pol)itive LA,
. elevated anticardiolipirt antibodies and elevated
anti-}32 glycoprotein 1 antibodies (referred to as
triple positivity) are at incre-ased ~isk for
tb.."'mbo$i~ llild prc;gnancy complications. ~rt..l}er
inves~ga:tion is ongoing to ob~rve the dwJcal
p~~nfalion of patients with AP$ that have more
thari.:o.n e: laboratocy criteria positiv..e in any
com~ination or the presence of one positive
labOra.tpcy .criteria only describing the .c linical
pre.s entatio.ns associated with that specific
:antiOOdyJ"-..
. ' .. .~ t\-,..~ .. -.. ~,. . ,; . ~1~~: -\:
' ;~in~~\:the ci.trrent criteria cannot pos sibly
-ex_Pliilil.~'atl the": possible ma.nifestatibns of APS, ~~~:~Q~\,
. . >' !.: t:. ~~-, ~ :.:~:\[~~~ . _ :
other laboratory f'mdings suggestive of APS F.iiuz'e 2:l.1 . ClinicaHeat:qres of APS.
con~ue to be studi,ed Uke the following:

------ --. --. . ... . - ...

'Table 32.6. Other labomtory non-~teria fe at\).res of APS.
. Summary of Re~ommendatlona .for Plagno~tlc
tgA ~tiCMliolipin
Jg;t. 'fUltl ~Ol}'cQpro~~ 1
Antiphoapha.tidy1serine antibQdies
Antiphoapha~dylethanolamine antibodies
AntibQ.di~a :(l8ainst prothrombin alone(am'-A)
Antibodies -to phosphatidylserine-protlirombin
1apS/PT) complex . cleat, the fact that the diagnos tic eriteria ru-e
Low positive ACA
Anti-prothrombin
Anti-anneXin
ACA Ig<;l.in Africap-N3leric~~
Antibodies to neutral phospholipids (P~, PI, PO, PE)
The _presence of a ny of thes e n on -criteria
manifestations des~rves .close considetation for
antiphospholipid syndrome.
Although these criteria require r~ peate~
laboratoij measur"e m ents to es ta blis h a diagnosis
of APS, there is n o eviden ce tha t "tra n s ie nt
Teattn~
. Altho~gh many researches .are ongoing,there
seems to 'Pe niore qu~stions tl;llm answers~ Since
Cl,lrrent Under~tancling Of the con(tiijon is far from
derived from a consensus .o f a panel of experts
suggests that this classification will continue to
ch~ge.further. At the p resent' time, the following
aie the recommendations of wh.o to test. .. Testing
for antiphospbolipid anti:b.odies s hould b e
restricted to pa tients who have had thrombosis,
embolism .or pregn~cy complic~.tions that may
attributed to APS, and-- to p a tients with SLE be
eve.n if t~ey do not h a ve any of the __above
manifestations.. A papel.of tests .should al-24\Ys be
done when APS is suspected sirice L~divid~ tests
xna y ~ield -.fa-lse negative s . _P er~_i stenc~i'Of . the
a bnorma l t est s h ould .be co.n(irmed . af(er 12
weeks. 27

~
Scanned 8y: 1:_:.:1
488 SECTION V: HE:MORRHAGES IN PREGNANCY

In the ACOG Clinical Management Guidel:ir)e s Pregnancy Loss and Pregnancy CompUcations
2005~ testing for anti-phospholipid antibodies is
suggested in the following conditions 16: In a follow up of a series of 100 patients with
primary APS (6~%) and 38 perceht secondary
1. when there are one or more unexplainf!d APS (3.8%) . pregnancy loss (6"0%) was the most
deaths morphologically normal !e~us at or frequent clinical manifestation of the
beyQnd the lOih week of gestation, syndrome.4 5 In a group of womenwith recurrent
.2 . one or mor.e prematur~ births aor pregnp.ncy lo ~s. the preval~pce rate oi
morphologically normal neonate at -or before antip.h ospholipid antibodies is 2'0 perc~nt
34 weeks age of gestation res:Ui:ti~g from compared to only 5 per<:ent in healthy women
preeclampsia., eclamp.s ia, _p lacental
implyin,g that primary A.PS account$ for 20
insufficiency or .
3 . . !hree cr. more cons'ecu~i\te spontaneous
of
percent c;ase~;~ with recur-rent fetal losses. .
abortions before the l011l week ofgestation
ln ~s~s of primary APS, tbe pre~alence rate
WliiCH A'NTIPHOS~PHOLIPID ANTlBOOY IS of .
a ntiphospholipiq antidies among women .
~..ssociATED WITH .: Mo.RBIDITY? with recurrent pre.ina.,ncy loss is . 20 percent
c~mpared With a prevalence rate of only 5
Thrombotic lUsk .PeJ:cen1. Jn he,altb.y women.~ :The association
bet.w ee n aridphosph~Hpjd antibod1~ s . ~nd
In a. meta analysis 9f-2 5 studi@i.nvolvi.Ttg 7 000 premature b.irth dueto'J)re.~clal:np~ial eclampsia.
pati~ts,_'.:Ga.Jli. ~~ . at. 41 s.l)owd ~t :.:t;be - ll,lPUs and -intraut~r-i.J)e growth r.e~tTi~tion fCtnains
antio~gu1anf: :is_$tr.ongiy: :a;s$oc~J!. ted .- with -conttover~ial $.ince:t he.studies~ <!Ontribu.ting to ,
thrOmbosis (mean odd$ ratio ~1 h())" .~xnmrred :-to this~ tend to be ~all, retrospective and have .
.a..TlticardiQ-lipin' antibodies (mean od<:l$:.nt,tio 1;.6). . contro.v.ersiidt:esutts~ a o wever, ~urrentvidence .
:It al~ ~~s ;the te$ult$:of siX eatli~. sti.J,dies: sUpPorts :the .. $Creen:ing for i\PS of cases with
. U~rl\lnawl.Y;:tW~ s.~~.Y.. i~tj.,tnit\\lt,:tb~.:q~cy- . .. early on~t $~v:ete .pr~:eeJ.runpsia.-
of e $fu4.i~:inCll,lden' uHlie U.~ta..,:~is $~ce .: ,.. . - . : . .
at p~~#fql~~:arz.: .1lo>:~:P.li>~ftiV~''$!U?les ~- }nCR, :~t ;,at.:,bbsetv'ed 'th~t 24' per~ent. of
.o f uxi~elected patient$ '"WltJ:l: pttpl\ospholi~i.d -patients w _ith the ~yn(itqi:Jle pre.~enting .a s
an.ti~_:d:f.,.detevn~~ation befo:te doc-umen.h ng .recurrent ptgn:4"1CY lo:;$ 'tn,S:de n6fit:li$$ic
tb+omboslS anllpho~pTi9lipiil ariuooai~s rikeantt:.aririexm
and :ahtl~phospha;tldy'le~hannla,mine .4 i
lfis al$o a strong liskfuctOtt otcoronary :artery
disease; In primary APS, LA-has a1so-b een$hown
The -risk of thrombo:s j$. in wome.n with
tb.have a:. grca~e.r association witi"fl: tlirQmbosis."2 arttiphospholipid$yndrome With pregnancy .loss
In pa~ehts~ho ~e p6l3itive for the llll~l?ie$.b1Jt as the only ttWc;al.rill:Ul:i !estatlon-;aPi>ears be to
J1av~ l.l<>' :thft>in~sis .yet,. the. P.$~ :t()r Uu:otnbosis
increas~a. in a t'ettospetiive study. o.f 6'5 women
~oh~:hcil:lthY.~~tie~t$ with,:the,hlclden~:findin~
.:o r a46ph"o$pholipid antibod:tes :ts tow (<1% per with A"Fs': that P~e$~n tett o~lY.'~~ P,:regnahcy 'tpss,
year} based on the randotriiUd testingo_f 5$2 blood 3. review of thrombotic riskin .women given
ctbn~t~ who were ;positive fQr a.~t:icardioljpin anlithroJ;Xibo.tic .prophylaxis compared to tlwse
antibOdies and followed-up .after olle year. th~t not given any kind ofprophylaxis, -Er.k an, et al. ~ 8
showed no throml;>bsfs. owever~ patients with found at dutiitg a :nre;;u1 .c;turation :i::if 8.1 ye1;1rs
SLE .have .a risk . ~f .th~ombOsis 6f ;~1.20 (95% CI, (3.. 5 years), -tWenty (59%) of the women. who did
l .A 3-1.14) if as~oclat~<i with .the lu.p us any form of anticoagulant ~reatment, had a
antit(>agulant ~d 6 ;So. (9S% cr; -1.53_.3. io) for venous or arterl;U thrombotic episode, whiCh is
high' titer_anticaroiolipin_.~3 . . . apptC5xiirtately.a risk .o f7.4 per"loO pa:tient~ year
compared with a backgr~und risk.of thrombosis
In the Framingham a eart: St:Ud.Y' cohor t of. app_roximately 1 per 10000 pe.r year in
howevet, .increas~d =M .tiG:a:rdioUpin ~ antibody was uns;e~e.cted _ p.re!llanopausal .womQrt. This
lnpependently B:ssociti:ted With an ' incr~a$ed risk . s\xgge~ts that'"tr~atment for APS does not. end
ofischemic stroke or transient ischemic attack in with, the pregnancy.
women b4tnot in men."~

Scanned 8y: ~
 CHAPTER 32: ReC\J~RENT PREGNANCY LOSS
~TMENT OF APS lN PREGNANCY
The optimal treatment of pregnant women with
antiphospholipid antibodies and one or more fetal
losses after 10 weeks gesta,tion without
thrombosis remains controvetsW. The main go!U
is to improve mate~al and feta1 outcoP!e by
reducing the risk of.p.regruutcy loss, preeclampsia,
placental insufficieny,'and pretertn birth and
reduce the maternal risk ofthrombosis due to aPL.
The main approach to treatment involves a
combinaijon ofblocldng or modifying the effect of
the antibodies, which is preventing coagulation,
and decreasing antibody levels. Historically,
prednisone, aspirin and heparin -hs:ve .b een used
and trea~ pregnancies had better results with
any treatinerit ~ompared to no treatment at a11..
(Table 32.7)
"- Table .3~:!1.~ ~mparlsoo of different treatment re_g imens
for.APS~ . ,. _ --- _______ - - - -
- - --- --- -- -- --------
UVeBj.rth Rate ("A.)
AD.y treatment overe!l 67
:N~ . ::'.-;:x>;<-,- .. 13.5
~:~ . 7~
~:~ne 31 .
-~~A
92
59
Predtlisone + Azathi~prine . '46'
lVIg . 85
In a 2004 consensus .reconunendation of .the
American College of Chegt PhysiC:ians, it is
sugge~Jted that women .w ith antiphospholipid
antibodi~s and a hi~;tocy o.f fure~ . or more early
pregl'iancy _losses 9.r: .o ne Qr mor~ late pregnancy
lo8$es but h ave no. prior history. of thrombosis
should receive treatment with a combination of
aspirin and:.heparln. Aspirin should . be . started
:w hile attempting con:ception an<t. heparin ,
unfnictionated. Qr low molecular weight P.eparin,
he sta,rled in prophylactic doses when a viable
pregnancy is documented. This treatmen.t is
Continued untillate m the third trimester,53
hi a systematic .review -of 13 r andomized an<:I
q\,lasi-randomiZed tr:\al$ :~volving 849 pregnant
WO!Jlen with -a history of pregnan~y .loss and
antiphospholipidantibodies, Empson; et al. found
Jhat the combination .or~uQ.fractiona:ted hepa rin,
5000 . ~nits .s ubc.u taneously . t wice d aily, and
Scanned 8y:
489
aspirin, 75-~1 mg/<:1. significantly r&luced
pregnancy loss compared to aspirin alone (RR,
0 . 46; 95% Cl, 0.29-0. 71) and there was no
advantage Ior high doses ~ver low doses. 54 .T his
treatment is generally extrapolated to ether APS-
associated pregna-ncy complications. At the
present time, there is not enough evidence to
recprp.Jnend L'le use of oth~r therapeutic regimens
(Grade 'C)
Unfortunately some patients will still not
respond with standard treatment. so other
modalities have been used particularly
i."'ltravenous immunoglobulins (IVIg). Treatment
in
with Mg has been promising a small number
of cases refractory to heparin 9r prednisone.55 In
the AAAAI consensus statement 2001. lV!g may
be giv.en as an .a dd-on to aspirin and heparih if
cUnically indicat~d at 0.5-1 g/kg every 4 weeks. it
has been shown to d-e crease the i.n,cidence of
growth restriction and l ess NICU adtp.issions.
Wlio to Treat
. ' ' . . ::~J~);" ..~~ -
The foll:qwing . patients are cantlidates . for
trea,t_I;ll~nt: Those with . two .or. more. re-Current
pregnap.cy -loss; fetal death in. utez:.o~(FDID., early
' o nse't ,p reeclampsia, severe. iri.tt'8.ui~rlri;;;grQ'W;t:h ..
. restriction (IUGR} and are i>osip.ve;foAAp.~~;Jili~se
with 'Unexplained infertility .du~ . to -iinpl.ari'fitt1on
failure in JVF_:.E'I' m ay. be considered' for workup
foT ..1\PS and treatnient if positiv:e. for aPL. -ltis still
contr.o~.ersi<'!l:whether~patientswith A.PS -features
but seronegative .for . LAC and ACA should be
treated as well as those.who are antibody positi~e
for Protein Si Protein C, Prothrombin and Anriexin
V sho'Uld be tr-eated with aspirin alone or together:
with heparin.,
. .
In ah algorithm for Antithrombotic Treatmen t
of Patients with Antiphospholipid Antibodies, Lim,
et al.. 200613 p:ropo.sed the following: (Figure 32.2 )
Ho:w to 't.-eat
Start Aspirin (ASA) 80,.100 mg daily prior to
con ception and throughout pregnancy once
pregnancy test is positive. Low .dose ASA given
before conception an independent and significant
prognpstic faGtor associated with. ~ good
outcome! 57 Available studies inditai.e~ that
unfr'actionated. hepari.n (UFH) ..s:ombindfi:. with
aspirin s ignificantly reduced pregnanty loss
compared with aspirin alone, and there was no
r-..
~

490 . SECTION V: HEMORRHAGES lN PREGNANCY
pafietits with Antiphsopholipid Antibodies
Vtoo\IS .
. tbrofribo$i.;
-
-~
adVan~:forbigh dosel?,OV<:i:: low:do$s.'M The data:
. Jtte spar$-e with respect to iow. m~~~ulat wd.ght
. .~ ;(LMWli), .whicll:t;~g~tl\er :\\?.~ .upirin did
.;not $ignlfiatrt)y red:ri~:~p~~q;,J91i3~.~paiied .
. 'tO :P4nl'rin; aton-e~"~ Still\~most' iilliruatms ~Uittrtti...
~ - . ;. .'~-~ - . . . . ~ . , . . . .., ...... . ... _: .,.., ...: . :. ' . ~ . ~~
treafq)atlent~t:h,...A;PS.. WJtb"l- a '. :0.tt)'bbiatipn-':of':, .
prophyll:(cbcd6sag~ LMWH~ptus~1ow.;.{io$C
. .i'hfre.is.inSUftident eYi4.encejn . ramto~ w:QJ:kmg .Yl) l~t~ :<1PJ:~.sa ~~:jgjg__:;, ~s_!ingJor
tria:b -r.ega'rding :'t he:ra;peut.ic be:Jt.e:fit :Of low
molecular weight heparin as compared to
'UnftactionateJ;i ~e.parin. 27
Heparin is added Ohce pregnancy test' is
posit,ive; ()r p(>sitive fo.r a fetal heartbeat at
pro.phy~tkd.oses (UFH to,ooo ~..Uts dajly). lfthe
}J~tient has ~ p'revio'l:ls histocy 9 f 'd:O~p v,ein
thromb osis, therapeutic doses of hepa;rih are
needed (UFH 2Q,OOq units dl:\ily) . Heparin is
dis:Continued once .the patient isin labor: Epidural
anesthesia is given except if h eparin and .a spirin
are still .being .gi~~m together because of the risk
cfan epidu:~ h.ematom~.
Heparin is te~umed .12 h0urs .aft~r delivery and
mairitained up to 2 w.ee ks postpartum t.O prevent
postpartum embolism~ Low .. dose as:pitin,is
.contmued p<>st deliv~ry as prlinaty pr.ophylaxisif
the ~tienfis notbreastfeeding,. Coumadin is:given
postpartum if there is a );listory of previous
thrombosis. :
J
Prior NO
thrO.ti 1bosis"!
CunSider Piophyl~ic
UFH UvfWJHr""-;th No~tor
:~~=
:~ious j)~tincy loss
(M;>derale .evi4coo:)
. .
. Co~trover.du . fn ~liianag~me.nt .
. .
1..~. Should we :Work 11P 'atldtreat :2 ~ spon~tis.
. losses:;-ora~ :poh-am&ee>..iliv.e. )()sses: . .. :
. . ..
:Sinee" fewwotn.enc.~:w;illing;t-9-'~\.-e lU'l&~er
aspirin.
l oss and the risk .of .s ubseqtJent loss inttea~s a s .
~qre tnJ.~~~ Ocur, so.~~ .~tiaJi$ .su~st .
antiphosphoupid .a ntib<Xlles and .other eause$ will
already ;Yield positive results even with oile ()r two
lostes. Req:\ihing $ 'l~sses wm.-unllkely .ipt:tease
the yi~ld of de~ting eti~logic .ractots.
2. 'Do patients positive 'for lgM -ACA Qr who have
1ow :J'(l$itiveAA ,~buhiegativ~ tot I.A:b ave
A.Ps? Snomd :t)rey.be nianagel,l?
Correlation be.t ween a:FL level$ and the disease
is still un.~l"fect. The '~L level does'not affect the
outcomeofthe,tt:-eated patient. Data frOm p.a tients .
having .subs equently treated pregnandts show.
tha:to\H:.;otne is not th~ sam~, regan:iless ()fsinlilar
treatment. -AP.S rilay b a ve remissions and
exa.ce.r bations. In . women with RPL; wide swings
in .aPL titers 1lre noted. l{.igb leveb a:PI;, may be
seen:hriniediatdj ruter: onsetof-di~e a nd::may.
be a market for certain ~s or tissue damage.s:9
Manage~n.e'nt of patients with per~iste.rttiy
positive aCL and LAC ~tibodies even without
Seanned lly: C
 CHAPTER 32: RECURRENT PREGNANCY LOSS
thr9mbosis consists in giving low do.se aspirin
. indefinitely. Most clinicians feel ~e givj.ng low
dose aspirin in primigravida$ positive .fot aPL
since the risk for a pregtiancy lossis higher than
:normal. L ow. dose aspirin is relatively .sar~ for
}>at:lents with recurrent pregnancy loss but with
low titer aCl IgG and/or lgM. At present, there is
no.consensus with tegard to treating this gtoup
of patients.
3 . Antiphospholipid antibodies and infertility
treatment
'ln"'48 pe:tcent .o f IVF patients with APL,
.S cht:nk, et at. 19.99~. gave this :g roup heparin
Mid low d'ose aspirin, The results showed a 1.2.9
pe~nt implantation rate in .trea~. seropo'$ltive
women vs. 7 . 7 percent in seron~tiv:e un.t ft.ated
wOinen suggesting--a benefit in 'the treatment of
the~ grot.:porpa;tients.!t'Utteh, et.al..l9976l-.aiSQ
studle:d l9.:Wornen With af1. Who~ete tra.te<l With
lose :.:dose a$pirin Md hepatin while und~oing
IVF (;yc!e.s ,;s 17 undex:go!n~ JVF but wi.t hout
treatment for the p~sence of antiphos.p holipid
. antibOdies. The pregnancy r&.te was 53-percent
in the ,treated grovp vs 41 ~rctnt- in untr.eat:ed
grou,p;.Tbere, :was. a benefit butbeeause-of the
fiunifkr,..t.Of;;,case$~ this findm:g did not re~~h
~nough .:srgnifihce;
In 1994, Sbet62 , et al.~ tree.ted his IVF
patients .with pelvi-c . pathology like PIP)
endornetr-iosis -tha-t- -also ---sh owed -.a . :4 igh
prevalence for antipho$J)holipi~ antibodies, wit.l-t
heparin' and low .d ose asphirt. His ~ults showed
a pregnanc=y rate of 49 percent iii ~e treated
group versu$ 16. -percent in pontreated ~~s.
Jlowever. this stu4y su.f:Iers from. ~et.hod()logi~
problems because of high false positiv~ r{ltesfo.r
aPL using 18 .assays.
Risk of Thrombosis in Infertile Patients with APS
Ovulation induction inc reases the risk of
elevating estrogen levels and subs.e quently
increases the risk for thrombosis. It is s~ggested
that coumadin -be shifted to heparin during the
conception cycle. Heparin is withheld .prior to egg
retri~val and started again after .6-8'hours. Since
the d\l11;\tion of heparin action is short, heparin
treattnent can be ,given even before ,ovulation .and
certainly after.
Scanned By:
491
MATERNAL AND FETAL MONIToRING "'~
Antenatal/ Preconceptional Couuellng
Women with APS considering pregnancy
should be counseled regarding the course of the
dise~s~ and its .complications. They Sh<?uld also
be made aware of the cost of ..treatment and
complieations a:ssodated with treatxnent.63
Branch~ et ~1. 1992 st'Ud~ed a cohort of 31
pregnancies on heparin treatment. Despite
treatment, the' patients :still developed the
followingeomplications: 60 percent pre-eclamp~ia,
>40 percent fetal growUl impa.i.n:oent. 25 percent
delivered at <32 weeks.
Balasch, et al.'li 9 obserted 77 pregnancies
tteated with hep~ an:d aspirin that had a take
hotne.baby r ate at 82 percent, despite treatment
the fo~9Wing q,mplications were still observed:
Premature delivery 21.4%, Preeclampsia 12.8 %,
lUGR 12.8%, GPM 11.4%, Thrombocytopenia
8~5%, Thrombosis 5.7%.
Fetal Mo!Utorlng
. ln the frrsttrimester, routin~ ~~~~ .esc,
platelet cOunt, blood .t yping, and ' lltiiWy$iJ}are .
requested. Plateiet COunts are deteed~'$eekly
Cot three weeks durin.g the initiation:ofheparin
treatment then every trimester. Thereafter screens
for ' thl'-oinbocytopenia-tha-t may be .due to
antiphospholipid syndrOme itself or- iilduced :-by
q eparin. Bas~Hne ultra-s pund is performed to
accurately d-etermine fetal age: a ssess viability,
scteen for fetal abnormalities, and determine the
presence of subchorionic hemorrhages. Anti-stasis
exercises, and regular walks are encouraged to
a-.roid venous stasis ar.d prevent deep vein
thrombosis.
During the second and third trimester, an
ultrasound scan is performed to screen for
GQngenitalanomalies. Close antenatal surveillance
is performed monthly or tnore frequently to
d e termine interval feta,l growth and observe for
'g rowth restriction, signs o.f abruptio placenta,
subchori0.nic hemorrhages, placental infarctions 1
oligohydramnios, and advanced aging of the
placenta. Ultrasound Doppler velocimetryof the -
uterine and umbilical arteries a t 20 weeks and
monthiy. there~fter .helps evaluaJ the
. ~A:- . .
~
 492 SECTION V: HEMORRHAGES IN PREGNANCY

'
uteroplacental blood flow. ahd :are the best
predictors for late pregn ancy outcomes. 6 ~ An
abhorroal umbilical and uterine arteryDoppler
velocity w aveform is an independent prognostic
f~ctor predicti:v.e of adverse ou teo me. 65 The ..
biophysical profile and .non stress .testing are
ttar:ted OnGe the 'f etus is viable at :28 wel!ks and
weekly thereafter. Non,-reassu..rip.g FH~ P.attern.s
CO.IllP\kate 5{) per.cent of all s~ccessful APAS
pr~gna.D:des re.s\llting. in early deliv~ry: 63 6.6 One
fuit-d of cases with antiph?$pholip'i!i syndrome
have preterm labor. Monitoring. frequency is
4:ldiv1liualized if com2 Ikations are present.
breastfeeding is:not possible, aspirin can be given
instead a s prophylaxis. . .
Prevention of thrombosis. requir~s a iong term
anticoag4latior. beyond:t."le postp9.Ttum period: In
a retrosp~ctiv.e stuqy by Erkan, et al. ~OQ2 67 ,
thrombotic events occurred in vatients wHh APL
and recurre~t pregnancy..losses.~nly in. 1'C 2erc~nt
of those cases with .some form of antico9.glllar.t
prophylaxis compared t o 63 percent of women
without- a;ny. intake of a~tico2:gulants withir.. 5
years.
;"'-~

.<;;our:rselj;ng during t he postp~.tum -phase

The r~sk of thrombosis is enhanced 'by . 'inclu4es advice against t he use of ho:tm.onal
pregp.c$t:y. ~ixty five percent o~ them are veno"tJ.s contracep tives .since t hie increases the risk of
in .or.i.g in .a nd frequ.ep.-t.ly invo~ve the, lower thtom.bosis.
e..~~ti~, :o.r .p ther ,~nusuaJ: :sites. Prospeptive
:stue;l.jes of Q~t wom~~ With-.~PS :r~p0r:ted ..a .Most bab~e.s . ho r,n to . mothers w i th.
rat!! of. 't:l:liom.i?os).s cf 5 perc.en~ a,n~ a rate of antiphosphoUpid. arttibo'd tt..'-'1 ha~..re no .congenital
s tr(}ke _i2 ,pe~t. 66 anomalies. hi.arettos~ctive;Gu~y byPbll~dJK,
.. .. _.. Scott :JR and arar. .<;l:i :o w (1992}66., the t';lonata1
otl;tei..c.oiD:olica:t;ions4ci:~p~e~{~fo!if.~:e<t;llo~e~. ;, .o}l.:toomes,;pfr~~ies<.bor:n::to\.th~se--women.;were'ndt..
"reJs:ted to. iliticpaglrtant tr~S;tm:ent,liJce,..Ql~e4~g.... si~c~.t~tiy.,4iffe.rent-.fro'm ..,c~. P0ITl. .tq. control..
.:t'nS:t :can pfes~~t \iS 'h~P:latuti*, 'iiDf.~ ble'e~g/ pl.O:$-~rs .~t~:~ .;~.e ag~: Pf.:g.estafion. A hi;gb.er.
:e~staxis~ f:l~paqn andaspl,f,ip. .S}lould be stopped pe:r.~'n~~q-{.t:h~.were.gr.oW:th.;!;estricted :bu~.th~y
:~. iLi;h;c)}le.~g :i~rife.,~eate,n,i.ll&:.re~er:~ 9f. ha...d:~gnifid;tiltctttch.)lp:'gr:cylth.)t!;nd no stgoj$cap.t
t,h-e:4~#te~t~!Vfth,:~9.9;r;p~):>9.Iin~ db~~t~f, l~ng:te$,~e.V.el~P.meii:ta.J::%:t:le~~e,,exqepHpr S<lth.e
P ,mtailiiiii;.siiffg<te
~ . . ,. .. t. ' "- . ,m;av
~
be
. .. ':.!........ ,. ,:Jlib-isa\@g
.. . . . . .... . .. .-.
~. ~- -.. _ . .s~cb.:
.'Henarin,.-. . r---: iieia:y.'in
. male:
. babie-s .......
m.~~,.~~oPenfu.;.~:;d.~,:ffi1d,~y be .
.ct~-$.z~:;t~.~~M:w~~.f~,o~ t;!l~.~q~.~~n.J.a
.!tf' ~; ~~ stio..J?.orosis..~.,.~ ri~lf..~wrth..::Rrolo_g~g OUtcome of ehlldr.en'.:Born 'to womcen Treat'ed.. b .u ring
:t;;\e~tm.:en~ ~~ :.b:~paliin
'at:id pt:e<;lnisone .that Pi'Cgi:iancy. for.AP.As
:pe:qu:?'.e~. ~i~ .s1-1pptemimts with vi~in. D
1~5Qb .111g .dilly. .29 d:wdx'~h from .2 3 :~'!o'~en Wi.Pt.M,'.A_S, . with matched
controls

Ch~~a~terhti4s . APAS s.;.1)i~s CO~tri>l Babi~~

. :. ." . . . ~ ~ . '

t~ .prev~~t .e xessjve:bledlitg P.urihg deliv~fY. Se\rete :neonatal' cocl.Jilexion 8 5

a.s pir:irl )n'~y. t:>e .dis~nQ.nued a 'few Q:ays 9fo~e NEC 2 0
term aildif.tb.e pat$ent.is on low inoi'eti..llar .'eight ims 3 2
h.e_p~. :this.1s .shifted to u;nfractiona;ted 'heparin BP OY~s'plas ia 2 0
a wed.~ befo,r;e d~:~iyety :or "ten'J.l... Rpatin is IVH 2 1
di~ntin~~ .q~~~ .tP.~ pa:ti~nt is i?.H:l.bor or. a"Qout &psis .i 1
six 'h<m~ !>efore cesa.E~~. s~'<;:tion.. If delivery is Cerebral Pillsy 0 i.
ur.g~nt: b~t'the ~tient i~ ~till 'fu'Hy .apti-coa_gulate~.
,appl19P.rl~1e: ;p~ood _.a;!} d. J;il.Q!{.d . cq~ponepts apd Minot. Neo!U!.tal :complexion 14 s.
.p.rO~ s~~l.t~ if;neede.d are :given ppor .o the Hyperbilifubine~ia 14 8:.
a~stt:p.tionlo'f.~~sthtsia. T.o .m:ll.lill:iize.the risk H;ri>othyroidism 1 0
of. t:h,roi:gh9SiS. during la'Qor., .;allo;.v. the .:patl~n:t;to.. "H~gly~~ia: . 1 '0
:amb~te, :use.~ti-em bolic s~oc~gs; ap.i:l do;deep. Cori:genital)yial.formations .1 3
b r~atli.ing. :exerds es:. H ~pad~ .. sh.'c!'uid "be Neonatal. Death 1 . .3 .
.
.administered again q houfs "after D-elivery and
maintained t!p to 4~6 . weeks postpart1;1m. If JK Poll.ard, JR Scott and OW Branch, 1992

Scanned 8y: ~
 CHAPTER '32: ~ECU~RENT PREGNANCY LOSS
----~----------~----~~~~------------~~~--~----~--------------~

Ot1tcome of~hildr~ Born to WomertT reated During Pregnancy for APAS . .;.:il'

Chil4bQod Complications

Characteristics APASBabies Control Babies

Medical problems
Feeding diHlcl,llties ' 2 0
$ep~/Pneutnonia 1 2
Mtiltiple otitis media 1 6
Asthma 0 1

Slow/Delayed gr.cwth 4 4
Small for Age . . 8 5
Normal growth & (le\'~topment 20 20
JK Pollard, JR Scott and DW Branch, 1992

POINTS TO 'REMEMBER

;.:n1e anijphOspholipid $yndromo1$ an .a~immune tonditionlhatia _chara.cterjzed bytbe :prese~

' .: 'of antib.odies UJat reeognii:e,ph~pholip'id..bindi~g proieins .and not negatively charged phOspboliplds
;!(~-..,~is o'tiginany. thot;tght Cilhically. they. mar.ifest as .venous or art~rial L"'rombosis and .._preg~ . -
, complications particularly :recurrent.pregnancy toss~ The antip~q$pholipld antibodie_sl.~t>;cm~~ .
. diagnostic .of :the syndrome are.the lupus anticoagulant, anticardiolipin .and antlj32..glycoproteiil''F ,
:_.
, .' . 3n:d
. : :.
'they should be positlve
. . .
1.2 weekS
.
apart. .

-;,~: ":~Tn:~i'~ain antigenic tatget ~f anti{lhospholipiq antibodies in -the pl~s~a p.;gtycop~tein.:C~hti~i$::. -:

-" -'.\' to'.a.nti~2-9JYC6pi'Otein: 1particutaity those that bind to domain lepitopes.appeat to.be cJoseiY,~ated; , :-
in APS maybe related to other:''J)lasm~F-~o.
to thrombosis. However, 'the meChanism of _pregnancy loss _
proteins maybe anhexin V rather than to anti antip2-glycoprotein I.

, The -pathologiGal :findihgs-in -thrombosis due to APSdo-not- shOw:ElhY' inflammation;--0tl .the..other,

complement activation of inflammation appear to be important in the .pa'l:hogenesis of pregnancy
loss. -.

. Our.underStanding of the cause of ftlrorhbosis and pregnancy loss is still obsctire. However, .infections
in
apj)arently pl~y a role .iiiitiating -the syndrome particularly with those infections that share similar
molecular epitopes at the antigenic site for antiphospholipids in a phenomenon called mol~ular
mimicry.
.Ba~ed on limited scient)fic evidence, testing for antiphospholipid antibodies should be restricted to
patients with clinical manifestations of thrombosis. and/or pregnancy complieatioris and it they are
diagnosed with SLE even wlthout c!inical slgns of APS. The test cannot pe used to screen the
general obstetric population.
0

A panel oftests should alway.s be done in suspect cases since just one test can yield false negatives.
'
The
.
persistence.
.
of an abnormal.t~st
. .should be.co'nfirmed
' . after
.
1~ weeks.

Based on consensus ~rn'd e!i!pert opifik>h~ 1reatment of APS should include prophylactic dos.~i .of
heparin and 1ow dose aspirin during pre!;Jnancy. This is modified durin~ delivery to prevent exce~lve
' bleeding. Prophylactic anticoagulation is resumed i~- the puerperium .. . ~-- .
. ;.

Scanned 8y: ~
494 sEcTION V: HEMORRHAGES IN PREGNANCY

Despite tr~atment, complications of pregnancy like .pre:-edampsia, IUGR and oligohydramnios and
preterm deliver-Y atilt occur.
. .
Those women with a.previous history of thrombosis should rece.ive full artiico.agulalion throufJhoUt
pregnancy with referral to a specialist for co-management and long term follow-up.
. .
long-.term prophytax:s is ~uggested ~n women with APS even if no.thromb9sis ;occurred during ttie
pregnancy because thror-r.bosis occurred in more than 50 percent of women within 7 years if they
were not given any :form .of'ptop~yla~is.

Chjldr~n born to women with.:an~ph~pholipi(j ~syndrome may have lowerblrthwelSJhts but demonstrate
sfgnmcant ~tch .up growth ~ct~le~ng .norm<;~l growth in the first ye3r. Premature babies due toAPS
do not.Pehave differently frcm ~ deli~~red dl!e to :ither c.anse;s. ....

10. de Uult B, Mertens K, de Gr:oot PG. Mech:adsms of

disease: Antiphospholipid antibodi~ -{:'rom clinical
ass~tion b pathologic mechanism .. Nat Cful PI-act
Rheum$12008.

4 . Wuserm:ann A, Nd:sB'e r ;.... ~.r.uck C. Ehi.e 13. :8r-lilidt J1';E arna :biC ~tr~pldt P!-- i:a:b-or,;tory
id.ezrt:ifl~tii~n'9fhtpus:~ticdagulan.U:~b-~ost
~stische;rL4ioil'bci:..~P.iliH~J:~
Med-V[Och~ 1:90:6: <r2:'74S:7%. 199~.;:7:4;ts9i-fO.p::a . ....

:5. i.:aurel.l:AB, NUSsoQIM. J{}J'dgrlilllt:na-::g!.ubu.+inae!llia,
~~ a,;nrl~~t; and ~.iol~c fal&e .po~itive
wass~.reactiot:L;A .stud.r. of2 casea. j:cab Clln
Mcifi9~:;f9: .:e94-'~oi~ .
.: .. .
: .. '
. . . fe~tl,tg. Am J Obst~t Qjnecoll992; 'i66:l'780-1789.
7. ~~ Mb, ~ .ML, GOci:S, et :al. AntiQP<ly to
-cantiOP,p.tn.ea ~tpredictpr CifJ~tid di~ ..or. death in
ptegnruiti~a.tienesviit~{sy.stedilc-lupus ecythemat6:su;~.
N Engl J M~d .19.8 5; 313: 1:52-156.
.8. 'Qc::ru.:C,();),:E~g~ltHJ:. H~s WN, et :a!.. FW Jo-s~ ,in
:~yndtome lupus .~ry.th~m~to~~,ts~ As~.oc:iation .with
.aoti~lipin ruiti~es. Br:J .Obstet.O..)'haecOl 19'85;
5: '207-'~99 ~ . titet'".".Obstet Gyneco11996; 87: 494-SOO.
14. ~plett;DA, Boffa MC. Ltip~s ~t: d~on,
st~dar:dization Em.d hete~~~city. In:' ,Mh.cron .RA,
,cexvt:raR;':pjett;j.t ~d :$~eld.Yehud!l(eth}. Thi
.An'tipli:<>,spt~.o:Hpld :~i,ndr:om~ :~t: . AutoiinmuM
~~):?~sis
. EISl~V..edH>0:2,
: M.lstetde,tp.
. .. ~-
p; ,
15. P~ac'eman .i\ivt, .Sih:er RK, MacGre:g~r SN, et iii.
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16 . .}.C0(3 ;~ctice Bulletin:.~tiphqspholipid'Syndrom~.
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i7. Silv'er PM, Pprtcr TF, Van Leeuwcen I, et e.l.
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9~ Galli, :Lu6inJ D, Be~olini .q, a~u}:t:T. Anti-oet8..2 18 .. Pieral}.gelli SS, Harris :EN, Cb:arevi ~ .et aL .A re
gl:,ycopiotem:t; an tipr.othr:om bin.arti:!.bodies. ~d ~~;risk . jmm.ur;1pglebulins with lupua anticoagulant activity
of thrombosis m the antipho spholipid .syndrome. Blood spedfic for phosp holipids? Br J Haematoi 1993; 85:
2003; 102: 27.17-2723, . 124-1.32.

Snanned &y: C
 CHAPTER 32: RECURRENT PREGNANCY LOSS .
. .
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41. Biclc~-~t,ID~~~~edUeto:bioo:d
- ~ti{)n protein/pbtt1et ~l~ectt~ -p~val~n~e,
treaunent and ou:rco~e ..-et>tttta. -"D~W Mt~o.p~e:x
'Reo.m-'ent ~e ~yn~- P.oo~tiVeGrt>\lp.
.C.-lin;."'-'.1 ~Th.ro.$h.Hem
-y)""
_. il~:!2..Q_,h6{~";;I*~l~~
1 . ,.,.~..,'-'-''~ , .., .. -n-'--"- '' ' .....- . J'h ~ a1.
60
. . .. . . . ... . - ... . . . ""'"'-... . .
'!8. Er$can .D;:J.!et:ritJ;t, X~~.Y. ~~-:I.; ~n-, ...
,JP, ~-.MD ~~~~~~~~o/
~.m~~~~~#~~
'~~~-~e~:200~>-:~~7. '
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.:tt".u:rettt:Jlregq.all'cy:~~-ir9\:Up,~t.~~~:~'4-
:~;t~~~~_ ii;~:~~:~-
'$); RAi. R;&hi~ j{; :oave ..M;=-R:~~- ,'C.'.R~il~I:CitniZdt
.:cont:Wn~ .trial- cif:8:$Pirin ani;\ ~:p~a oh~. :in.
pi:egnantwom~ with'recw-tent~:ge~te
.With phosx}bolipids :an~.ibodi~ .(or: ~tipho-~holipid
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. :::. .
sa. vm;a.t;ki.o;M~P. CoS$0:tiM, et.al..Antiph=pholip!ct
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~tnOO'sis .ElS).a.r.S eie:nce 2002~ p37S.
.. ..... -u_...:~ __ _,
.;K;J..1~"~ ot.LUi<:;.l'-"' '' "0 .U1~' '-r-c,.. ~~-=
a~mattnet')tyield~ hizy~hnpl.iui.futiQnn:tts in
rt-F patients with a ntiP,llosph-olipid s.htibody
~~ow~~rltY '-~~P.~e9 .. ~ ~~ea. B~eitive
~-pa~ts lune#a!?-Society:i>f.~u~e :Medicine .
.. Meeting_N~ l996 ,:Bost~~MA...USA:A~~~(i.
. 61. Kutt:e~ 'WH. -An.tip:h~li,Phol:il)i&a ~'tib~e~ tm-d
rc;ptoductlbn.. J Reptod:I$ril.t;PQll991; 3${2); 1S1-:-171'.
6Q .. ~r .o-,:~~ M., ~-~y-~ 9, #. ~ 11!~:-!.~dlty
ra~..::.f.q~gi!!-!JR!!9$J?holit:.id ~R2Sitjve :WOJ;P.e_n
:t:ra~ v.:i~'h.epaii:p. IU?-d 'asp& Hu: Reprod .1994; -~
227$-.2283. . ..
. .
63. sr:ancllnw: sllver- R1l,.Bl~ell JL,et~.Outcome of-
treated p,regpanq.es in-women ': with .anti-phospholipid
synd.rotb.e: an update f)f'th~ u~ e:xperi.~d.. ob~J:_et
M. GYn,i:c6!:~~2.; 8Q; ~ 14-'.62.0. ..
64.
al. Th~ ~econd.Wechsi~r
Le Tlii.-Huong D, B, Vaufu.ic--$rouze3 D, et
tFiinesi:er Dopp)er uftr,il.sO?:nd
e-xB.ID..ination is ilie best' pridictor of :laJe pregnancy
o1,1t<;ome :in systemic lupus e_gbtemato~us andj.or
antiph'ospholip'id syntlrome. :Rheum atc~06Yc.2ot-5; -45:
3~2-338:
65. carm.ona F, Font J, Azuiay M, ct .aL Rlsk fac;tors
.a.ssoci'ated v.ith fetal J.o~ .in .tr.eated antipho;;)iliolipid
syridtome pregnancies. A multivariate ana:l_y3-U. Am J
66. Lima.F, Khamashta.MA, BuchananNM, K~lake-.S; et
ill..A study obixty.pre~cies in patients with the .
antipP,ospholipid,syndrotlie; Clin ~ Rhmunat.Ol1996;-
'14: 13'1-.136. .
Scanned fly: C
 CHAPTER 3~: RECURRENT PREGNANCY LOSS 497

67. Erkan D, Yazici Y, Harrison MJ, et al. APLASA $tudy: 68. Pollard JK, Scott JR and Branch DW. om~me of
primary thrombosis prevention in asymptQmatic children born to women treated during pregnancy for
antiphosph<ilipid antibody (APq !)at:iehts with low dose the antiphospholipid syndrome. Obstet Oynecoll992;
aspirin (ASA) -(abstract). Lupus DW. 2002; 11: 57.3a. 80 (3 Pt 1): 365-368.

..,

. . -
~ .:: ; .~ 4. . oi ~ ~. ,

Scanned 8y: ~
 _.,.

~
.. .
.. : ... - -' ~ .. :

. - . .... . .

Scanned 8y: ~
 33

ECTOPIC PREGNANCY

REGTA L PICIL\Y, ~ID .

Risk Factors

Pathogenesis

Clinical Presentations

Diagnosis

Treatment
Medical
Surgical

Persistent Ectopic Pregnancy

Prognosis

Other Types of Ectopic Pregnancy

Heterotopic
Cervical
Interstitial
Ovarian
Abdominal

: ~
;.
.....
.......

Scanned By: ~
 :50_0 SECTION V: HEMORRHAGES IN PREGNANCY
..
-
'J

. . .
Implantation of the blastocyst outside the RISK FACTORS
. --~dOmetrial!.i.Wn:g of the ~terine cs.v.ity leads to
__- -tOpic pregnancy. The.m~t common site ofan Alterations or damage of the normal functi.Qn _ .
-_ecropic gestation is the oViduct. Several reports of the 'fallopian
tubes are known contiibl.).tory _
. have. identified other sites like the ce.r-vb\, oV!arles, factors of ectopic pregnancy. The bighest:risk cf
.a"Qdcmen, spleep., and even :previous cesarean obstruction is noted following surgery of. the
- ~- ~ti:on scar. 1 (Figures33.1 &33.~) "The20064ata oviducts (reanastomosis, tubople~,ty or
-f rom member hospitals of the Pbilj.ppine .steri:lization). Previous pelvic inilat;nmato.cy
-:Q~retrical and GJAecqlo~ $ociety,.N:ati6nvtide .diseaSe (PID) that invariably resUlts in 1JUate.r al
,Statist;i.ce (POGS-NS) . showed tl;lat L 7 per 100 sa)_pingitis is a -common risk factor. cbiknycii8, -".
: :PP1>tettic ru.l!J;iis~i~ms at~ .~p~c _~~t.i~~.'v,p _ trh?~'t;is is one of the pr:imary..~ !>fPIO
:rr~. I.2'per }~: f!~e y~ ~.~ ;p.ii.s)]?.b~ri~ .- -arid it -is th~ most ,prevalent bact~ in SJ'ls
. _:.1'fa:t~_ ,e9.n.~itipti ha8 i~c,i~se~ i~ 'i~~ide:n.~e : ;I-~~ wcir~dwid~~ - The st.Uczy of'~: et a1
. -~ therlse m then~ dwo~ With i::Orut!m:its pte.sence.~:ci;npst 'lill~#.cW:l~C.-ts .
,.... :~~---:ti~~~~tC.n :hif~.tio-n~...!Siiji ~ tlie. froJil patients with>topic' pregnaricy}::TU:bal
~- .. _n~W of couples seekin-g aSsisted. r :epr9.ctive kinkir:i:trana n:arrov.iing :of the lumen :f:roin-prijtuhal
.'~hniq~es (ART). Theid~ntificationofiiskfactors adh~s.ions .'folbwing pelvic infections Or-smi~s,
. ..:~ ; the aVailability .o f sensiclv ~~tic t ests appendicitis and end"<>metrio.sis,..are :o'U).~.~sJ{
_:. . ila~e'- 'a tlowed earJy O.tagnp~i:~ and pl'Ompt factpr~. (li'tgure 33.2) FAU~ eontracep:ticri_ ~~- .
. \ij~~rit of ectopk ;pregnancies. As a re?tilt, "-intrauterine '.device (IUI?J, so.m~ .foi;IIU ot.j;ub~ .
. >~~~rna! s~iVal- is imp.r:oyed ~d reprod'l;lctive steril;ization an:d .p roge.s terone-only ~ :~ve .
. --;~ctions :are? p~e~ed. incr:e~sed the relf!-tive . pumber o.f e~lopi~. .:-:-.',
. . . .- ; . pr:egnany-: .. A'list-::of.~e~:oth.er-"fu.ct:oniarefWwid ' :_ - : .
in Table 33.1.
-
..
.. .. ,

<
.:- . ~.' :.-'
. . . .

. '

.
~
~ I

~ -
.~~1...-~ preg11$cyat~eleftcimpulliey. ugtnent -.:1 . ;.
..
.
.... dtk-:ovid:utt
. ,. ..\':" . . .

Figiu-e3Z':i~ Tubal adhesions on laparoscopy. (Fr:oa;: Donne%. ... :

. f"i~To .33,3 . .Mic'roscopic: {lictur~ of . tub~
. J, Nisolle M. ;Ali Atlas of Operative Lapatascopy. 'S.nd . ! .
pri:gnancy. (From: Dept of Pathology, MCU"FDT Medic;;tl Hysteroscopy 2nd ed 2001. The Parthenon PubliShlng'Group, . . . . .!
- Foundation). NewYork). . . . . .

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 .CHAPTER 33: ECTOPIC P.REGNANCY .. 501
--~--------~----------~------~------------~--~~----~~----------~--

Table 33.1. ~k factors. as.sociated with vigorous pelvic examination. or .:

coitus. When tubaJ rupture. occurs"duiing the
RiskFactor early weeks of the first trimester, . p~gna:ncy is
High Risk
most likely at the isthmic .s egment while late
Tubai ~rrective sutg~ry 21.0 ruptures are associated with the it:lterstitial
Tubal sterilization 9.3 segment.
Previous ectopic pregnancy S.6
Intrauterine devjce 4.2--4.5
Documented tubal pathology 3.8-2.1

Modified Risk
Infertility . 2.S.21
Previous genital infection 2.5-3.7
. Multi_ple partners 2'.1
siigirtRisk
~s pelvic or~ surgety . 0 :9~~.8
smoking 2.3-2.5
Doudling 1.1-3.1
lll.t~urse before 18 y.e~ .. 1.6.

--sin~ valQC$ -~. eo~on o4da tati~: rr:e~ ho:ilogencl1s

studie_a; do\lble v~Ue$ xange .o f ~ues from heterogeneous
stu::lita;{From: CuiulirigliamFQ, Levc:x!o K. BlC>om S;llauth
J, Gilstra:plii L. Wenstrom K (s): William!fi Obstetriq~, 22nd
eiLNcW\Y-I>rlc McGraY..-Hill. 2005) p .2 54.}

PA'i';BOG~IS TaJ>te;.33~4. . . : ph9to <>f mb81 ~~.,~t.

~ - ~i :,;;.:.): .. ..,. .. . . : v~ ~ .~pcy :uterl.rlC: :caVity .;:Ro :- Q..qrm&J. rnw~
.. :.Majority of~..opies are l<>:ted in the oviducts, Complex ina5S ;. tubal pregiiancy~ rigij(f'Ffi:i#~P~:Pt
Obstetrics & Gyneccilogy, MCUFOT Medi~ FbH:iM~'fi'Ott)~
The fertilized ovum may lodge in any of the tubal
sgtP,.ents gM.ng ri.s.e to in~er~titial or com11~.
W.!:h!!lie . .~P~ . ~4. f.i.W.Qtl~ ~~. . Q..( ih~ . . . . .
<l.i!fe.~t .~.J!P~-~.: J.heJJUl~l .oo.mmon..is.~tbe Jn_some ,,Jnstances,-Jhe:-tubal-rupture -m.ay cbe .
atnpulliey.;.followed by isthmic. From the !;>viduct, a .small rent resulting t:Q hemorrhage or~ o~nipg
tbe. coneeptu~J may "be extrud~d from Ule f~brial tl}at i~ lm-ge enough to !lllow the ext..r:u~ion o!tbe
end to.developJn the n~by pelvic organ~ giving conceptus out into the peritoneal ca,vity. Both
rise to seC.ondary types na.Ill,eJy:: tu bo-ovarian, eventswill in.v~ably ~use signs and symptoms
tu~~abdoinlnal and broad ligament. In.ectopic of hypovolemia, Conunpnly, small concept:u.s is
gestations, the embryo is either stunted or absent. resorbed afte~ extr:usion while bigger ones JD.ay
re~ain in . the cul-de-sac f<;>r years as an
When the transit of the fertilized ovum is encapsulated mass or may calcify to form a
blocked along the oviduct, it promptly burrows lithopedion. Rarely, if the fetus. is extruded b~t
t}lroug\:. the . tubal .mucosa to lie directly in the the platenta retains substantial tubal attachment,
muscular .lay.er .beca.use of ~he absence of a Juther .development can be expec.t ed. The
subtnueosal layer. . Wit}) little resistance offered abdominal pregnancy that results is maintained
by the.muscularis, the rapidly proliferating as the placenta grows out of the oviduct to implant
. trophoblas~s eventually inv-a~kand erqde thr~mgh in the surrounding. abdominal organs .
it. At the ~e time, rnatem.a..l blood ves.s.e ls are
opened and blood pours intQ spaces within the Another progre_ssion of ectopic pre~a,ncy is
trophobla~ts o.r . betwe~n it. an4 the adjacent abortion. :fhis is mostly noted when ~ stte is
tissues. . 'fhe :~panding produCts of conception the ampulla. Disruption of the . conp.ection
eventuaily caus~ the. thin muscle walls to _give way between the . conceptus ;:tnd the. tu~al wall
leading to tubal n,1pture. (Figure 33A) This event -immediately follows hemorrhage. Complete
is spontaneous but may be. .caused by trauma placental separation ~ay lead to the extrusion of

Scanned By: ~
 502 SECTION"V: HEMORRHAGES IN-PREGNANCY

the conceptus .out of the fimbriated end into ~e . broad .ligament h ematoma. Presence of a tender;
peritoneal cavity. Bleeding may stop at .this tiine soft and elastic mass on the adrtexae is
with _sti9~equent resolutiol} of syPlptbmE;. When ap.p reciated.in approximat~ly 20 .percen t of
soineproductsr-emaln in .the .Oviduct, bleeding will patients but its absence does not ex-clu,de an .
persist and blood will pool in llie cul.:de~sac. ectopic.gestation.~ Car:e mustbe ol:>setved-d;th"iri.g
Obstruction at the fimbriated end will lead to -the th~ course -of ex.am.ination to prevent iatrogenic
accumulation of blood formii'l.g a hemato.salpin:x. rupture.

CLINICAL PRESENTATIONS
. : ' ' ' o " : 0 I l
'L aboratory Te.sts
': .

sl~. aria :~ptb'~s . '.

Human. Chorionic '(i1onadetr~pin. (hCO) AS;Sgy
.~ ! . .'~ . . . .

The:4U;ii .P.re~nt~~lon:':.~i :~pic .g~ti9~; A positive pt"e;gnancy t~t de~ts th-e presence
has7a~rrom. the_ :<#.~e ~ o! :al)d~_mfpal. of pre_gnancy bpt not its" lo-cation. The :r...a.dUy .
~:i:i.ragffial'blecillng >
and. amenorrheato' Si~ availabte'.latX: agglutinati,on inlll'bition ~e -~ts
a;i.td.'&y_mpt~~s that -~ . 4ive~;. ~:Ubtle ~~P. :or .are posi~e at 5~800 mlU/ mL hGC levels~ The
ap.s ent: :' the - a:V<i,.ila,'b.pi~y O:f ~-~t:e.:~~-~4-~~t~ more recent enzy.m.e '.link~ i.mm~noapsorbeni:

;~~~~~!!::J~:~~~~~~~.~.. ,=~ -~t~~~~r;;.4~~~e~!\~~~~

; .. . : . _. , ... : .. . ; _. .- rot.. ~q
i~..pQsiti\'e .iriover.9s peroen~ of:eciopiC
.. :rhe. ti;ost;fr~u~n~-: s)~Ptoni:~t4- J~. pregri~6s/ . . . .. ..

-~~~;~ - ~-- - ....

-~:D:ipltiilt;W-;at~~':nQ:t~:d::'#t,,:.JP..e(~*{r.~;p~&;-'\~I- A .p~ge~Y;ron.e level of more :than "2$ ngf'niL .
.
;p.r~;~-'~ Jol~-~~~"i;~:'f~l~~~~- .. indlta'f~-.:th."eptesen~.ofa ~~~~ pz:~cy~"ld
t':b,~ ~ab.d'otil:'::n ,.w~'il~.-,. ~~ae:~~;-:~d')!~hlt.~~g :-- .: e-.io;ql.:Udc;s .e~t-Opie pr-t~gn:a~ty.: w:lth:~;.\9_7,;5% '

.-~=t~r.~~:~~~~.:r~~~~::~~~;~~~py,--~.::~~!~~~~~;==~:~~!~=~~~-
. dein~s:e. Umo~rt:U,nAt~}y; pr&g~1it~t:~:h~ :J~vel~
Patients .with ectppi~_ge~t?.li$ ~~~~e
~.":'.}'!-~.....:~
~. tweet\ :s'ng;1 m L to-:2 $ n'gj'rtlL .,..~~ t olli:!!i'()n!
--~~ ... - '~"' '~-- 1~-- > ~.....,,
0 . ; . ) ......, , , 0 - _w, ,o
are
.:: ._, _ ,, ...,, , .............;. .. ;1...;:...;..._. ,..',

.a'onopnai..:~enses ..:....Ch~f~~~qs_-ot_\73.gi~at .' ~s :test_~<i!u~iV.e.:;..:Jt ~ -:likeWise::P.!

'bleeding :~~y tniiillc -ili.~t~-o! #~i:irial: ~ec~~r qr Iirl;lited:V:lil\letowomen:w1)-~$derg<?:ARf~trse J
:Ul:cotp.pl~teat;>prtion. Ma.Joiityo.f'the~~fW.omen'Will they .:coma 1>-. assPGi~ted :hl~er-Jete)s -of 'roth
pfesilt -~th:amenotrheab~t-a. fou...1:hofih~m. Will i;roge;sterdne:~ Ih ''200&. ''Bl?-tWq~ .et -1!1.=iix9ted
:~~i} .thatjt -~~- CQilclt;tsive :itt :25 pe*~t ~pf.:wom.en
undergomg evaluation f~r ect9j):ie -pr~.1o .
"Si~"l~ vital .signs ar.e 'liote4" ;bef9t~d,~pt\ii'. -bf
a.n . ,~~i>~:pr:cif.aney. Wlm =m~te .P,i.eeamg:.
V:it?I si~s.mt.y -temam normal :or:~h.9w a:$iight.
e1~~ii:bh 6. blood pressur.e:'~r 'bta:dya.r.dia:mtl:t
:hYP<)tep)Hon. Pr~gre5Sivelo3S :ofblo<Xi wili-res:uit
.in-~~ =f<tll- of'b~909;press~e~d~-fi$eifu~e~:plilse '1;hj~ i~'the tech'rtique .6finsertiil.g albO:g, large'
ra:te. :Jn-'sci:giqtl11y confuiried.op~cgestailon~. bore ne.1e {g?:~:rge 16;1~): t:Prough::a n a:d~ately. .
it -witS =i-~ported that .qn.e..,fottrth P,ad~hQ:Ck;~ . e xposed:posterior..vagin:ai'fo:mix i,nt~ the po~ch'd .
DOUgt!i~ ~d aspita:tirtg :the co~tents_ .. A positive
.D~r:ing pelV;it: ~e.x:a.mlnatio,:1, . e~qu:i:i?ite culgb(iceil-t~sis- ..confit.ms th:e :pre:sence of
tende~ess ~ -~gted. on.motion :ofo.the cervix. -This hemQ~rito~eu:m and has been r~~rted to be
find.ffi:~ noted when th~iubhl-~cy is -~oout compat,!Ple with ectopic pr-egnancy in ,9.1IDo:st 8p:
.to.iuptQre or is :aJr~~Y :n.lptili~: .Ai;>out:a-!Qwfu pereent ,6'( pati'ehts. A. ne~tive r.e~ult d&s -not
o f :p;;ttientS will not experlehce --tendeine~.~w~"len: e.Xcl:ude .a n 1fitad .<>r .ru ptl;lred.-. ~topic gestation: .
is
t he tube unruptured. The uterus is-doughy- and C:u:trently:. this pr~edure has been -.reP.~ced :by~
. .is -~I;tl~g~d in' a fourth of patient.S:.-6 lt:in~y :be 1n9te sensitive test s,- ~however, 'it ~s: still Perlorrned
pushed .t~ .o ne side by .t he e Gtopic mass or ..by a in :areas with limited resources.

Scanned 8y: C
 CHAPTER 33: ECTOPIC PREGNANCY
Ultrasaund or Sonogram
The early diagnosi~ of ectopic pregnancy is
fa,cilltated by the utilization of a non-invasive office
procedure - the transvaginal Ult;ntsound. Over the
years, it has emerged as the imagL'lg ter.Jmique of
choice in eady pregnancy~ The vis~tion of a
complex adnexal tnass that is se_p arate from the .
ovary is the .common fmding of-ectopiC pregnancy. "
(Figure 33.S) The findi."lg of an echogenie iluid in
the cul-de-sac also increases the likelihoocl of
ectopic pregnancy in over 50 percent ofsubj~~s. 11
Barnhart JUld c~worlcers pbted that an empty
uterine cavity when t he a . .hC(} titre is: l,SO,P@Ut
mL or .more .was 100% -accurate in e.lltiding a
Yia'bie intrauterirte pregnancy.-12
~ -"3.3.5.1'ub'ill: ~9. ldl tUbe.,o n ~acopy
.{F'roi:n: .T~ O, ~bzW" T, YexilM ,C: J .Ain AaaPe Gynecol
LaparoSe, 2001; 8:3: 33$).
Direct visualization of the pelvic organs
remaih$ the gold stairdard in the di<lIlosi$ and
sub~equ,ent tn,a,ne,gc.Q:lent of ~topic pregnanGY:
Figure 33.6.1'his ~yin\rasiv!;: ~h.nique is
favored over la,p.an>tomy bccaus.e of the fast
'!Ccovecy time and .associate4...low tnorbj4ity. 13
DIAGNOSIS
Pregnancy Test
- .
Patients presenting w.ith a.tnenorrhea, vaginal
bleeding and pelvic pain .br tende rn-ess- are not
Scanned 8y:
'503
~gUte 33.6; 'Tubal pre~cy, .left tube ~ b:parosco-py
(Fro~: tewa 9< Ebner T, Yaman C: J Am ~ (!yn~l
Lap~. ~:1; 8 :3: 33~).
-c onclusive .findings . of ectopic ges~tio~:. ~ l'a~t.
some i'nvestigator.s. ~Qade the. CO.J.l~::J~~~~J:}f~~t
. b:jstocy, and 'pbysical~tion :~l.~ljl)ly
identify_ ectc;>pic presnancy in it~:;,un.~..:..P...~.~ed
state.14 Wl)en a patient is hemcrlynamif;any..a.ta}lle,
. a.quick.p~~cy test:_lQilow~ .:Py. ~. ~al
is
.son0gram ;:wammted. -A t thl,s ~~:-~t.-weu
. e._q uiPl"":"
'.......A and ad. ~atev.. ,.iJl.a.ntied~
. tv . . . . -~ ~ tetS:
. ~~ .-.,d
diagno~ the presence of ~pic ..pregnancy~with
is
cer:Wn.cy. lt accepted that when theB-'hCG is
':\bove l.OOQ-2't9.00 m.IU /iiJL, a rtormalbitrauttririe
pr~cy ~s visuali;ed (disc:rim.i.tiaq>ry B-hG
lev.el).- --Rence;--its-abs~n<;:e-highly $Uggests:tbe
presence of an ectopic ge1:1tation or a pon-viable
intra"Qterine pregnancy1215
A situation tnay arise when pregnancy test is
positive, with ~-hCG le vels above the
discriminatocy level, but the
uterine Ca.vitY is
el't;l.p ty and no adnexalmass is identifiei:tOJt pelvi
sonogralll . .This condition is referred to as
pregnancy of unknown -lpcatiou -(PUI,) . Three
poasibilities ha,ve to be considered in PUL, namely:
1. Early pregnancy failure (abortion)
2. EarlyJntr,auterine pregnancy without definite
identificatio-n .
3. Ec,t opic pregnancy
..
To re$olve .the dilemli;la.posed ~y. this ~nditi.on
sei:ialsrUm 13-,hCG levels are
helpful. - I~ormal
pregnancies .Ule -m~~ .doubling#~~ fo~rB~hCG
is. approximately 48 hours and
. th~ lowei>t value
for this increase is 53%. 16 When -the ..initia l
~
 504 SCTfON V: HEMORR~/,'GES IN PR~GNANCY

p-hGG titre is bdc;>w th,e discril1linatory level, a Medical Treatment

r:epeat assay is requested every two days. If the
titr~ does not double on follo~-up and the repeat The u se .of a. folic a-cid ap:tagonist
TVS reveal~ .an e mpty uterine cavity, .a live (Methotrexate) aimed at rapidly proliferating
intrauteri,ne pr~ancy is unlikely. A dilatation trophob1asts has been revived ih the corr~tive
.and curettage ma:y be performed and the absenc e treatment of un:ruptured ectopic preg'nancy;
of products ofeonception will 9nfirm the pr.sence Maxitnutn ber!efit from this drug is expectedunder
o'f ~ctppic p.regQ.ancy. On the -other hand:. the fue folloWing .conditions:e
presence -9f gest?,tional prod?cts ~s. di~ostic .of
a .failed pregil?--OCY. or abortion. .Jndtca.tion.s
.

Ruptured' ect.o pic _.gestations _prompt reG.l.l:i:' 1. pregnancy '1s les~ than 6 weeks
'diagnosis~~ ~a_gement The ~ed~urces 2. ~bal mass is 'lesS than .3~Scm
in. s0.me ~terarequire 5n 'alternatiVe procedure 3: non-viable fetus
tO; -identj.fy i:be.~. pa,tien~. J'he :s bbck indeX '{SI}, 4. seni.m !3-hcq is less than 1'5~000 iniU7~
which -is the .ratio. of heart rate"U:> syst-olic blood
pres~ure {HR/S8P), is an easy and quick n:i:~thod Cont.ra.indicatio ns
to identify such p.<ttients ~ppn .~dtriis.sipn,. The . .. .
nOrmal sr i s D;etW-een .o.s to o:7. ~7 ~- Bitleh3:hn-, et 1. -a~tiYe ::~tr:a-:-.aba~nll,nal- blee~g
-~-- rep~rted that the lik~lihqod o(;redict~ng 2. i?~~tte~~ . -:: . . .. .'.
ruPtu,ted ed-.qlicpregn:imcy-was an :sr 'of >Q~$5.18. . 3~ imm~6de.fi.ei~ny .
:trsfrii:~i~)i:i~thed ~a-tt9: ~~~ri~ i:.DOs_qb.s:' Lind. 4. _Pl.(l:(bt.se;r~sia.- .
.g:Ban -~'cluoe<I(tJ:ct.:sJ!h.adf1~6sv~~:ftiW.cy s ~' . 11 li. ... : .. ; - - ;.. ..... . :
rla':46~~citr:f:p~dl~g~setf.~~io&{... 6> Pe~ti~,tiS:~:_.di~~-:. . : '. .
kiss ~teaWith ~tiJ.ptu:r~a.: :tubiilfies#tiqns. 7. l;ivei.::.oi-.-re#id .di~ea~- . .
Tbey.at~n<?t# tl~J'!:ftP.~ 'i#.~~- v;~~e ln'er.~sed . 8. a9t:iv.~<:iwJinpn~::~s~5e ..: ..
. among.(~tients';with'.:low ba$dirie.~he.nroglol:>in.,-. -
-~!s~at-:th*'aefuuttin . gi:e:<:ti0n'19'~ .. .: .\ . . . ' :s..s......_s.._:~. .: ::,..,~_-..~ ..; ...f_p:,._':a:.c...Y' .'.~;"""_~~-_ :~.:te..~ :'.~
To.:.-'a . ;f.
-~:~ ,;.. ..
~: i::.~ :-. - :.-::< :: _. '. ~: . ~:.~ . . '. . . M: th ~; ~~~r;:. "'nit.. ..,;J;~a~~
p:rirr~tli:(a~~e or~cif\9!6c.~tit-e~'i.~ 'hlay p,e n:rm:Ihem~~bi:Ish~~:C~ti~/~~~
-:cl:btting
~t.~:. .
~~-~;:tiffi~.:~d.*~:as~!h:~P?~-ol.t!~Ji- a.rase.w.
.bl~:..:.:w:h~n_p-z:egnancy.~te~t.~lS-P:C>Sl~V.e
...
..................~ ..
.. ~~~:'~./,.s-p.: -.,nd:~-~-t..rn_
1 E _ ~-.n.-~.-~~-g:_~l~.-:e~:.;r.";m"_,._~_~., .:..tt.~-:. .--~,-~: ;__:. -~,~.:~~
.. _ :v ..o..,.. .:v.u~'~eJ..u.;..;.v.. ._ . . -.-... -)~_:_~~a:_~.i:_est
~--
J;riglily sti&teS:ts an ectq-pie p"t~~cy. It wa s wee~ _pe:rioo fu:~t,at-e -~U.cCe'S$ful"tr:~t:ln ~-
-f9iln.a : ~t:abd6.niinal..J?SID, lmv:~~C?W.o.bi.i?,, illld ...
.t he .p~~ of large imoun:t .ofeeh&gei)ic flP,'id . Stiveial protOC91s i).aveb,een .tp.eQ.and the two
~the .PP.uch !)f,Douglas.on t:p;m.sv~ginal.son'Qgi'S.IP. commonl)i ti:?.c d regim~il:s "ai:e :th~ '~mgie :dose
.-aretb,e~o~tseil.sitive p:<edicto~.<>f.mptur.ed:iubal SOrngfrn:i IM and the variable 'cio~. fral;>le .3$~2}
,geStation.;~ The (armer is .-.easie-r to administer 8;hd to:mofiito'r
but :i~ assoCiated ~lith ahl~er rate of -~t
-;r)iEAt~~- ~ctopic 'Pregnancy. An :ir.itia1 hl@.l. titre :df:~hCG'
(10,0.00 lU.froL) -i~ .r~tport<;d to. be the single.most
the increased awar-eness o f the risk racto'Fs imp6ttan~ f~ct~r .t ha t fa.Uurell.S ca:uses-
-aided wftli impreve~ diagnos tic. !tools_. h a s
faGilitated -t he e~ly -<;liagnosis ~d treatn;le:r;tt of 'With s ihg1e-do se int-ta!XiUs_cu:la:r .. . (1M)
ectopic ,pr~gnancy. this' ,is- an. en-couraging Methptrex'ate, tfie.tneah. seru'In: ~::hro ~'for
:devCiopment.be~a).:~s~ when ectopic:sate diagnosed the first 4 days after- .inJectib'n: then gradual~y
they requir-e i.inmediate management.. Ther-apeutic declines witha mean resolution :PeriodofQ7:aays.
. .opti~ns will ~i-epend o.n the pa"ti:ent's need for In c ontrast, surgical -ma-~a.g~ment with
another pregnancy; hemodyn~ic status, and the salpingostomy would show-ther apid d~e of the
~v~bility .0-.a:dequat-e. and:. :prop~r::.m.edical- and P-hCG titre and it s gra du'a l re.so~~tion .after .20..
,aurgi.Ca,l tesoutee~~ .. ~opic .g-estations ..'that .an~ days.21

diagnos .early are commonty m :theii uimiptun~d

.s tate. In such cases, .they can be martag~d either To counter th'estde effects -of:the d.tug 'when
medically or sur~call.y. using the other p~oto col, Citr()vorum factor is

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 CHAPTER 33: ECTOPIC PREGNANCY ' 505

Table 33.2. Methotrexate therapy for primarr treatment of ectopic pregnancy. {From: Cu~gham FG, l.eveno KJ, Bloom
SL, et a.i. Williams Obstetrics 22nd ed, 2oos M.cGraw-Hill Co., Inc, Medical Publishing Division, USA)

Regimen . . Follo\v-up

Sin.gle{)ose Measure S-hCG levels ~ays 4 and 7

Metho~te, 50 m_g jm2 IM If dijierence is > 15 percent, repeat weekly until Undetectable
J.f dilfe~ce < 15 ~t, repeat methotrexa~ do~ and begin n...-w day 1
Iffetal cardiac activity present day 7, repeat meth9~te d9se. begin new dey 1
sUrgical treatment if ~hCG levels not decreasing or fetal carc:liac uciivizy persists
after &.tee doses or xneth~trc:xat,:
Variab!e .Dose -Contipue altemate-day Wections until S-hCG ~~~ do:crease
.Metr.otre:xate .i ~gjkg !M, da,ys 1,3~5,7 15 percent in 48 hr, or !Qur doses-methotrexate g;iven.
. teUkavorin. .O .l mgfkgiM, days2,4,6;8 Tben, weeklyS-hCG un~ undetectable

,"RegirJlena.ftQ.m Buster and Pisarska (1999); Lipscomb and co-WQikers (1"999b),and PisarslaJ UI1d o;Olleilg\ies(1996, i999)

adD)iniskied' -altemat~ clays thto\Jgh 4ifferent .

on
routes (lV, ~ ora}). While .e n this therapy, the
patient .~~,advised .toavqid coitus and alcohol and
to .refl1J:1n fi'om ta:ldrig folic a.cid or prenatal
vitan'lin$;: .. .
SUJ"gicaJ:.).lanage :m.ep.t
- -~ ~
- ... - . .. .
. . S~N .:treatmentJor: ectopic gestations ean
be .cop.~ative or radical and it is ..achiev~d
t:lmlugh~.scopy orlaparotomy. Con~tive
sux:gery ,~. l.1<~rVe.d for .the -p atient who des~s
future .fertility .and .is .~~1ll<>.i:tl'l}!VP.iW\UY .$table.
These IeC.!lnlque~ -.-..~t.e .. _..aa..lpingo.s.tom,
sa1i)Iiiioi.OJiiY, partial.. salpingectomy, Segmental
reSecti.Qn With or withqut .reanastotno~is.
~11;par~scopy .is the modern treat.m ent of
ectopic pregnancy. It has several advantages over
laparotom_y. It p(eserves .pelvic functions, has less
morbidity and faster recovery time.

When the ectopy is loc.;tted in the distal tllird
of the .qviduct, salpingo~tomy :o r salpil}gotomy is
the preferred procedure. 4 Salpi~gostomy is
performed with a . llnear incision . .on the
antimesente.r ic side of the involved oviduct,
through wttich ~he conceptus is carefully and
completely remqved. The: incision is left to heal by
"itself. With ~pingotoiny, this incis~on is clo.s ed
with fine suturel:!. {figure 33. 7) It was .noted that
both techniques have simUar prognosis. 22
Segmental resection with o.r without
teanastomosis. is recommended for tubal
gestations at the isthmic portion ...Performing
Figure 33.7. Transv~rse ulpusourtd view i>f heterotopic
pregnancy {From:. Gerald .~strillo, MOjlxprutment of
Obstetrics and Gynecology, MCU~FDT Medi6ll Foundation).
salpingostomy or salpingotomy at this muscular
tubals.e gment.may caqse scarring and subsequent
narroWing of ,fue lu111eh. 23 Salpingectomy is the
excision of theovidu~t from its uterine attachment.
lt i.s _.performed when the involved o~-uct .is
damaged beyond salvage (ruptu:red orf:b""'ot). A
wedge incision is commonly done ;;tt i(s outer
interstitia:! portion as prophylaxis -against
recurrence of .cornual pregnancy. Kalchman and

Scanned 8y:
 506 SECn6N V: HEMORRHAGES IN PREGNANCY

Meltzer .report ed, h:(:lwever that even this 7 high parity (~ore than 3 births) and with
precaution has not _prevented.'its recu.rreiice.cl-4 unruptured ectopic pregnancies. The rates dip if
it occurs during a first preliuancy, being lower if a
PERSISTENT ECTOPIC PREGNA.."lGY history of infertility is present and
higher if it is
absent. This is likevlise observed when .~ history
conservative management of ectopic of salpingitis is present, the co ntralateral widUct
pregnancy has its e.stablished .a~vantag.es as we11 is obvieusly diseased, 'and when rupture h as
as worrisom~ compUcati~ns. Incompkte relllbval occurred. Women with IUD at the time of ectbpy
.of ili~ ~uctS of,eonepfum I~ds. to p6tsj.stente. are ~ported . to have nonrial rates of subsequent
oi the eet:opy. It complicates 5 to 20 .~t of fertility.
salpingecto.m.ies and 5.,.14 pereet).t of wome~
treate-d initi!illy with system.ic M~th<>trexate.;s . Conservative treatment 9fUntupt.J.reded:opic
Pern~stence js r;lft when the ~hCG titre .ls ~ss pregnancy shows a high in.id,ence of subsequent
'
-than 50 . percari.t oJ the' pre6penitive vahi'e. 2 ~ . 'f~'rt.llity.30 Afte.t-:. tWo ectopit pr:egnanci~ in ritro
Patienu who .teGeived Methotre:x:ate th~py wi1J. .f~rtili.iatioh (IVF) tan be ~coinmended. to a .patknt
eiperknee:increasing . .pain .s everal days after. desiring to conceive again. ThUJ technolcgy will
treatment. This "':separation pain" is .often mild enha.nc~ her chances of ~ po:ssible viable
,_ and'~lf..:!..imited or ca...'h be ~lieve4 :by'non!"nattotic .pregna;ncy ~nd reduce the risk o! a third 'ectopic
F. .
::..
~ics. Tho~ .Wj.th .seyere ~. slio:\:ll;d be ges.ta:tion. W'nen an ectopic pregh.ancj 6Cctl:i'S in

::~~.:~~~~ji; . ~~:~;~~:~~E??~~~~
., :catfi'~nk' : . '..''o
-.
;. .-:-r;:;:.~i';r:- . ~~ence.
. . .. .' :.- ~~ ... .. :r.~:iStm
:...:-~:~.-.~ . ee&:',6;;..iris . .. d'PHER TYPESoF ECTOPIC'l?R EGW..NcY' .. :
;_ ~ -.. ~ ... :.-:.,.: yJ~
. . .
'tu~:Qccurnrig 'in 'S-,L'O p:et.cent'9f::cases.

'i\1*-T~~~~
. . .... . :: .,. ' ..
~~e;~~~:,:~~~~
Ht:::z:::::U>af.~.rs~~~Dbrm.l
(\~ 'in:tra\xterhi.e!pregnancy:-i:s,:te.t'ihed'.'nefeiotopic' .. ..
.. ~::.J~~~i?~ff:::t~r:?:~.:'::: :. .'<::_:. :. .,...... ' .> : ..... .. pte'~~ - M~~~tai -.~~~-pre~~,~:~
. ~.~~an~.(~cm).. , _ ...... ....,., .. , , . ..- reporled: tiL~..m ..a . smg:.t7, ov.ili.uct,.s.s.~ell. as .
. ~.;2~tli&py.:.{ba'orC-:42ifuin"~yt:} .:..:.. wifu:on.e.l:n.each. rube:~'..:P-rm:ousJY-nO:tM.tooecur.
.i.;~..:~qo~~;ei~~~~g:~~~:~~~ ratdy, its 'incld~nce is c~eri~ at 1 in :7.~ A.

. 4.'~~Ui;n;.a~t.~~ to ~e~j>~M.$tQmy: Site 6veraJL 4 .It appears that ART; like o'Vulaticm
ind~ction,; m, and embryo transfer [Et) :!:'lAve
. :p.~~i~teP't :ec~pies .h ave.:~n su~.essiully contiibute~Ho the note~:i:rise in its :in~deDce..:31>\.3S
:.t;;r~t~:~th ~~.~(:)~te :pr 'S~ery. 29 : .

. ;:::--:.>. :..:. ..' , .: . . '.: . " .sti~picion o.f'its..im~Sence'l's :hi!ghtene~fl?j'the

. :~l,t.~~Q~I~ . ;. ,. ... . . . f01loMn:g:

:toP:ov/ing ;~ ~~p~c Pl'Y.~~cics, the .ove~iill 1. Following ART

sul;>~~e~~ .~neptip. :ra~~ is .60% With .the te~t 2. Abs ent va gim3.1 bleedin-g with sigrrs ind
.rerii.~\nirt,g infertile. After:.-an.ip.itial ectopy, about syiilptom.s of ectopie pregil~cy .
one <;>f three to. four conceptions will~ :another 3: Pet:s,is tent or rising HCG- titres after D &C for
ectop~t .p regnancy.. .Patients who .conceive s,p ontaheous abortion .
following .~ e4topie gestation .~. 'therefore, well 4. Uterine size is bigger than AOG
ad.Vi~ ~to . be :'monito:r:e<l wly.with.ultr:aso:Q:nd . 5. VisuatizaG:on of more 'th;.m'one corpus iuteum
.Sev:eral :fac.t-ors can l,liodi1Y, these 'figures and they 6. Pre,sence of intr-a an.d extra uterine
include the age, .p arity, h'istory of infertility, pregnancies On ultrii.sound
.d iseased, .contralateral p:V.1duc~ :ruptu-re ur
tlruf.lplured state and: .
con:comltant use of IUD ..
, Tt eatmeht: for this cype of ectopy is ttie surgical
. Ithas:been reported that (~rtility r a te 'h igher is :approach. Utrr).ost care in the preservation of the .I
:among parous patients :younger .than 30 y<!ars,. of n ormal .i ntrauterine gestation must be obs erved

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 CHAPTER 33: ECTOPIC PREGNANCY
--~--------------------~--------------------------------~----~ ~
during surgery to allow the growing conceptus to
reach term.
Cervical Pregnancy
Thill ~ of ectopic pregnancy occurs when
th~ blastocyst implants within the endocervical
c.anal and proceeds to grow and develop in the
fibrous cerVical wall. From an estimated inCidence
of 1 in 1 8,000 pregnancies .in 1966, it has
increased as a result of AR1' ~pecially IVF and
. ET.36.37 It was reported that 70 percenty of c~ses
had previous dilatation and C'llrettage and uterine
.scar.u The te.st had no kiiown riskfa:Ctors. fu the
country. th-ere have been Jour n:porttd ca:ses.:!942
Thecrles in the pathogenesis of cervical
pregnancy ere the rapid OV\Ull transport or delayed
ovum ma1:!lration predispqsing\t to impl~tw fue
endoeetvical. canaJ.. . ln 9 0_pet:cent of patients,
pffi:~Jess \~gina:! bleeding fol1owing roneno_rrhea is
noted wiJh. a thir~ of
thetn having massive
,. hemorthage; 43 lis the con:ceptl..lS grows, the cervix
becomes dilated and is disproportionately enlarged
wheii:- compared with the uterUS ; On visual
inspection, it is bhiish or purplish in rolor.
i.s dis~(\~,o:r edematous. lt rarely gtows beyond
2o w1e~.~ . . . . .
-. - - ....~~-~~:~::~!';~ . . . .... . . - . . .
. klu~delC of suspiCion on 'L'le part of the
clinician leads to the early diagnosis of cervical
p~. Timar~Trltsch and.10igman tRgether
w!~..fu~~ ~~.s.oc,i;;~.tes P~O.P().se.ci t};l~ fc:>J!Q~~P.:g
~.Q!l.plo&i~.~tit~ri.g ..t.Q.SQnfir..m Jt prelie.tH~e;_~1 45
(Figure 33.8)
Figure 33.8. Ultrasound photo .cf cervical pregntmcy. UB-
urimuy bladder; YS-yolksac; E-embryo (From: Lyra Z<>leta,
MD, Dept..ofObstetrics and Gynecology, MCT,J-FDT Medical
Fouridation). ::. . catheter inflated with 30 cc s terile water.
507
1. Placenta and entire chorionic sac witlj'Hl live
pregn,ancy is below the intern~ os
2. ~rvical canal is dilated and barrel shaped .
3: Empty uterus
. When the sonographic results are
inconclusive, MR! can be employed to confirm the
diagnosis. 46
Management of cervi<;al pregnancy depends on
two factors namely. the desire of the -patient for
children, and her hemodynam.ie status .
Hysterectomy is reserved for the patient with
completed family. intractable hemorrllage. .3e0nd
or third trimester pregnancy or who 'WOuld not
consent for blood transfusion. During su,rgexy,
care must be observed hot t.o injure the urjnary
tr~ct beca:use the enlaq;ed barrel~sb:ap(1 ct:rVix
can pose a t~chriical challenge. 4744
To lessen the morbidity risks.that accompat).y
surgical management of cervical ,.Jir.~gnP-:J)cy,
several conserva tive methods have beeri~,ivith
S\lCC~SSful OUtcomes : C()nservatiV~_;,,UJ;;mP.:<mtic
and .options for this type of ectopy mclude rirte~:o.r a
combination of the followillg: 4 ~ss
.. . .. . . ..... .. :;:. . ... , .: i . .
. ... ~ . .. . . . .. . LSj.steriiic:niethotr~te and sulpiQ~t69-;;;.',_ ...
2. Intra-amnionic injection of meibo'tt.~te,
i>otassium chloride and hyPei:osriioJai.:.gtiJcbSe
3. LoCal injci;tion Of vasoores~in, .methotrexate
w.~Lim:~.:;m_glnn.~ . ,
4 ..Tamponade_.(FJgur.e _33~9) . _ . __ - ~ ..
-5. Cervical and uteri.rie artery embolization or
ligation
6. Cerclage
7-.. Cure.tt8,ge
.~.\'f~~:f.&:-:.
. . .;f :: :t_f./ (
.l;~; ':, 7~1~~i~~~ ,.,;~,
rt
~;~nch::t4 Fo ley
Figure . 33.9. CerVical .tamponade .w ith
banned 8y: C
508
lnt~r-stitial Pregnan.<:y
Interstitial pr~~ari,cy is a r.~tively rare type
of ectopy. The conceptus is impl~tec:l in t.'le
interstitW segment o:f the fallopum , tube at is
embedded in ~e :ut-erine comu. {Figure .33~ 10)
The anatomy of t~is .area allo~s gr~~ter
accommodation of the growing ptocfud::: . of
conception .accounting for its difficult e.a.r.Iy
.d~agno~, Iat~,pn$:et .of s.ytnptom~. artd occasional
ieports6ftenn-fut~titial;pr~~oes. 59 !he term
cornual ;p.regn.a:p.cy it! -sp'tnetlm.es. ~~ forthis type
of gestatiot;l but in its true context, cornual.
:pr~cy embe18- .anQ. deY.el~ -in~ :P<>r.o. of a
bi:rotnuate :uterus:
. The in~eased va:scula,rity 'i?f the mt~~tial
segment -of .Qle :o:Vi~.wt. where ~e u,t~e and
pva.rlan vessels joinj an'd the Jate Q.i~~o'S:is;
inc:rea.S.e the .r isk of t,ra.\.un.-atic t'upture . an-d
~~oribigi~ shook .. '
. _ . ' ._
: ;Th~~$rst;tP.\)I;t-~.;:;J:t~i.1>V-~S$M.~~~-ea.t,of..... . th.-e.tQviq::Jt.;W;i~-..sUr~l:ienhh.llii:alr.~byrtiothM&\ .
:.ectopic. pib~cv.:With meth<:(trptate .wa,s .:for. . ~-ovarian:-attach.nl~D.t-.a;ri.d
lnter.st.lti;al. pregnanP.Y~57: .s:uc~srol. oJlt<.-in.~
.U:sip:g>is.lrioce. ,of ,t teatment: ,h:~ r~Uy)l~n
. report2d .bj oilier .iny~ia;oo.rs.~ Tl'a~tii>.willy, . fir14mgs. -~e n:9 :.-altferent. from those.' ()f. tubal
tb_e m~e.ment!or-tlih~.t}':P.e.- :Of pr~-Wa:s: .Pre~~cy. :Tr-dt>.svagip~ UJ.;rr~~..-~o:und:.~: been ..
.1 :_a~~
..- ._.m
_._.- ~0'~-.P.~:~.~-Di;"'~.-~.~-~.}~~
'"'~ """'~,..,........-...
.:~s-~tcer_.t_."""w.y:.a._,~.
~...,;.~.:....~
:~l~ct~-:;p~tient~~ m:or.e f;P!l~tv~t)ye :atf4 'less
r:ad!Cal~~~~pie-appr:oa94e~ma:y.-be..~pj.o'yed
p-riw:idedthat-the-~s~~s:ctu~y~cyfl).e,P.ttnt
_ ,1~ .$4tble_.
Flgure33,10. . pn3D\ll~und
(F.rom:AngelitaReye_s-teqtico~ '$ ,: ~~ent.of Qb*tric:>
& Oynecology; MCU-FDT 0eW.Cal Foun,~a~on). .. . . . and. only nid~Son of the peritoneal sv,rface. its
SECTlON \f. .HEMORR~GS lN PRE~NANCY
Ovarlan _-Pregnancy
Ovarian pregnancy is another rare type of
ectopic gestation. Risk factors are similar with
thqse of tubal pregnancy a..11.d among the known
is
f~rs, 1m IUD as~ated with a high prowrtion
pf cases, up to 90 ~~qent in one series. 5960
ltistoricilly, .there .w ere two ty.pes, ;primary.and
second?rJ. 8pieg~lberg drew the ciiagn()stiG 't riteria .
wbich !lpPly .to the fon;ner type end are e$tablished
ori.ly d:Uring s~ery-.:61 The'Se included.:
1. The tube .including th~'fi.oib~ ovo.rlca.is intact
2. The..~tatio~ sacis L11 .the norm.al 'amit6init
~oc:ation ?f thd ovm:y . .
p. l:he -sa is _connected to the utenxs :qy th~
ov~ Ugament .
4. DeJWtive ov:B.d,a:n. tissu~ i~ lti._stologic.a.IJy
d.e~on$traled--in : the w~s w~
ln th~~i;o.!l4<4.Y. ~:}!<.;;- .(~~tion occur-$ .in'
_gro:wth.. : .-
. . . .
. .lfh,~;..pn; ~enting. ~y~:ptptp:s. and P:4Y~ical
~. _m_-~~
. .:..~'~.:~-~il.~_!.i;~.
' .l ual_:
l'-4,k<'';.r....
.. .-::,~
,f.il"r.:'_tv.....',:. :h~):p1\1h'U(its:.ea,r:lyae-t~c;iu.:~J.u;i'~~g~ent..~-. ..
' Rg.pture:~t-~ e?.T:~y:st?.ge.'.i.s - tlie q>1n:ino~ co~
Ol :;m ,o~atiap :ptegn~t;iy ntteess:j.tating .pi,Q.J:iipt
ti-ea:tii;\en~ - ~ . -
.. ... - .. - ... - -- ... --- -------
Previously, the .classic J:!:lanageme.I).t was by
4>. laparotomy. Ovarian -~re~g.e_ :re-s -e ttiqU was
... ~tf~~ w:~en :~~ ~volved.. ar~.n~ s~ and
Ov-$1.~. Yiherrirwa.sJ&i:g. :With.'th'~air~s
mqi~-~~ti~,~~~e~~:_s~.-CM s~:,,~ope~tive
tecb#.iCN;,_md.. :~~p.ii:Pment ...fo.r ::~pa;tpS;di.P.Y, a
_illji;HJtlM'HY. m-v~~.ive- apyr;oacP...'(r~~ti6n or. ia,Se;r
a'Q~tk>-n~ts r;_o;;. the prde'f!'ed. treatment~. tn
its up:il,lpture.d; -sraJe-; suceessful tr~tment Wj.th
M~tho~~e ha$ :be~h t~pPrte~P7
. .. . . ..
Abdomin.il Pl'~gnancy .
. Approximately l .percen~ ~i ~l ect.o_pic
pr~grian.cies are abd_om'i:nal,' a,ti4 -its rare .v?rlant
is 8.n'?mep.tal:pr:egnaricy.~9: lt;Jlas;the saine fisk
.factors as the afor~~en'Qoned types.
0 0
. . Pnmary abdominal pregnancy refers .t~ .the' fll-St
Snanned By: C
 sog
--~-.,.....;..,..---:-----,......- ....................__.._~--...............- - - : - - - - - - - : - - - - - ,.,,
..
;;:

diagnosis must fit the criteria published by

Studdllord, which are:
1. Tubes app'!ar normal with no evidence of
recent or past i."ljury,
2. Th~ b no uteropla.~ntal ftstula or evidence
. of uterine .ruptureJ
3. The pregnancy is exclusively attached to the
pentoneal surfaces and i$ early enough to
eliminate t.i le possibility of sec.ondary
implantation followin~ p.rim~ t\lbal nidati~n.

.or
Most of tbere}lorted cases are tbe ~con<}ary
.type $uggestiqg ~t abdominalp regnancles dCcur
following tubal abortion or early tubal on ut~rine
rupturew,ith subsequent impl~tat;ion.artd growth
hl periJon:eal .surlacea.

Patiep.ts :CPIIlplain . pf abno&.m al :u tedne

bl~~-an'd abdo~al pain follu--wing a }XriQ<i of
amenorrhea. Vlhen the pr.e~cy iS established,
-dbcomfQrt. nausea, v()mhing, diarrhea or
wnsti~9n are c~rienced iil_vatying degr:ees.
Pilin{u1 fetJ.ill:ovemepts are felt late in ,p regnancy.

. On ~a:tion, fetal parts .~ ~pated with

~ .anc~>~bnonnal :fetal positions ~ cpmmon.
On :~;~ation, the ceniix'i s disp!aeed and
unetla~'i.Wf.lle the
\items is noted to.be .separate
from the pi:egnancy mass.

Early in pregnancy, an unexplained anemia

that follows the ..fuitial tl.lbal til,pb,.ue 'Or a~rtion
may~be 'helpful inits diagnusis~ .. so-metini;'es,
elevated serum alpha fetoprotein levels are
noted}0 :Pelvic Ul~sound findings may not be
helpful and half of the casea are m1ssed; 69 (Figure
31.1'1). 'MRI has been rec.<>mJJ1ended following a
suspiCious. ultrasound fjn:d iilg b.ut is not
con.flrtnawry in some cases. ~-1 When radiation Figure 33-.1~. Live, term, grossly normal, baby girl delivered
eff~t is not a concern, computed axial tomogrttphy from an abdominal pregnancy. (From: Angeli M. Castilla-
scan coUld be diagriostic.69 Reyna, MD. Department of Obs tetrics & Gynecol9gy, East
Avenue Medical Center).
The diagnosis of an abdominal pregnancy
warrants its prompt treatment because of the risk
of a catclstrophic intra.:.abdominal hemorrhage.-
Thus, adequate and appropriate preoperative Placental separation may precipitate life-
.preparations with .blood compon~nts, 'infus ion threatening hemorrha ge, hence, severing the cord
intravenous systems capable .o f rapid delivery of near its placental attachment and leaving the
latge volumes of . fluid, and when feasible, placenta behind appears to be a safer course of
transcatheter emboUzation of major feeder vessels, action. Resorption of the placenta is monitored
are recominenc\ed.72 Fetal survival lUter 30 weeks withultrasound
. .
and serum 8 hOG titres. .The use~

of gestation is. r~ported at 63% with fetaL . of Metho.t rexate to hasten this proc<:s.s .J~mains :
malformations and deformations occurring in . ,t ontroversial. 'Leaving the placenta behind could
20%. 7 ~; (Figure 33.12) be life saving but its post surgical consequences

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 .510 SECTJONV; 'HEMORRHAGES I.N.PREGNANCY .

''~' '
.':m~y l~d. to adhe~ion:s, infection V(ith ~bscess, Symptoms vary from s~ty vaginal: bleeding
:}n~tjrtai ~P3tnlclion, W:oWid del)i~pe. pai.tial to life-threatening hemorrhage when in;<iMion of
U rethral 'O .Q stn;iction with reversible the myometrium qy th~ growing c onceptus leads
hyd.rqn~pli:ro#~ .. : a:nd :e ven p~rsistent to uterine rupture.
p~p&:.a:,,:76 :Ift he p~c~ta caii be delivered
sa!ely1 poten!ial pleeders a..re.ldentified and ligated. Sonography is ~elpful in the 9-iagnosis of t.."lis
.:pii{)r.pHts r~~al_. . . : . :. tYpe of ectopic pregnan cy. The features included:n
.;wp~ tlie.~~~i~ .;~: ina4e dhri.t?.g,the:~iy L Uterine a nd cervical cavities are ~pty
tri,tt):es{~r.t ~pQrtS o'f SUCCC:sSful l~f)arb~c9.,Pi'c 2. Development 9f. the gestational sac -:in the
.~* ~f ~~ c.o.~c.ep~s. :.Y:~n .~ . ~t~ rUpfiif.e9. an,teri6r part of theuterine isthmus
~$'ta~ltiv~ ~~q;::pu]>j.i$heiL~;n 3.. Att:a:chmen't of gestational sac to the scar
. . . . . .. ' ~ . .. . ..
4. Abs<!pce of healthy.myoq:1trium between the :;.
urlnaty bladder.wall and gestational sa(;.
~ . : ..
.. ms b' :th~. nr.;st:..type of~~,pic pri:gn.~cy The management is sit:D.ilar to the <ithe:r types

.
::;:=~~=:~~~~~u!~~~~~
l'n.yoinetl.i\l.in1P'l~the.ijarGU~tis.Sueofthe'previo~s
of ectop~es with the .medical optionof methotreXate
having the best result when the gestation is
betwee11.6 to ~ w~ks., tl,le 'gt:;~tp!ipnal~cjs 2 em
;eesar~ section s~. . . . . . . or-smaller and cap:iiac..acti.Vi~ i.s.ab&:::it. :.
;.. -~..: . .
' ...It.~p~.that.an. :i,mportant..riskfactor:is the . Other treatmept mt:>.dalitiC:s inclu de.
:. . ..... .~i:fom~c(;;c;:.esu~~~<:m;~}J:en..the.1ower+ . .. \ , .. . . .. .
utef..:ie.,~e,rit. is.~vl.Y -develop<;<}~ StlbS?!qu.ent L .Lap<Q:oseopic. ~xcisioa of i:h~ gestati.Grtal sac
:iltiprppe(hea:Ung -prowcl~.. possihle :unplant.atiqn followed by rep'a ir of the'loweruterlne segment
' ,~~:o'f~'9~t:.-pregn~Y.~. 2; .Vterin:e artery ernqo~ti_oP,
J. '"; . 3. 'S:uction.curett.age"o/ith.ultrasouod
. ... .
gi:ti4e
. ..
. .
. :.~ . _;-1 ~ . ~ ~. . .' .
. . .. .

:. -. .. .. ; . .
..:PriJNfs~to:
. . . ... . . . REME~R
.

~ i'm'p~tatio(l qf tJ'le ~'astocyst outside the endometria( lining o'f. 'th.e uterirye .cavitY Jeads to ectopic
preg~pcy ..
An ~opic gesfi3#oh that ~xists .with anorrilal.intra.utenne :pr~nancy is t~rme.d .h~te.ro.~qpicprggnan~.

Th~ ~a~ in th~.incld~nce 9feetopie pregnancy par.aHels :the ~s~ ih the num~rofw.omeh With .
sex~alty trar)s.m itted infe~ns (ST!) .and the number of eouples tmdergbing .assisted reproductive
'tedino!Qgy.

The iderjtification of'r:l~k factors .and the avai!~bility of sensitive diagn.ostic.t ests have .allowed early
diagnosis and prompt-treatment of ectopic pregnancies.
. .
'Alieratiens or d~rria:ge of the .normal function of the fallopian tubes are known contributory factors of
ectopiC pregnancy. ~

~~~~ed ansit.c>f ~tl)~:fertiliz~ ovum ~long

the .oviduct causes it'to li'e directly- the muscular lo.yer in
be~use of the absence fa submueosal 'lay.er. The ~xpandirig produ~ of conception -eventually
cause .the thin muscfewall_s to give way leading to tubal rupture.

Snanned 8y: C
 CMAPTER 33: ECTOPIC .PREGNANCY . 511

Tubal mptures occurring during the early weeks of the first trimester are most likely located at the
isthmic portion, while those occurring late are associated with the interstitial segment

. The clin!cal presentation of ectopic gestation has deviated .from the Classic triad :of abdominal pain,
vaginal bleeding and amenorrhea to signs and symptoms that are diverse, subtle or absent
. . .. . ~ ' . .

Ectopic gestations th~t are.diagnosed early are commonly in their unruptured state;

During pelvic examination, exquisite t~nderness is elicited on motion of the cervix~ 'rhe presence of .a
tef)der, soft and elastic mass on ihe adnexae is appreciated in approxirriatel 20 .perc~nt of pati~nts.

. A positiVe pr~~nal"!cy testdetec~ the presence cf pregnancy but not its locatio~
Enzyme linked immunoab$0rbent assay (ELIZA) .of serum
and urine' is sensitive. to leyels of human
chrionic gonadotropin (hCG) at 10-20mlU/mL and is positive 1ri over 99 percent of ectcpic pregnancies.

- Visualization o f a complex adnexai mass that is separ~te from the ovary is th~. common ..sonolog!c
finding of tubal pregnancy.
. .
Direct visualization of the pellfiC organs by laparoscopy remains the gold standard .in the diag nosis and
subsequent management ofev""'topiyi)regnancy. . ......., ..... ...,,.,..: .

Rl:Jptured ectopic gestations r~uire prompt diagnosis and management. . ~_. :;~ ~-~:~.H\~4-;..,..
,__ :.;t:~.;

.... Therapeutic options for ectopic pregnancy wm depend On the patienrs need fo'r. another pregnancy,
.hfnodynamic statlls, and 1he availability of adequate and proper medical and 5ur~ical resourres; .
. i ~ ' '

Folic add'antagonist (Methotrexate) aimed at rapidly prolifera~ng trophob!asts is the medical treatm~nt
of unn.~ptuted . ectopic p~gnancy. .
. _,, . ,

.Surg!cat treatment :o f ectopic gestations can be conservative or radical and .it is- achieved through
laparosropy or.:laparotomy;

Conservative mana.gement of ectopic pregnancy can lead to persistehce of the ectopy. Its ~tastrophic
consequence is r:uptur.e oceumng in S-10 percent of cas~s.- .

Followi!'lg all.wpesof ectopic pregnancies, the overaii subsequent conception rate is 60% with.the rest
. rem9inlng infertile.
. 0 .

Fertility rate after an ectopy Is higher among parous p~tients younger than 30' years, of high r;larity
{more than 3 births) and with unruptured ectopic pregnanCies.

The diagnosis of an abdominal pregnancy warranis its prompt treatment be.c au se of the risk of intra-
abdominal hemorrhage. Adequate and appropriate preoperative preparations with blood comp.on~;nts,
infusion intravenous systems capable of rapid delivery of large volumes of fluid, transcatheter
embolizatio.n of major feeder.vessels is recommended .

Pregnancy in a previous cesarean section scar is the rares.t type of ectopic pregnancy. A risk factor is
the performance of cesarean -section When the lower uterine segment is poorly develop.ed:

Scanned 8y:
r-..
~
 S.ECTION V:>tftMORRHAGES JN P.REGNANCY

;1 -
. .
Rlt:FltrumcES 14. Garcia CR. Barnhart Icr. Diagnosin-g ectopic pregnancy:
De~#on .!UtaJy~>i3 cQmparing .~ix ~trategie&. Obstet
. .. Gynecol2001; 97:464-470.
l. Maymon R, et al. 'Ect opic pregnancies in a cesarean
scar. a review of the medical-approach-t o an iatrogenic 15. Cacciatore B, Stenman UH, Ylostirlo P. Diagnosis of
eomplitation. Hum Reprorl ~pdate .2004; 10(6): 515: ectopic pregnancy by vaginal ultrasonography tn
523. eombina_tion with a discriminatory.~m h,GG.levelof
. lOOOIUfmL{IRP). BrJ Obstct'Gynaecol199o;l97: 904.
2. POGS Nationwide Sta:tlstie:s "200~-2006.
16. Barnhart KT, Sammuel MD', Ranaudo PF, et ..:1.
3 . C:a-~0. ~Psl+ganiban .L.. ~c~ala~a~RM, Luna. SymP.t:bme.lic patients with 'a n early via,ple in.t:raut erine
.trP.J~liliunydia ~~ornafisin-~ b:ilie~en pre'gn8:ncy: hCG 'curres.rdiefined. ACOO 2QQ4-; 104:
from Pafient3 with ectopic pr-egnancy u 'detC:rm:ined . 50.
by polyme_ra.se chain ~ction. Phil J Obmt Qynecoi.
.....lll-116. . . . 17. _Rady-MY,.Nighting-!Ue.:P, Little t>-A..Edw~.JD. Shock
. md~: a ' re..:..;valtiation il:l acute ciriful.atocy -faii:l~re..
!' ~-..:.-:->.1-.o-.FQ ).~..-~
~.. ,Y~~ r--.KJ J BlownSi
.
:ehl. William~
......,, ...
' -t3uscita:tion
.. .
1992;. ~3~ 227-
. .2 34.
Ob&:etno n'"'ed, 2005-Mc<Jn;.w-:HmC.o.,)ric.-~ 18. Birlchahn. RH; Gaeta TJ, Bei R, Bore -J J. Shock inde_x
~...1~~ DMSio11> usA.
in fu.e first tritJ?,ester ofi?rep1ancy 8l1.d ~ts re1~tionship
to r .:tpt-.,li'td e<;~pic pr.eg:n~cy A~ Em~g N!ed 2002;
.S. Dbrfm&n. SF,Qrim.~ nA_. Ca:t;U W -Jr-, ~fru.' ~OJ>.ic 9: 11.5-_1.19. . . .
.pregnancy. mortalitY. UD,ite.~ :Stat-e~.. 1'979 to
19SO:C~Cal~ Obstet'Gynecoll9S4: 64: 386 -19. DosdosKL,Hal:)anaMA. Shocldndex.and~.et>rrelation
' : .. . ~- . . . . : . ..
.. 'WitP ru_ptute.d tul:)!ll pregpancy. J Phil 0b5tet;Gynecol
1
6~.,~~ "4 -~~~.JG..~?ll:;~:::X:.~\[eyl~. .. So<:2006; 4:0 "(3}: 12fi:--124.:
. 6f ii:lciile..'lce,-.etio~ogyo-ap~h.~o3tl<;-j:aBp~~")Db'ste.~ ..~.. ; .-: . .. . . : . . . _., .
~1:~ 199o-;:4S; 335. . . . . 20 . .M~l.I~:WJ, Hajen};u~ PJ:> E~gelsb'el ~. !':t 31. Cannon
~asiv~ diagnost;ic tools'pt:edictmbal.rilpti.m: or a ctive
7 , .:lUil1ria\ci .MA, . GU'33 .DA. -Hemo~g $ 0Ck fr<1m -a . bleei:Ung.in pati,~ts~th tU~!ilpregmmcy?. fcrtitSteril
:TU.~+-~~- ....,..:""ia~...,..,,.,...inai~tibrtwithan~e ..~.-.nn 9 ~.._1..,._:lL7~..I:7'"'. . . . .:.- ... .... . :
-~p~C)<~;;;Jl;A.lin?-~-;M~~~;:40:... . n < v v
-10.2.' . 21. s~j=AJ,WilcoxJG , N~j~l;Ja~S. t'ai.Resalutio~of"
.;. :. ,: .. : ... .. '. ~ .. : . . : ~-: . .:.; .. . . hwm~il.!il:~ar~~of!ecW:p~!::rg~~ti9n~~A-.ia,n.do'mi,zed~
a. lipaeomb:G}f:<M~rii<~"fl:;;'~tovrulTG;-":et',aL"'Piedictoril.:o trial. com parin.&:~ingJ.:~:.:dp.s~ ;IM.' jn~t,}iqti;~te With:
of-S.Ucali !oethotrCXa.te: tr.eatment .i h wom~;n with salpingostomy. bostet Gynecoll~S;92! 989.
tu~~ectopic.pre&nflil~N..;Eng.J M~ 199:9a; M l:
19-1.4. . 22~ 12ulandi.:.T ,..:~h,LS.~gj.~~c:'n+~LoLcctopic"
pregnancy. Clin'Qbstet"GynecolT9..99~ -4(2; 31 .
9. Perki:ns SL. Al-Ran,tahi .M , Cbm~ .p. Cm;npat;i~tl'of
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2ooo 79: 4 99 .
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. . ... :J',

1.0 .. Buckley RG, King KJ . Di!!ney JD. e t al.Se:rom folloWing.h oniolaterB.l salpin:ge~ctbniy:.R~po.rt of 2 case~
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C
514 SECTIO~ V: HEMO.RRHAGES IN PREGNANCY ., '

'Jj -
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61. Cunningham GF.' MacDonald PC; G~t.NF, Levene KJ,
Gilstrap LC lil (eds) : Williams O.Pstetrics: 1993,
. Cooilecticut; Appkto11 and Lang~. ..
62. Sidek S, Lai sF, Lim-Tan SK. Primazy o..;iman
pn;gnru)cy: current. diagnosis ap.d i:ne.nagtment.
SingapOr~ Med J 1994; 35: 71..
6~- :Eine.nkel J,. B~er D, Horn tc.. et ~ 4-paroscopic
the~py ofan i.I1tact primary.ovarian,hypers~pllition
syn<lrome: case report. Hum Rep~. 2000; 1:5(9): 2037-
2040. ' . .
64. :a~us M, Go~l'lll.H, Ozer K. Su~l~ic
treatment of a ruptured yr.imar:r.:ovarian. pr~lincy. J
Am Assoc G~ecol Laparosc 2002; '9(i) 37-So.
65. .carterJE~~anJ,.KallliisGJ:~~
. .,and..excis:ion of.~ intact. ov.~~ :P~:maztcy, ::k.CS.se
. ~report1 ~' R~rcxf M~l99~:;r38~~~, .: -. :~ ~. : :
66. :Go1denbergM, Bider D;'Ma~a.clt S,'et~~p::;
. ,la~er s:u,:~ery oJ p~ -ov~ P,regn.cilcy~ "Hutr;~.
. Reprod 1994; 9; 1'337.
67. .CheJmow o, Gat~:.s E . "P.enzi.as.- AS~: Lapa.r.o:;eopk
' ,-diag:nosis: aud- metho~e .tt:eatme.Ot-.o~ an-o:vari<ul
, . .preinancy:_a: .c ase repOrt. F.ert:it ;Ste:rjl i994; .t)2; 879.
68. Cbung.MT: .Iln Y, Wu..MP, Huang .l<F.. U;,parp$ccpie
. :.s urgecy:.Jor_omeilbl .pregnancy~.,J.:/un.AssoC~~ecol
- Laparo~2002; 9(1)84:86-
69. J;
Costas SD, Presley Ba.Ster: G. Advanced ahlominal
pregnancy. Obstet Gynecol Su.rv 1991; -46{$):515-525.
70 . .Bumbard AT, Nakagaw~ S , Runowicz CP, et al. Early,
detection of abdominal pregnancy by .nuitemal .serum. .
alpha fetopfotein screening. Prec.at Diagn 1~4; 14:
1155. .
71. Wagne r A, Burchardt AJ. MR imaging in .ad1ar.ced
abdomina.l...pregnancy.: a case report :o f fetal death.
Radibl -f995; 36(2}:193-19.5 .
72. Kerr A, Trambert J, M.ikliail .M, et aL Preoperative
transcatheter embolization of abdominal pregnancy
:re~rt of3 cases_. J Yaac'lnterv Ra~oi 1993; .4: 733.
73. Stevens CA. Maiformations and defcrmation~ in
abdomi.""Ullpregnancy. :AmJ Med Genet 1993; 47: 1189.
7 4. Bergstrom R, M~eller G, Y~owitz J .A ~se'illustrati11g
the :continu~a dilen:m:a.s rn .. .treat~ng afidp-mi.aiil
pregnancy anda.potential-explanation fi>C ~e.l:\igh.mte
of pes.t-surgical.febrile mC'zy1clity. Gyn.ecol Obstet Invest
1.9 98; 46: 258. . .
75. Wej.ss 'RE_, . Sto.nn'! NN .Pe~:si~tent iil~ternal
l~ydronephrosis .1l.fter.:.mtta-abdoinin.al.ptt:gnancy,.!HJ~
Uroll994; 152: :l l%.
76. Piei'ingwy, Ga.rancis J(1, Beclcet' CC, et .a:t . .
:P.tcetlaji:IpSia relat~. tp .a t.lind.iohi.ng extrauterine
placenta:: rePort
of a case and:2~ye81: fullow"up. AmJ ..
KidJ:l;eY~Dist~3; 2 '1:-.3-10.
77. shimon: o
. .
~"'~,t.;'M :A:Vi (;.' et:.aL successful
. .. '\JfU-L-1- . ..
,~~P
.......:.......;... ic
t;r4tllient oht ruptured priina..--y abd-Ominal Pt"eg:nancy.
FatiLStcri1.2000; 74(3); 6.0.lf.602... -
I

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 34
.ABNORMALITIES OF THE
PLACENTA,. .FETAL METviBRANES
AND AMNIOTIC FLUID
SUSAN R. PELEA:NAGTALON, MD

Placenta
Placer.tal Complet~ness and Attachment
Placental Size
Placental Shape
Matem~l Su:face
Placentai Parenchyma

Umbilical Cord
Cord Length
Cord Diameter and lnflammatlon
Cord Vessels and Insertion

Fetal Membranes

Amniotic Fluid

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 .,.
(
SECTION. V: HEMORRHAGES IN PREGNANCY

. 'TJie placenta presents~;t tissue history of the .AU.or part ofth~ pla~nta is retained .in t.cciet:a.
pregri.ancy. Examirui.~ion o.f the placenta and
._ .{partial adherence} (Figure 34.2). AbnorinalJ;y;'firin
. eytilu~tion of the amniotit fluid can yield attachment of the placenta pie~.y ocq.ubeCS.use
infonnation {hat may., b"e important in the of.p()Orly developed d~idua. In this condition,:
:ii:n:$eruate and late tnanagemetit of the mother the
placenW tissues grow into the myotnetriwn
'and the infant. The data derived .may: e.:lso be to lesser {placenta accreta) or .greater d;;:ptb.-s
.. :e~entia1 for the. protection cf the =~.tten9,i;O.g _(pl<J.<:;e4-ta k creta ~d placenta percret;lj.
:p~~cian ii"'l the event of an adverse pregnancy
o~...ceme.

'. Ev.aJ.lf?-fion -o f -t:he .amtij~c il~d iis.-~ciqle

~thiU a hu#}tier :Of tQ~liic .n;eth.Jkt~ ;b:iS9rd~11i
-~ of ~tic; . fluld vo11ite .41flu~6 'i"1~ oU,tl.qQk
:.:f'or-~ hifant.arid :the mOt:her;:"Exairim:a-n()nof'tiie ;
._, :~l~ta .:i~ und~~en::un:fu~a~lY :~
. . :tl;~C:::On.l!.uct of fu~ third stage or labor
in an
: - - ~~~ nonpal course of ~ti.on, .i s part of
: )l~ medical practice'. DQCUmentation. 'Of
. :'4ifdlii~ . ~~uld -b e .strictly ~omplied v.'ith. The
"-:~~gphy~an is re_$ponsible for i iet.en:nining
~lie,t.Jler further pathologic evalu~tion will be
:.~. : . .. . . .
. ~-: :: ...:.~~~~ .
.' . ~?EtftA: ..

i'1ac~n1;a! C<l~pletene~s ~d -Att.achlil.e.n~

.. Y..:Asses$ment "Of' completeneS-s-is lnfportant. aDd .

..~ ~~1 :-"Retaine.d.p}~~n:tal ti~e : ~ ..as~ated .
.,M.t.hJ"""~..,t;;1,.,.:-liemorrh.age;:-e.n-d.:IniCcti0n:"Tbe .
l,:-:or_~...:~~~-~
Microseop
.. .
itallv~ .iJi;B..ctriita~the-:r\larentili"Villi
. . . ~, :J r-- .- .. .
. mii~ s:utface sh(>~d be iii~~ecf.for misSfu:g .
. ' . - . ..
interdjgita:t;e dlreytly withthe u~ my.otnepim:n,
without--an 'inter:Vening.. dedd\1.al'Plate.~g4T:e.. .
;,'9ttl'eati8: . _the.letar memorane~ "$-nouta t<e 34::3); . . ..: . . .. . . - . . . . .. . . . : ...-~ ..... .
. :::~Ch~oo :Pait"t:he-piacenTaFect&a:'"JSa:tge. "J'es~s 4
. ~(iind .t he ed~es indicate possib~ pr~:n.Ge of .a
_.ptaintal lobe :(succen~te ~r .a~sso.ry .lobe).
't)ia(may have been retained. An. '1'\lstra-~otl .. of
::.tbe,;~ssory l~be of the placenta i~ shown iii
!:~3~.1..'
' . ..j'
')

Fl~~ 34.3 . The placentaivill1~terdii;it:atcdirectly-intntlie . .

.~~34. 1. Accessory lvbc of the placc.~ta. 1 . uterlrtc myomctrium.l . .
: . . . . .

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 CHAPTER 34: ABNORMALITIES OF THE PLACENTA, FETAL MEMBRANtS AND AMNIOTIC FLUiD .517

....;_.
Table 34.1. Classification of plac~ntal invasion into Placental Size
myometrium.
Placentas less.than 2.5cm thick~ associated
Depth orinvasion or chorionic villi
with intrauterine growth retardation. while those
AcCreta Superfici.all'J into' myometrium greater than 4cm thick are associated with
Increta Deep into m~etriUD\ maternal diaPete.s , fetal hydrops an~ intrauterine
. ~ta 1brbu~_t}le ~~etrluil;l __ fetal infecticns. Micro~pic changes within the
place:Qta in hydrops are described in fJgUre 34.5.

, . 'I , ,",, 1 ; ,

. At the p~W ~pmntatio.n stte. adher~nt

~aH$ .ot the piaeen~ will <p~c.ven t ,Cffec~ve
-coiltrMtion arid rct:lletion-.of :tb~ tnyometri\Un.
th~ey w~s-hem0$tat.h and thus.a#socf.Ated.
.....:'4-1.. nn--n,.,..+,;,.,;,. h--"""""'"'ll!r-"'~ .
~~r~B~~~ ~~~- .

. The plaeeU~ . ~~:y ~ in.l;t~t~d .~v.er the

:.cJfDteal)Y
~*=c:\: A1tr.r:.~~~-~c
bnpotfi~Pt ~~-~o_tfbil aQilo':-m(Uit:y
have. Ji~en :-re,ca~ T~tcil Pla~ta: P.t?fria
.
1~cai()s~mp1ete)yeovt,re<i\7y piaCentah PCutial
~;'Pi'evia (cerviCal :O$ parttany covered by
placenta). and M~PlacentaPrev4! {placental
edge a.t the .margin Dfthe -p:s)
.~..~ ~.~,."~.~~~~~~...;..:,_..~-' .,.f.. .
t~ .:.~ -~ : .

. . .. 7 >4~1fAL ~
. Placental }lydropic ob~ge ~ :he~*~,i.fie
choJ;i:oiiic Villi is aecompanie4 by in~~tal
. e~bhmtts andn~ql~ :ruJ.C. 'iif(e,talves~13
m --vllli at: the upper~1eft;o(l!1~~3'if:6j-Tfi~e
c'hanges--c~a;ec~:nx~-pl:rny-any caU:$eTorretar
anemia, wheUier immune_(erythroblasto.si$ fetalis
from Rhincompatibility, or other~ antilx>dy
dir~d atfetal RBC;S) o~ non-iuim~ne. Non- .
'im~UAe c{iuses iu-clud~- inJections, genetic
<Uso~ets_, an<:I.n:ulny.othera. Perhaps a fouith toa
. third ?i.the tiine. no cali$e for hydrops is .readiiy
apJ)arent. fn this case. L'-le fetus most likely has
hemoglobinopathy: alpha 'thalassemia major,
leading to hydrops.

In this plate, placental villltis is seen at the

bottom in conjunction with hydropic changes at
. Fi~ 34.4/~'he p~ta linplated over the iht~ffial cetvical the top. These .feature.s are seen in congenital
os. 2
cytoin.egalovi.tus '(CMV) infection.'
On higher magnification (Figure 34.7)1 Ja!~cental
Maternal hemorrhage may o~ur as dilatation hydrops consist of enlarged ch.orionk~~H with
of the c etvix disrl,lpts the .pl'a.cent~. Digital
. palpation to try to .a.certai.ii -relationship between
marked edema fluid in the strOm;l. . ~:&~- .
. . . . . ~
the edge .Of the placenta arid the' ~ntemhl os as An extremely thin placenta that lines the entire
the cervix dilatation c an incite severe h emorrhage. uterine cav.ity repre~ents placenta merr~branacea:

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518 SECT~N V: HEMORRHAGES .IN PREGNANCY

It may give riSe to serious hemorrhage because
of associated placenta previa and delayed
separation after delivery..This .v lacerital cot.u:lition
has also been . associated with a vety poor fetal
outcome.
maternal hypertension in pregnancy, haste in the
conduct of the third stage of labor (too much
tracUon n the cord) and blunt trauma to the
maternal abdomen.

Fi~~~~:~-.~~Abru~poQ:~~l~.t~f~.~,exhihifs
the ~stlt .r.e,d t.:emp.taeent(U "clot.. the,~ ha$ !:lepreasea .the
-p.l~.tl~i~b.~(l;l _ . . . . .
. . .. ....

,Plac~lltal Shape Thi~ otos-s. secUon :of .uie

,piaceiita shows the
dark red re~placental . clot that has depressed
It is .i mportant t.o estimate :the <;limensions. .and the pla~ental bed. MiE:r.oscopically (Figure 34.10),
volu.tne,of the placenta, Distortionof the placenta exten'Sive hemorrhage is seen at the top of the
.m ay occur 'in the pr~~nce of bloodthat is adherent image at the decidual plate. Placenta\ villi can be
,;to . the
~. . .
m ate.
.
m al sur:face;
'.
..at:or. near.
. .
themat:gin~.
..
seen below the pl~c~ntal. pl:ate;

Figure 34.8 ; demonsb;-ates a . dark red .: Multiple. placenta with a- single f etus tnay be
.retroplatentai clot fram a .bruption. A\>ruption may . obser-ved occasionany..The placenta is sepa.rated . I
6ccur in association with shortuml>ilical cord, into lobes but .t he divis"ion is incomplete and the

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 CHAPTER 34: ABNORMALITIES OF THE PLACENTA. FETAL MEMBRANES AND AMNIOTIC FLUID ..519

vessels offetalorigin extend from one lobe to the

other before uniting to form the umbilical cord.
This vanety is called placenta biparti~ /bilobed
~lacenta as shown below in figure 34..11.

A .B c

Diagran) 1 : Placenta ~d .m embranes in twjn pregna1'1cies.

A. tWo placentas, two amnions, tWo chorlons (from either
dizygotic twins or .monozygotic twins with cleavage .0 zygote
durin$Arst 3 .days a:ttu:fertiJlzation). ~- siQgle.pJ.aeenta, twG
ai:nnioQ.$. ana two ehorioris.{fropl_eitper dieygl)tic ~ or
niollQZ)'&Otip n'iina with deavagf: cir Zjgote:dllriiig first 3 days).
C,one ,,~~ ~ne' chorioP~ iWo ainiliona.(monozygotic
twin~. with d~e of iygote. rtom the fourth' to th~ d,ghth
day aft~ I~tionr ',. .

1'he .J&atenull
. .. . ' . . . . S'Urfa~e
' .
~. -'
. '

t=-~~r;:!~~ut~U:~~r.~:=
,
, . .
-~ .
m
. . M'Qlt.lfet~Lpregna-n~y :serves as a 'rnique iilfa.:l4.frox.p~n:ta:is ~gbter.jn~ color:;;;G~P.illor
opportticiW t~r the .clintcii\rt toestablish zygositY. of the '~.iiUu :.s}ltf'aee;i})dicate~d'etid ' M~
.D,c lM#y or tile .j>laterita stie~d be aq::oJ:b.Pushed usually .\:)bserved :hJ. 'fets.f b'emon-t-.:ag~ as~ted
With.;.e&.'-CrJo :preserve,t he :a mnion and chorion With yasa.previa~ Dark Clots on the maternal
. atta~~~~f t~ ;the :.l>ta~c~nt:a:. ~. consitierln,~.
id-~ ;G;>~ ortli'e- ::tela&nsl:iio cf.~1-.em
fhe
brilnes
surface, particularly .adherent ceng~lX.: lpay .
~~f.& . . . .. . ..- . """~ . eJn . represent pla~ntal ;aJ?.ruption. :The: P.~se!tig( 8: .
. fu eaeh~~1ber~ Witll one.tQ~onamnl.o.nk sac, Qr thic k rlrig of membranes on the fetru,sitrlace is
. 'Withj~ .a:mn!onsnot ~paratettb,y cltorlo1;1 seen iA cirCUlnvallate placenta (Fi~ 3#~i~).
ari~lu.g..~tvie~u .,the... fetuae:S.~ ;tbe:.in:fants . ~re
mo~~~.g~_tj~ JJ ..th~. J!J!JA~.~ni. ~ru.n1~it.s. . :a.re
. ~'ted _l?y.mQrirul...the.f.etu~.ould .:either~be
dizygo#c or mo nozygoUc, t>i}thougb dizygqsity .
.seems to be more co&iU,llon. The .d!3,gram in the
upper right wiJt allow identific~tion .ofth~
differe1;1ces. in the p'!aceirta and membrane
structures in multifetal .pregnandes. '

j
i
i
I

... . . . ' : .: ., .. . . <~> :.<. l

. This rmage of~vallate placenta s:w ws .the
m:embranes :double back for a ~hort dist;iflce6ve~
. . . . . . . . ~ J{\~. '
I
1J
Figure 34;11. Vessels. l?ffetal origin extend;fro~ one lobe.to the fetalsurfacewhe.nthe chorlofl:iCpla te is small.
~ 0 ~~ . . . .
'fhe cause for this is unknown; It is found in
i

I
!

C
i

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 I .

"520 .:sECn0N V: HEMORRHAGES l~.. f'REGNANCY

association with prematUrity, antepartalbleeding, The principal histolo.g ic featu-res from cut
abruption, multiparity and e~ly fluid loss. section's .of .the infarct will r~veaJ flbti..I)oid
degeneration of the tropl:loblast, calcification and
. There may .b e situ'l;ltion~ where in~.m~rous ischemic infarctio~ from o~1usion cf the spital
sm411, fi.~, white, gray or yellow. nodUle.;~ . ar arteries. Infarcts less tha..4. 5% of the p"la.ceutal
pre~eilt" o_
n the fetal su:Ffa~e. These nodules ma~s u~ually .a re unimportant. "These :are likely
represent a...'7tnion nbdosum {Figur.e 34.13). Its a~ted With aging of the" trQpho])l~t 'i n term
asebciat::lon ~th o:ligohy~os, ~ ~enesi~ .ges~ti~1l . Occasionitly~ ~ :~ Jip~ of
at:ld:poor 'fota:l:outcome P.ruJ ~n OO:t:ed:-~. . ~e .p~'cetih).. !rdD:i -4if~~ ~~-~Jin.:ec:ieyp~ts :i i 5een..
thiS.i$ ;laJ*Ie"~ a~nri:~ar~r 'iJ?.faw.t;lori-an:d is
s.s:soclat~a..Wit~ Jeta~. d.;~iitJJF. :s..~:?-ii~m to
sigfi~ ;Ute~op~8;eh.WJ _jp)s~11$ciencj~ Theie
~ illustra~:the i~ of .nliiterrtal
~~;:,ilffi.'ii.;;fic;>n {Ft~e:S -:34.'is-& 31.1Q)~. .. .. :
. . .. . ' .. . . .... . . . . .. . . . . .

. . . ..

. .
~a.~~w~~nc~~ .... ... ... ... ......
. ~:~ 'may.;r:~_~t~ Q..e~\iQ~~pt

~~-~-
~vtdis :,iif.illi.-~~vere {h~ti~ T.hey -~iiult
ff~~p>.iu~9~ ~r::~aJ~~-:~~ .wP~lY \.: .
b
ibi~.~e.ta:n ap_~tc:zof..fue l)~tal~Ia:te.
-~. <;~1"\~~quence ~{:.diff.\is~ fiiJ$ cd.e~s~tio:n:
asi9(;iatea Wi~ Ii:la.t;ernhl-:flO.O.t )nfarcti~n~ b.:n
rclcro5CQpy. extdi~ive depo!iition of~<fr6ni:Ute.
d~cidi.la.down to :the viiU _~s,~~t.(F~~..34.J6.) ~

I
I
Fif2u_re 34.1:4. Fkm 'th-~as repi~sqt. fi.j:Jrln d~'si~on or ng\lre ~4.16. EXtcnsive'-deposition of fibrin from the dc,cidua 1 I
in!m1;tion.3 . . . : . d own to the viili is evidt;nt.!l
I

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 CHAPTER 134: ABNORMALITJf:$ OF THE PLACENTA, .FETAL MEMBRANES AND AMNtOliC FLUID
Focal fleshy, dark red iP'eas on the sut;face of
the placenta represent chorioangiomas. Small
lesions, however , do not bear din!cal significance.
These benign hemal)giomas, when large, are
assbciate'd With fetal anemia, thromb0Cytbp.nia,
bydrops; :b,yrami1ios, lntrautet.i~e grQwth
retat.dation, .p rematurity and stiilbirlh...l-a,rge
chorioS:ng'loi:p-as were found '::to ' prc~ide
arte.Sii>vQ16~~ :shU:n~ m thetew :ir'Culatibn that
cari lea~ tp .heart f&ih:ire .:.u;a its t1u~erous
compllcatio.rt~
. ~;Oe~tio~ .q opMb)ajtlc ~ptaSia.. hit:,~~iling
.. benign hyda~difcnn . ~tes, U.~ivc moles ..fuld
~horiQt:arcino$a . ' tately e:xsst with Viable
: prtgna'JiC:i~~ }.dOle; ~~ u grape-like clusters
of ed~tnato.us villi {F:igut~ 34. i 7), . While
. ~~~e.ppear. sa\lcltli~ an'~ ,.' the
hiSW~te-a:~()f:~.;;mole~Sliowsaf.Y:Pichl
tro .. . ' . cproUfeta&ll.
. .I?hoblasti . .,. ... .. . mith
~ ~J)resen&
. . . ofoome
r.~rmal ;~~grionie vll1l (F)gute 34.18).
0~
M~lea :appeU .It$ K&.,.,...-UI'";;
edem.atous villi.1
521
In partial moleS., some villi appear .nofilllal,
whereas others are swollen, avascular, .8nd grape-
a
like (though not as large as complete mole). There
is minimal trophoblastic proliferation. ln complete
mo_les, there is .atypi~ tmphob~stic proliferation
with very few chori~nic villi a s demonstrated in
Figure 34.19.
. .
' .
F'-iUt6 '34~1'9'. ~"JP~~hob~ pro.,lif!!:l.~on~Vitti~:\Velry
r<:W cliorioni9.~ ~in ~plet~'molea.2
,:: :m.mrot~: 'C9RJ)
C9rd.Leqgth
r.~.~~~~~~{.-~In:.~
determined. ~'_ ;9ii.~~:tt~G~~~i~~~:u;
some instances,. the umbilical cord
is increased by the tension .the fetus: places ol)
the :cord. A short cord is found in asSociation with
a les& active fetti:s: fetal malformations, Down
syndt:Q.me .end.l:)ijgt>hy~ios. Shor:t C:ords may
to.
predispose . cord rup~rire. hemorrhage .and
strlct>.lx:e. Cor9s .o.r !n!ril{Ji~t length may also
result in breeCh, prolonged.second stage oflabor,
abr_ttption .a nd .uterine inversion. On the other
hand, excessively lpng cords 8.I'Q associated with
entanglements, t .Qr $io:a :a nd knots. In m ost C1\Ses,
a knot does not compromise the fetus :unles s
significant tension is p4tce.d on it. cutting off blood
how with resultant fetal asphyxia .
Cord Piame~er and Infia.m mation
The typical <;ord has ~ r.ility .uhrrorm. i&m~ter
(2.0cm-2.5cm). Focal deficieriC'J ofWharton's jelly .
result to na rrow a reas and increa"s ed risk for
torsion. Diffuse edeq1a of the. cord is associat eq
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 SECnON V: HEMORRHAGES IN PR.EGNANCY

with hemolytic disease, m aternal preeClampsia f this placenta (Figur e 34.22) :wm1: congenital
eclanipsia and 'd~betes. cytbmegalovirus L.1f~ction. .

Seve"re inflammation :of the Cl:lrd termed

n~o~g iuhisitis, may represent syphUis or
oome e.cute or lo1.1g scanding infection.
Cor.d Veasels

. :: :N"orma,lly; the cord ~ntains 2 ~eri:~ and 1

vciri~.~Feta,l.aijqinaly:~te'-Ui .higQ. Wheq~y .J, :~cy
and 1 v1n ar..e. ~...n. Malt~tiQn3 rclat~ .'~the
~~. ,genlto~8_r.y.~; gastrOmth~
..sy.Ste~ have. bein de~~s~tea. . (. ;,
.
.'

.Cord
. IMerl:ion ... . . >:

N!tc~.ntal m~:mbr?:nes are typ.i!illy

:trans1uscent..p~~d,b:p~q'4e~~mbm:rie;i .ro~ be .1 .

;G:hb~oni.tis :tn'fi!t~aticih; 't~rtil;ed ~~~~~~~~~~~~~~~~~~~i

. .T:n(t1t; ~~~ <llseo19~.,or. f{?pi
d:u* 'to ieutroph'tl
.. 's.nii:llili~ -embrall,es..in.i~~t~ po~~ii5le severe
in.fec:tion. 'Feca1 odor has o~eh rtmntf t<> be
a:ssOc:iited with .Fu:~dba:H~ril;itn: or :.8a.cter(iides, ~
while- ~~~et Odor' ~ay. .ind~ca:te c tostiiUiuo. or . .
j,.i~te~.

... Bacterial irivasion of the:f&

. tal membranes
'. . . . itoin .
prolonged rupture of membr anes is .evident in
figure s4.2o. Placental ~llitis~wf~ tn.ieroabs'csses
. ~ostly . containing r~utrop~ils -ar~ . fe.a~\l~es in
.:L istene. monoCyt.ogenes 'i 4fection (FJ,gUte '3 4.21). .

. . Placen:ta.r vill1tis .at the bottom is seen in Figure 34.~2. With 'hyidopiccllange .!J,.t the
c onjunction .with hydn?picchange a t the t op in the
t op of place-qta with c)1:omeyalorirus.infectio.n.i . .

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 CHAPTER 34:-ABNORMAUTIE:S OF IHE PLACENTA, . FETAL MEMBRANES ANO AMNIOTIC FLUID 523

Gre~- colored .m embranes frequently result In Severe -oligohydramnios, the AFI is <2cm. This
from ti{econium staining (Fig~re 34 . 23}. carries with it a pefina,ta:l mortality 40-SOx greater
}Jeconhim can ~silybe rinsed off the membranes. than. that o.f normal pregnancies.
Membranes may be. discolored r~d from
hemorihe.ge. Clots adherent to the maternal side
of the plllntal tnempranell are consistent with
retrometnbranous hemorrhage. If the hemorrhage -Table 34.2. Cause of oligohydraminos.
occutred.days befo'I'e delivery, the pigment .in the I. PRFAlNANCY-REL\TtP
membrane$ . P.laY be brOwn .Or yellow. Pl--m.llt\U'e Rupture of Membranes .
Postdate Pregnancy
Intrauterine Infection
.Placental Insufficiency

n. FETAL ANOMALIES
RenafMr.eaia .
BlAdder. OutJet:ubatruction
Postenot't1rtthral Valves
FetalCh.:o~osomal Anomalies
Intrauterine Growth RestriCtion

m. DRUG-INDUCED
. . ~~~Synthetase lnlu1>itora
. -ACE.Jnlillliton

. . Of:th~. 1be piOSt'tom.tl;lon cau~;i~(Pt:e.~ture

....,. rupt).U'C :of ~e~b~~s. .Those. :~ili;'l~lt~P~~e!,
Dtiid 1oss wberem .t he fetu~es sur'vlve~(:adhe'slons
betWeen the. amnion and .fetal partii'.fui~~~se
seriou1l defo:nnities like clubfoot, 'incl'liding
amputa&n. Nll:iiooary hypoplAsia due tcf thoracic
,cdntpr.ei:~non : hilv.e als'o oeen . ieporte&.
AHIOTic-num. ~~on; tne-ffi.fiiSionof'-crYstano-ras~ --had
been reSorted to in .tb,ese sit\,iations. Success with
Early in the -s econd trimester, the vol\Ulle this interv.enUon varied among academic .
occupied by the fetus isabout equal to the volume institutions.
of Ute amniotic 'flUid. Throughout the seqon(J,"and
thmi"tri.tnestets, the volume of the' fetus incteases Polyhy~os, found to complicat6 1%-4%
in compariSQn to the fluid voium:e, and late in of pregn~cles, . is .associated .wj~ significant
pregnancy the flUid ap~ars sman in comparison maternal and fetal morbidity. In worst cases,
to tl).e fetus. The amniotic fluid volume normally syniptO'mS a.rise from met,:ha.nical causes .and
reach::s about lOOOPll by-36weeks gestation, then result princi~y :fn>m pressure exerted within and
dccre;ases ther~er. Diminished fluid volume is aro~nd the . di'$ten~ed ut~rus upon adjac.e nt
tern)ed oligohydra.tn.r..ios, while mbte than 2'000ml organs. The gravid :suffers from dyspnea when the
is hydramnios l polyhydramnios. Sonography has is
dis:terttion exces:rive. Preterm labor is a threat
. _l;Ilade the objective measurement of amniotic fluid in these cas~s ot hydramnios.
possible. Two routinely used objective methods
are l) measurement of a single vertical pocket of On cliru~ evaluation, the uterus is enlarged i
fluid (SVP),.and 2) calculation of the amniotic fluid with. difficulty in palpating fetal parts and !
I
index .(AFI) ~ A single v~x:ticS:l pocket 2-8cm is identificati~n of the fetal heart. The .use of I
I
ultrasound wiU differentiate hydramnios from
considered normal. The amniotic fluid index varies
with gestational .age, but as a nile, this falls ascites and a huge ovarian c yst. The prognosh~ I
i
between 10-24cm after 30we.eks gestational age. for this condition i s related to the degree or l
j
I
!
'

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'524 . . .'SECTIONV: HEMORRHAGES IN.PREGNANCY

hydramnios. F-etal malformitlons , t:hlitltl.osomal placental abruption, uter.ine dysfunction and

abn<mnalities, and _prematurity .ac;:couilt for poor po~tpartum hemorrhage.
fetal outcome. Maternal complications include
In.sum..mary, a!!t~partal evalua~on of the
amniotic ,fluid. and postpa.rtu._~ exap:iination o! the
placenta should be part of standarq medical
Ta.blro 34.3: Causes of polyhydre.m.inos.
practie. . I?.o cumenta.tjon :Of findings is nf
Idiopathic p8.ralnciunt importanee. Th~ ihfon:aat:i.Cn,ga.thered:.
rn~ute:rilie lnfectiot:1 . ... . may influence 'immediate orlater ~nt,
Fetal MliCIJl.$olliia {With orwi;ih.olltDM) or may be essential for protection of the physician
MaterruilDi.abetea M~s in the event of adverse pregnancy outcome. A
Twin-twin:'l'ransfus:i1
thori:>~gll. accurate, and hr;9nolg~ ~tion
Fetal.Anoma.lie3
l!ydrops -of~e:p~~~ta is ,reeo.~~d~ ~hould.!fhci-e.~
CNSDhorders .Affe.:ti.>1gS~g a .ned:{for. furth_er -pathol~gic -~atilih~- the t
orr Atr-esia 1 Ob~cli6u . ... ph"~ ls ~(!. t() in'di~t-<:..on..$! r equest
CVS Arioalles the .specifics -.~ :th.at .the 'co~t ~d ~ent
_F<;WMa~s fuid4).gs. can be. shared.~ . .. .
... : .. - ~

. :

..... ~ ...POJ~o.r.r~ ::ro ..,...,a::~E""BE>:> ..;

... . . '... . .... . .. ;... ... ....
..
~ ~-,J~~ : J . _,,f:\..._lYJ .IV.I, .. ~""~"' ' . ; ,. ~
. . =_... ...... . .:. .' .,

. . . ..

-. &arruhatiO.n of'thel_pla~rt~::al\o.,~idtic tJ0Jd ~ieW'1:ht~~dh: im~$~t:-in rt;_~~;~iih~:~~~:cl~th~ . .. :

.>. :..'.mcitn~:-~~c!_:;infSrit:.:.~- :i:.: . ;.: ~.;:.....:. :, .. ,.'::-.: . . . . . ;.:;. .,. _. .:;. . :.<. . . . .. _:- .. :, .: . , .. ,. : . .
.~ .::~~~~n~rc;>t;jpfate;flta}i~i:J~- ~hd::.atta6hrrieni.:i~ . i~wr.tahtand ~~~;.ih:(~~poo:t9 : ~ . . .
ocru~ of:pOstparturil~.g~;ant(inf~~: . . . . . .. . . ~.. .
. .
, : "NthQ.ug:h-rare.~t"t~e;.-pre;Sehce.,Pf.an.~unt~nrzed : acee"ssory.lobe of.the placenta , wh!l,i"etaioedr ha.s
been~ ,of.the cii;Jses'Gf ~:bleeding.
. ......,
Tne abri<>frriaf.adh~rence: :Of::3 norm~lty .implanted p,la.c.enta termed .acereta, pccj,Jrs because Pf ~
p<)orty.:deve_!oped :decidua.
' t

Ther~nnay beAn~tances~wnen;fue_pl~nlal vilfi gro\.1i. de.ep into the rny9metrium :(acereh,3 vera), .or
in .gte?tter 'depths:{tncr~Ul'~o~:.~tcre.ta)~

In place.r.ta pr.eyla,. tbe"pl~centar-may ~e'imp.lantedin th~ lower 1-~terine segment, par:tkllly.c;Ovenog, or

completely cov.eiing the int~m~l .os.
'\

.big1tal,palpation:.to::asee:rtainthe relation'sbip between the edge.of the placenta pndtha inte(J1al.os can,
. incite :severe hemorrhage in ptaeen~ previa.

Plaeenta <2.5 em thick.has been ~ssociated with lntrauterine growth restriction, whil~. pl~centa >4cm
has t5een found 'in Gas-es of -dj~betes t~Nittls , hydrops'f.Eltalis and ?evere .intrauterine felallnfection.

.DistbftiOn.:of .thep!ace"'~ 'rrii:lY :~t;Jh -the presence of.:retrppia~.e ntat clot found -i~ abr::uptier\..

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 CHAPTER 34: ABNORMALITIES OF THE PlACENTA, FETAL MEMBRANES.AND AMNIOTIC FU.iiD 525

.,/ '

Multifetal pregnancy is associated with unique placentation ( monochorionic-monoamnloc,

monochorionic-diamnionic, dichorionic-diamnionic) with its corresponding influence on fetal outcome.

The maternal surface of tile placenta Is lighter in fetal anemia in cases of vasa previa.

In circumvallate placenta, a thick rim of membrane can be seen on the fetal surface.

Firm, white, gray or yellow nodules on the fetal surface represent am!lion nodosum. This entity is
associated with oligohydramnios, renal agenesis and poor fetal outcome.

Varying degrees of Infarcts on the placental' parenchyma represent fibrin deposition in association
.with ocClusion of maternal vascular supply. ~:

,. Grape-like clusters of edematous villi are demonstrated in H-moles, while the mcrtemal surface in
choriocarcinoma appear like infarcts.

Umbilical cord length {40cm-70cm) is genetically determined.

Facat~eficiency of the Wharton's jelly. cord edema or cord inflammation were found to be associated
-.with risks to thefetus-in-utero.

' Normally, the cord contains 2 arteries and 1 vein. Any devi.ation..to the .normal.vessei .conteo.ti>J.~
should meke one consider anomalies or malformations in the fetus.

:J:;ordJnsertion may be at the margin (battledore) or in the memikanes (velamentous).

. ... ~ -. -:: .:. .. .
. . -- .........,:.., .
' -SignificSnt.neutrophil ..infiltration and diffuse opaque fetal membranes are found in chorioamnior.;t!si;i.

low amniotic fluid volume is tem1ed oligohydramnios. Most cases are seen following rti'pture.rOf:t:;
membraMs.

Severe oligohydramnios (<2cm amniotic fluid index) is associated witt'l40-50x greater perinatal
tfiorlality.

Polyhydramnios (>2000 ml) complicate 1-4 perCent of pregnancies, with significant maternal and
fetal morbidity.

5. Kaplan CG. P.os~partum Examination of the Placenta.

Cliriical Obstet Gynec 1996.
1. B eisher NA and Mackay EV. Obstetrics and the
Newborn 2nd ed 1986. 6. Pelea-Nagtalon S. Abnormalities of the placenta and
fetal membranes. Baja-Panlillo H, Villanucva-Gutierrez
2. Benirschke K, Kaufmann P. Pathology of the Human R, Pagtakhan-Luna L, Negre-ParejaM, Ramos MMJr,
P lacenta 2nd ed 1990. Sumpaico Weds. Textlxx>k ofObst~trics 2nd ed 2002.

3. Cunningham FG, et al. Willlams Ob~tetrics, 22nd 7. Ratten GJ, et -al Placenta. Am J Obstet Gynec 1973.
edition, 2005.

4. DeliaJE. Placental and Fetal Development. D;mforth~s

Obs,t etrics and Gynecology 6th ed 1990.

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 .. .- ~ ... ... . . ..

..
. .. ;:... ..

...

Seanned 8y: C
 Diagnosis
Treatment
Prognosis

PlacentaiSite Trqphobtastic NEX:Jplasia

Definition
Pathology
GlLt1ipa!eehaVior
.o1~gn.osis
'Tr~atme:nt
r;pithelioid TroPhoblastic N~plasia
DefinitiOn
Patholo@y.
Clinkat Behavior
Diagnosis
:':Z Treatment
. PrQgn$s.l s

Phantom hCG

Low Leve! ReafhCG

Saanned IJy: C
 CHAPTER 35: GESTATIONAL TROPHOBLASTIC DISEASE
i... ... Gestational trophoblastic disease or GTD
~ encompa~J>es a heterogenous group of neoplastic
r
-~
disorders that arise from the placental
trophoblastic epithelium after a normal or
~ abnormal fertillza:tion. It includes .eompiete and
1
partial hydatidiform mole, invasive mote,
ehor.iocareinoma, plac.e ntal site trophobla~tic
,, B~fsijlaa~SI., epit helioid trophobla.J.tle - P.~:>plasia,
i .exagg.er~ted' placental site and .p lacental site
: nodules! .Although L~e clinical mtmagement of
t ge.s tali()nQl tt-ophoblasth~- (Useasee is often
und~ without a specific histologic d.J.agnosis,
.eaclf ofthe pa~ologic entities bas cbtiracterisncs
tr that make .it distitlct from the others. MoreoYer,
TCCent ~dvances :in the nelda .o f Cytogenetics,
itlmi\mohl!~tqcheniistty and imaging have h elpcl
U$ further Understa,rid these enutieS.
Thjs chapter discusses the clinical and
f~tbo!qg'ic featutes -of each specllic fotm of GTO,
a~ well ~~ its 'cUnic~rbehaviot, die,gr.osis and
ma,pageriient. !t . ~gUis Witp a desd4..pti0n :or the
classification curr~ntly being u s ed for GTO,
ron~ hy a discussion ofhydati(jjfottn mole and
the maligruUit -f otms ;Qf .gestatic'mlt tropli'o\)lastic on morphologic, cy:Wgenetic, and cliiU;c:Opa~Iogic .
dise.a:se:. ' features.
CLAB$'MCATiON 'Ol"'GESTATIONAL
TROJ'liOBLA~C DISEASE .
-~,,._
..
'Tli~_WJ!Q C~$$.:P~tiott of G'f:P ha~. r~e.ntly
been ~c>dffi~ to .itltifqde the recently described
f=
~
~iit!tf.es-:- In -ui:ti:l~i~1fi~~n, ::Gft!Js :~J.Y@~11.
-L.:to molar and n<>n-'t:Q.olar- lesidil$. The molar
r lesio ns include comple'te hydatidifonn mole
t .(CH-M), partial hydatidi form m~le (PHM) and
t invasive 1noles while the nori-molar lesions
:include -c horiocarcihoma, lesions derived fr6m
th.e implantati3n -s ite in_termediate c;:ells
le1aggerti:ted placental site and p1acC:m't ci . site
tiophOblastic ne.o plasia) and those ftoJ;U the
cho-'rioil~c type in.t ermediate troph<:>hlast
(placennil . site nodule a nd epithelioid
tr9Phol)tastie neoplasia) (T~ble ' 35 . 1) .
Exagge'r ated placental site and platsental site
nodule used .to be designated as und er
~Unclassified GTP. Both lesions are benign and
have distinct histogenes is a nd morphologic
features-tha~ justify thd,r separate designation.
Also, the-modified cla,ssifica:tion already ~ncludes
epithelioid tr:ophoblastic neoplasia (ETt), a from 2. ~ perc'e.nt. to 3.7 perce~t pe~l ,OOO
r ecently .d.esctibed tropho'bla-~tic neopla:sia
distinct from choriocarcinoma an<;!. placental site
trophoblastic tumor {PSTT).
Scanned By:
529
Table 35.1. The modified World Health. Orgari~tion
cla:ssificati~ of:gestational trophoblastic disea3e.
Molar LesiMs
Hyd_
a tidifonn Mole
Complete
Partial
lnYasive Mote
Non-molar L.e$ions
-~a
Plac.etitat Site ~phoblastlc Tumor
Epithelioid:1l'ojjhob1a:stit Tumor
Misc.ellane(;Ua 'f'icph6blastic Lesions
Exaggerated ~tal Site
Pl4cel!:al :site Nociu.lc ..
HYDATIDIFORM MOLE
A hyd~difonn mt):e (HM) is an a:b.n ortnal
placepta Cb8:tacte~ by e!li~geq. edematous
. arid :VeSicular chorionic~ villi a.ccOmpani~ ;\>y' .a
v~le a:mount of prOliferative trophob~ts"' .. It
is sqbdiv.ided into <:omplete hydatidiform;:_~olc
(CHM} and pattUil :hydlit!difsmn niole ~HM},J~~
: ... :
B~sed '<>n recent studie11, the estbnaled
.wo.d4v4de mpdence or CQ~pl~te and ~jnote
.HQ;,~~~4=~~~i:f.~~~~4r~~~:r~
exist: woddWide w.ith
molar pregiut.:n,cy higher
~e<iuCllcles in rome ~ of
Asjs., Africa. l..a:tin
Atperica ,an~ $e Middle East. The extent to which
theae differences ~IUl "be attributed to
niethodolQgical difficulties in obtainfug t\CCUI'a~
..rate$ :is unclear; The iricidence of HM 13 highest
in Asia with :t.ates ranging from 1~21 1000
preg:nancle$ in J,apan and China to 12 per 1,000
pregnan~es in lnfionesia, India and TUtkey. Rates
in J'!orth Amerka, Europe arrd Oceania a:re
iipproJICimately 0.5-1 per 1_,000 pregnancies. Data
frt>m South America .and Mrica are sp~se and
lirtrlted. .
In ~e l'hilippines, the Philippine Obsterical
and Gy~c:ccilogical Society (J_ocson, 1995--2602)
reported,t hat the -prevalence rate ofH. mole ranged
p.r.gnanoes. MaJonty of those affected we~young
(less than 30yo-55A%) with a inean age or'33 (+ /
-9J years old and median of 28.8 (+ /-9) years old.
~
 . ;5.30 SEtTfOH v: HEMORRHAGES IN PREGNANCY

.. Pathogen!!$ls Cpmplete. Mol~

The role of oncogenes in the pathoganesis cf
molar pregnancy .has increasingly been studied
in recent years. In complete moles, over~ression
ofp53, cfms, c-m.yc, c-erb B2, bcl-.2, p21, Rb and
MdM2 have been desGribed suggesting a possible
impt>rtant role of these oneogeaes in its
pathogenesis. Expression of the ~id.nllaJ grt>wth.
Cytog-enetiC analysis has. r~vealed that
complete moles generally have a.diploid ~ocype.
CoinP,lete. rP.oles with ,t~trapll)idy7 t!i~loidy~
haploidy, a nd aneuploidy have been qetected with
fl<?"Y cytome~ and eytog~netic' .anel~ :bUt 'th~y
ar~ .r~e.
. :-.....

ractor receptor {.EGFR} :h~s be~~ sk).ow~ to be .An impo.~t breakthrough ~g fu

.signfficruitly higher. itt .mpl~.Juotes~ partial
moles and nort;nd1 .plact$ta. . .Matrix
met:@oproteiila~ 1 artd 2 "(MMP-.1~ MMP.:2}, whiCh
~~:.hnport:ant iri _the ,ntOdtili\:tlon. or :cell. IJ1'Eitr.ix
~tera.ction and ba~m~t m~b.rane degr{ldation,
are- al$0 m.o~ hlgp!y ~~-m molat ~tation-s
than in the norm-al placenta. .Additio-n a lly,
complete (Uld partial moles.show lower expre~sion
of. ~u,e iplllbjtqr ()f:NU4P:-1cQ~ed ~the
'rio~hl;pl?t;ehqt. H~~fu_ny:o :.as .~re studi6 a:re
4pne on -t~i:S'toplc, we.,wJll.'havea d~arer
Uliii~iiig"as:-'ta'"'ine'' etfulqgy of.fuis':di:sea~
:eti(l;ty: . . . . ' .
...
cyt-o,felidics
. .' :Ges~~onal tro,p~-o.~I~sts:: derive. #om:: the
~bij9n:ic': mesOO.enri;:a,ri..d.,~iiro~ut~tn\ihe .
de:.,#<>p;nent, of~ 'pl~C:te,ntaf, _villj ....- Cy~g~netic:
~n~ly:si~. li~s . ):~Qri-tnbn-t-e:c! :.JAui:h 'to:. our
una.e-r::stan@g-of.the oiigm.:cif&tfatidi!ot-in moles
th~ biology othydtitid.ifoi-m.molt;s.occ.u..'r're4 in 1917
when.Ka:}ii-and Ohama Q.e;n:).6nstra:t:ed -~tail the
chro~osoltl;til DNA in COtnplete . moles w;,ts .of
pate~; or anm-qgepetic, .-orl.gln.. .Thq ~e ant~
to 'dete.c t this .6oridi:tion,- k.nown ~~ dia.ndric
dip~oidy;by .com~. ~\ym~~-P~ in band~
clfromosomes. of the ,_ niol~s with thQ-Se of-the
matemat and pa:terro...aJ. clrromosomes..
E~.m~ P~.liln:<~,rp~~ .ap. ~<>r~~t!y. .
~lynio.qjfiisiifs : ~--~e :p_NA hav~ . ~so beeri ::U~
to asci:#afupat~~i0~9f:~fur cl:n'9~eS.
M~~~-~~~Ji~ti.~~#~~u~;~n~b'~~~~a~,:Of= . .. ...
restri.tion: fritg;qlentlen',.gthpP).YP;\:O~..{?..:F.Q')
or P.o~e~Se:.<;:h~-- r~ctidn .(J>PRJ.~~llpn
of
variOu~ DNA- Stluenes::have --r;ev~:~ :at
least 80 per-te~t '(a,li<lm I p.tiny;.series; tat' ;li?.Cir_e): pf
coniolete :m.oles.laGk,a:!.maternai~.'CQiltribution. :to
:the -~hr-6mb;;ma{di:J.A.::T1la:t~au<~4.inYPlv~
at an ~support~ t?:Y.~the de,m1)n~-~ the
mi'triC'ii'onnniU,
...... , ~: ..
ln. c(:)m~
.:D'N-A .. J?;. . _. .., .
leii...Jn.(jfu is .
~r
... . r
' " " '7,'
...

ma.te:a;iiy-:tlenv~~.~-:chu:i?;; :q(!"sJ5ite-tP;e~l&;S~O"f'-'the .

._gbd:.t;~ili&"~!{;jii6~~4>Jki::i6-;p~ie~:m~l~-. rttrer~DfM~-:nrrmea.ns-wtuC# .~.:e ~;-tne

$d: triploid p8Jtiai .xh\~ . .' Se~etlc ,stu4\-e.s in
-~Y~il~v~- ~y-~tab1isli.. th~t tiJ;M .is.
ii:b:Uo.s~. -atw~y& :purely -'~4t~gen~~~- whji~ :~liM.
bc:urs.~he:n,t;hete.m .2 ox:.ore ~~-.d,~riv.
~~- O.f_~q~~~~~:a4d ~f~~.t pht -~~Je!E~~1
P.eii~ei;l ~-~t; :TJ;t. -t_yp~ -~of:
'i:!;l"ql:e, -prqdu~. .is,
fh;ei.efQr~; . ;ge~~ti~:?.lW : i,J:~te-:t,~j~e:R, .a-ri:Q.
irpp~b~}astih O:v.ergto~ -~p~ilrs ~ a~ted t9 .
Witht#e pi~S<;~~e.pf.~ot- th~ ones~t of:p;:tte,rn~
~hromosomes~
. The use of molecular.~: ~e~etlc tech!4q\ies...h~s
revealed an increasirig n~iQ.b.er of mples 'wrui4 do
notfit.dea_r:ly into the more .es~plished 'categories,
and h:as hllowednew ,i nsight int_o .lhedevelopment
of mall'in~t trophoblastic i}eaplasia~: .CvtJ.tjnued
.rese~ch ~n -tills field. Will -~oP!!fiilly. q.dvance. O'\ll'
Understanding of the bioiogyof. these lesions and
p~~~~-:~nii~~orr- -of dia~~st.te._ and:.P+:9inostic
. ,signi$~c~ .. . .. . ., ,,
citopia~tiiicJ):NA'9f .th~ -~~ol:\i:d. ev.j:un h .'rCbiined,
just t.~ it.~ In:. nort;lel ~go.tes.
. Sevetal.p0tehti?). m~ruuiismscoUld ;~uce
the.di~'d.~c .d:~plpiqy ~en ..in -~mplere "JDO~
. .
1. Fer:tf'ti~;tin ~or" :r ~u.C:l~ :c)r CJ;n,W. ~
by 'a :Si:ilgk-Iia,:P~oid sper m 1wq.:ich sub~ritly
d:upika~es its ~4r(?mos.orn~l ~o~plemeri.t.
Mo:le~ . de.r.iv.ed . ~ia . thls p'(-o,ce~s , of
endorepJiati9+l, . .!n v;rhich cbroino~qma1
materi~ is-. dqupl~d w.ith.<>ut a;.soc:iz..ted/~11-
divis ioil, -w.otdd . pe 46)>CX- an4 completely'
hom<m'g<?us. 46,YY .moles"co.1,J,ld ~ nii~ .b y
this ~echanism_, b~ t tl}is .g~notype is
-ptesumaply letl).~. lind WO\lld not suivive to
unp,lanbition.
2. F<:rtilG:atio~ .of an ~.nuclear or -'~~P!i' ovum.
~y two -ha;ploid sperms, r.esu~iing -a 'in . ). .

Snanned 8y: C
 CHAPTER .35: GESTATIONAL TROPHOBLAST~C. DISEASE .. 531
-;.. ..:

heterozygous mole which is either 46,.XX o r 1. Fertilization of a ~aploid egg by two haploid
46,"XY. (A 46,YY constitution is also possible spenns. The resulting zygote would be 69 ,XXX,
but is nonviable.) Because such moles are 69 tXXY or 69,XYY most common much.
derived irom two independent paternal haploid 2. Fertilization of a haploid egg by a single haploid
sets, each ' locus which . is paternally sperm which then replicates, prod'l\cing a
... . 'hetero~g9us !la~ a SOfSO cbance of being 69 ,XXX or 6 9 ,XYY.
homozYgous or hetero2:ygous in_. the fuole. 3. Fertiliz-ation of a haploid egg by a diploid spenn
'. . . . . . . . -. .
prodqced by failure of either the first or second
3. . Fe~tipn of an ~u~ or empty" ov.um 7,Ileiotic divisiop. Spenn produced. by non-
bya:gip,oi4 ~~ p~ueij'by .~~ o.feith~r diSjunction et MI would lead to a 69,XXY
thefirst or ~~c~:n.(t ,..JAeio.t ic d1v.hnon,. If zygqte, whereas those from non-di~jUn.ction at
! :iiS~~j~netion oCciiriea :at the first nielotic Mi.I wol,lld produce zygotes that are either
. <:JM.slcm (MI), the ~ling aperu(;(and mole) 69;XYY.or69,X:XX
'WOUld :t.etain l>Qtb 'tlotrioldgu~ ~tau ;paterrtal
. ~tWno$0iile~t ~(1 tllus ;~Ql~ o~y be 4(l,}CY. A conceptu.s with: a diploid 46~ maternal
.: .. .>~nlikt 4f).J(Y ..:c.omp~ete ~oles. of d i$pe"*ic genome caused by failure of the . frrst ,m eiotic
.. :.~fnf .~$C dipl<>~tiJlie)riQJ~~ ~uld re~n . divis~on and a., haploid pate.rnal set of
. iill...Jiatema.l: ~e'teroqgou' till~les. l{; ttOn- chromosomes results in an abnormal triploid
disjtiQct;ion. ~~<!(et flie. ~nq Jneiqtic (69,XXX or 69,:XXY) (etus.. This e vent, however,
. -~:..lclci ~Utn .""e ...... --- ' ' ti1d -contain . two referred to ~s a digynic {maternally derived)
\.4.~"-- . -~-v,......~ -~ .Jp.en:o, . We> . .. .. , . . .
, .r. _. '[
"""'""' :. :
., . ~.f'~~ Q. W~':" ~~,LJ;IP.:',, . ,. ~~ . .:.....;....;;.. 1 J1ap1 ~M ~t 9rid :~ould
. ~ ' . conceptus in which ~ of the .3 haploidse:t~ .eire o f
. . Jiav.e-~ :be-lt-6.,XX be(:au$e 4(;~yY !s1;lp~rttly matert'lal origin~ generally do not pr~e~t~~~s a
lethal. Whereas tilost l<>ci, ;partic:u larly those molar .pregnancy. . . .. __ ;~.:.!1.
nealthe cetromeric region, would be
. homozygous, some heterozygosity would be Diagnosis ., .
~:?tpected at distal loci be.cause of
retQPibirul,tion ~fore MI. As $tated previously, it -is now .~eU.iy.o,~
.. ..,., . ....:~.~.~~- . : ' . . . . that molar . pregnancy . c~mprise~. two .9j~~ct
Sti{cf.i~s . of cytoge.netic, enzymatic; end entities, co!llpl~te (CHM) and. party!! {~r.il~iV,i:~se
mol~'\il?r:gent:tic polymorphiSin using techniques . two en_tities ean be difl'erentiated fr?m #~~tp.er
~imilar to :tho$~ employed in detert;n'ining EU1d ~u~.gi}o$.ed based on . the pattent's ~..c!inicai
parentage; have found that at least 75 perc~nt to
85 percent or coniplete m.otes.are horiiozygoJ,Ie ~:h:-f!nll;~:J:fit~~~6~ti;~~'h-p~~l
..... .... ... _____________............ ----W .-.. - ..... R..... - ---.. - - ). - -
46;x~n:m<r mosTlixeiY 9iigtnal~a- rroiii"'a hapioici histopathologic examination and; when necessary,
sperm with en~qreplication (mechanism no. 1). chromosomal analysis (Table 35.2).
Approximately l5pert:en~ to 25 pen;ent of.complete
moles .are :heterozygous; these are predominap.tly
46-,XY, but so!ne.'46.~ -con;tplete.;moles have ~n. Taj,~ .35.2. Cl.inicopatholQgic features of co::nplete and
reporte<t Both the-46,XY.and 46,)0( heterozygqus parliid:P,ydatidiform mol<::S~
moles are fa:r more :Ukeiy to be products , of Feature
dispermic, rather truin diplospefmlc, fertiliZa.tion. Kruyritype 69 ;X)O(..ot 69 ;x:x:'l 46 .X or 46,XY
PAntOLOGY
Parlial Mole Fetus Often present. Absent
Amnion, Fetal RBC Usually present Absent
Villous Edema Variable, focaf Diffuse .
. Partial moles are generally triploid with a Trophobiastic FOcal, slight Diffuse, slight
69,XXX, 69,XXY, or 69)0lY karyotype~ Cytogenetic Proliferation to moderate to sev~re
etleyine, and molecular genetic analyses have CLINICAL PRESENTATION
revealed that most triploid partialmoles have one Diagnosis Missed abortion Molar Gestation
.maternal and twO paternal contributipns to t~e Uterine Size Small for 50% larger for
genome. This condition, in which the extra haploid gestational age gestatignal age
Theca Lutein Cysts Rare 15-25.% .
component has a paternal origin, is.called ~iandric Mediail . ...4.
triploidy. Several mechanisms could account for Complications Rare .L ess 4f..,an 25%
PHMs, including the following: Postm'o lar Malignant !.~-.

Sequelae < 5% 6-32%

Scanned By: ~
 SECtiON V: Ht:MORRHAGES tN PREGNANCY

Clinical Presentation of toxemia is limited ahnostexclusively to patients

With:markedly elevated hCG val\les and excessive
1. Complete Hydatidiform Mole uterine .s ize.

a. Vaginal Bleeding

Vaginal bltedin:g is the' most 'common

. presenting symptom in pa:tie~ts With complete
mote, occu.tlirig.m s:9~97 pe~t ofca$es. Molar
~hOrlon,ie -vill.i mlly ~si'upt ~~tetntd ve$~ls 't>y
separa~g frotn :the d.:ldnaa a..Xld ~. 'Vp1Utnes
ot tt~ed blo;xl may distJ1i1 -.the eiidorne~
cavity. . LiqUefaction -Gfin:tta~t~e:clotS :may"l~ad
to l~e oUlliid 'With the 'tolOt .JlUd CQn$lstency .
of pl'Uno jl,tite. :ale~4lns 'mll}' be prolo~g.ed,
~tl~d~bl~ and- >eUlt. patients may: be un;J:nic
~t =present.a~n. Howev<;r;$Ul~ more 'an~ ~te
hydaltcliti:>t;if ~oi tire. -dt~~aed eady in
ges~ti~>no hei$pgtol,)~ Jeveute:~ tl).:an 10 g/loo
t:111.- :oceuili tn .()i)ly.S ~~ pi etirtent :Patients.
Sp~e:~~ts ~s 1ll:~W ~~~
b~-~. EXctssiVe":tiu:pne,ilJn.IargeiJieJit'f:.

.Jl;xeMsive uterine size iS assoiated with . . . . .

.mat~e~y ;~ *lev~ie4 ..-levels '
.Qf J}bCQ 'fro.t'Jl e. Hypereme$is . ;Gra,vidal'urtlc . ..
tri?ii~b~\'o'VC:L~Wtb.~: :~~~~ :-50:... .. .
-~h~r;pe:~n~ ~~th~~~p'e~~~liyoafidi!c)r.ni - .c: . ,llyp~remesiS - ~Vid~-.tomplica.t~~ali)Und
m:o1~:~~~~~e7~em~t~re~itluu1~';:' .15;;.2$ ,,:~nt cf .m~s .of:~mpl~te.=hydatid.trorm .
'ttte~_p~~~ ~or.t~Pl~P.. t#JJ>~~l}?D.l~an m~le ~d.; ~ uaua1l? as~~~ted. With '\lt~rine
.is du~
. : .tt)"th~
. ... .....*taltied
' ....., . : blbl _: ... b. ~.d ..n5pi<: .vl1lL
.... . ,:,...tild .... ~e-nt
:. . ~d
.. ~natkMJy
".": ..- . elC9ated
. hCG ti~
. .
. c. . Th~ L\itetii:ey.Si$ 'o1 the ovary:.

'nl:CS. lurem eysts bave.been :a.ss:wned to.a ti$e
as a re.stilt of extremely J:gb bCO :levels. Thus.
th~~~ itte.detect~ atm.ost .~1'\l~lvely' in .p atients
with v.e.fy ~ -~i:n h 0. value~.. .n ie ~pO-.rt~
ing~ente oC:theca..lutein cysts ~es depending
Qn whether diagno.sia..lii e$tat)li$hed \:)y clinical or
. ultrasound examma:tion. : Incidence rejx)rted in
l,it~ratur:e ranges tivm 1.5 -46pertnt. The~ lutein
cys~s ate'usttally \lila:ter~l and rou'ltieys:Hc,
.cqntain;ngserou~-pr $ e'ro5ap,gUinQus n uid {Fi'gure
35.1}. Though usu~y it} ilie 6-12 cni ~ge, they
may reach substanllill proportions of larger than
20.ctn. . .
d. Pre-eclampsi!l .
CO.n fliet$g,evidene dists asto whether;hCG
is the tll.YJOttopic.:faetor re~pa{i~ible. fot st:i.tnUlating
thyrot:Qxiesis. c~caity ~ent.:hyperth,y'ft)jdism
is-a feature of ro.t:p:plete .h ydatitltrQnn mole ih:-2-7
pereerit'O'fpatients. Howeve.r, !abota:tocy evidence
of hY.rthyroidismis more .eo.m mon. h'e~ptlng
symptQms include tb'yr oid enlargement,
tachyc~(iia, fever, and tremor. Patients with
untreated or poorly controlled hyperthyrQidism
may develop thyroid storm at the time of
anesthesia induction and evacuation. Theref()re,
while blood samples .should be drawr for
laboratory confl.Illlation. the diagnosis of thyroid
storm .should be made clinic.a lly so that
appropriate treatment may bepromptly instituted.

Pie-eclampsia is.associated with l2-27'percent g. Pulmonary Insufficiehcy

of patie.nts with complete hydatidifo_im mole.
However, this is raie. if the .molar pregnancy is Two percent of pa tients With complete inole
diagnosed before 10-12 v:eeks. The. occurrence. develop respiratory irlsufficiency. This is u sually

Scanned 8y: C
 CHAPTER.35: GESTATtONAL TROPHOBLASTIC DISEASE . . 533
------~------------------~~--------~----~----~--------~---------

observed after molar ev~tion in patients with

high hCG levels, excessive uterine $ize and very
large theca lutein cysts. While trophoblastic
embolization may contribute to respiratory
distress, it mayalso result.f rom the~-~e.~
complications of t-oxem:ia, thyroid storm and
massive fluid replacement.

2. Partial Hydatidiform Mole

Partial hydatidiform moles are rarely ~9scd
prior to uterine _evacuatio~ ArtY of the clinical
rnanlfe~tations of coMplete hydatid.itormmole_nw.y
be -a.ssociated with PID.kbut'they tend: to be inOre
subdued. Instead, m0$t pe.tienta prei;c:nt With
sjgns and $ytnptoms s\Jggesting it\complete or
missed abortion. Hence, :the ~osi,t of. ptWtial
mole tnay be made .a!~ histoloi;csi review of
curettage spec.imens for pie;Jumed incomplete or
missed aborti~ris.

The availability of modern ultrasQu.nd;

machines revolutionized the diagnosis of
hydatidif9rm moles. Most ' CllSCS ~r:e now
diagrio~ early. prior .to tlle-C)q~ of it$ claSsi~
signs :;~d, :symptoms.
..
1. Co~plete Hydatidifom:t Mole '

Ultrasonography_has prbven:to l:Jc aQ. jlccUtllte

and . se~tittive toot ror~lfie a;igiio~:)r ~iii1i~ ... .
hyaa:ttauorm:-mote. COiiip1~te ~1e ptiid~a a
charact~ristic vesicular. p~tteril due to the
generiwzed -~eiling of the cborie>tue viUit. ~id(:nt
startingon:the eleventh week ofptegriluity (1'1gure
35.2). During the (rrr.t triin~~ter, th~ ohononic
villi tend to be smaller .a nd have less ,c avitation. ..
Nevertheless,. the majority of :fll'St trimester !

complete moles still demonstrate the tYpical

ultrasound appearance-of a complex, echoger..ic
intra-uterine ma ss containing mahy smal! cystic
spaces.
2. Partial Hydatidiform Mole
Ultrasonograp\ly may contribute to. the
detection or partial hydatidiform mol~ . . It can
reveal an abnormal gesU!_tional sac; but the classic
vesicular pattern of a complete tn.ole is usually and u~erine ~nlargement" iughly s~gges~~ eoi:nplete
not seen. Focal cystic spaces Bfld/ or hydropic
changes in ..the placenta are -significantly
associated with the. diagnosis of PHM (Figure 35.3).
H!l.man.. ciWrwnic iJo.naaottQpin
- .. . . .
(h.CQJ
:.
An imp;o.r:tl,l.n f chara(;teristic ..Qf mo~at
pregr;.ancy is its a.bmt:Y to pr~uee. hCO due to
trP.phoblastic proUfe,Tatiori, Without doubt, serum
quantitative bCG pro-vj~e~- a v~r~t imp.ortant
infonnation for ode:Cidi,rtg"o.n .the UlC,~lihpod of ~
molar pregnancy~ Meci.surem~nt of a h igh .hCG
(> 1oo.,oootJ I L). in a~soqation with vaginal bleeding
~yd;itidiforni. ~ole. Iri contt~st, partial
hydatidiform mole is: less "commonly associ:a ted
with markedly elevated hCG values.

Scanned 8y: ~
 'i.l~~

534 SECTION.V: HEMORRHAGES 'INPREGNANCY

--~~~~..,....,..---..----'----;...~-------,..-.-......-----........... -------- . . . ~ '..,

b. Microscopic Findings

While ultrasonogroph:y bas bee<>nie a very the two most important featur-es of a coinplete
effCtivc <liagm>s'tic tool for the ~Y dete~:tion .Qf mole are enlarged, edematous 'villi and abnormal
hydatldifonJ;l ~oie, Jt does not always ~tmmtee trophoblastic proliferation (Figu~ 35.S). Many villi
corr.eOt~sis .~~peclallyinthe:ve.ryearly . itages display c entral cistern formation characterized by
' of gestittiOn~ Wb,enllie chorionic villi 'have not y~t a prominent (:entral space thatis entirelY acellular..
a.ttiililed ~. clian\terlstic ~sic~lar pattern. ln . A few smaller villi are usually present but th~,
su,<:b ea~ea, diagnosis i$. ~&.de only .<l~ting too, are edematous. The trophoblastic proliferation
hi.$.t(.)togteat exami~ation of :spec:h'nens .for in complete mole is circumferential around the
px;e91..t4~ incomplete or xni~sed .~bOrti<ms . TbJ.s villus .and
is com;p.()se d of a In:iXture of
fact ~pha~s the.'WI'O.t1a.il~ ot subrnittirtg ail cytotroi)ho'blast$, syncyiiQj:!'Oph<>blas~ sn~ Villt>us
prqa~~-o(~cq;Qt>~ ~~ed -d~g cllrettag;e intenn~d'iate tropbol>l~$ta. Th.e . ~uno\u1t of
for. .btat()path<>~Cat-~ation. . ' . .. prollfenttion-te b!ghly,vaUiiblc and -tni!Y'~ 8\lbtle: -
es~ in caseaofe'Mly (romplete moles. LMge
1. Complete ttydai:idh'rom Mole . sheets ohropbobtasta may also ;b e seen dettbed
. . from the villl..Th~ b'()pboblast ofacomplete Jllole
.a . -Gross-Morphology always disp1ays cyful()JPC atypia, which may be .a s
marked ~s: in dlo~oma.
The c~ssJc .grof;s appear-an.ce .o f a well ..
devCIoP::4 co~plete hydatidifo~ mole is a mass " . I .

~.
. ,~

.... .

. .. . :/ . . .
~~. ~~ ~picpictu,r'C ofa~;nplete .
mole ibt>~g ~yl:lropic Villi wi.t h cistern Jorm!ltiOQ and
~erentihlbi>phob~tic proliferation. .

2. . Partial Hydatidiform Mole

a. Gross Morphology
/
The placental tissu e is less bulkywith variable
proportions of vesicles presep.t (Figure 3 5.6). Fetal
membranes or a fetus with gross con genital
~bnormalities may be present in some ca~s.

b. Microscopic . Findings

Mktoscqpic ,exam.ination,-shows. ai. ~* of

edema tous and s mall, relatively nom:.al-eized villi

Scanned 8y: ~.
 CHAPTER 35: GESTATIONAL TROPHOBLASTIC DISEASE
. .
(Figure 35S). The former show a variable degree
of hydmpic swelling with centr81 cistern fonnation.
They often h.ave an irregular scalloping outline
with tropi:io.b lastic inclusions .The cistern ma,y be
less :well formed with the qevelopment ofa maze-
. like pattern. Normal~ sized villi are present. There
.may be evi<:.en:ce :of fetal development. a lood
.vessels <:})taming .fetal ~d bloOd cells .may be
det~cted. T he pattern of trophQ.blastidlY~lasia
may help to distinguish a partial t;nole from a
silnple hyc:lr(>1>iC abortion. jn partial moles, th~
ViiJous trophoblasts often ~how.fo~ .nm1tif9..
or cir-cumferootial proliferation while polar or
. lateral ptoliferQflort .is . Seen in lll:St trimeSter
. awrtions.
a
ri~ .3 5/1. MicrOSC9pic .picture of :Pat:ti:2ll.tydatidiform
Jl}Ole ~oWing la,rge; edematOUS villi O?tack 8JTOW) a~i;X:ed
m ixed with normal-s*d Villi (red arrow)~
Scanned 8y:
. 535
~
G-enetic Imprinting
The histologic distinction between the two
typ.e s of molar pregnancy has become more
difficult due to its increasingly ~ly diagnosis and
evacuatjon. As a 1e-sult, genetic imprinting
through immunohi$tochemicat techniqUes have .
been used in order to differentiate the two entities.
ihe irhPrl~ting 9f genes, whereby the inateinhl or
patemeil allele of a particular gene is ~ted,
le.a ds to differences in expresSion o( particUlar
gel)es. Using immunohistochemical teclmiques,
the expression of~ 'k nown imprl'1ted gene caa-, be
used tQ indicate the l>resence of a functional
mete.q utl <:opy of that gene in partial molar
gestations, and absence of the. maternal ':copy in
coinpl~te mole~. I~munostains used fer .this
pul))O~ inClude the followipg: .
,-1. CD!CNlC, a inatematty i!Jlprlnted gene that is
. expressed hi n.o rmal placenta, .. villous
cytotn>phoblast, villous mesench:Jm~~.i~nd
intervillous>trophoblast islands~ and '~tci.dua.
2 . ps7. which eomplete)n9les:showe~
of staining in villous cytottophubla:$ F1md
. "illous ~~nch~e and P9Sitive.: stafumg. in
..mtervillous trOphobli;lst islarids' aritt:(!eqduas .
:: .<>f.~niplek.moles. Partial ,Jilol~s;.fu':ton~~
had a: norm.il staining profile.; . . .-~--A~.~ ;..tJ. .:::~
3. PHLDA2 is another Jlla,ternally impriilted1gene
that is present in pat:tia1 moles and ~bsent in
complete mole,
While complete and partial moles differ
bistop!lthoJogica:liy, cytpgenetically anti :in clinical
behavior:, management is similar :!ild indudes
. id~ntifieation and treatment of cc:.e:Klsting medical
comp)icat,ions, &Qrgi~al evacuaticn, f<!llowed 'by
dose monitoiing of hCG post-evacuation.
bnce .the diagnosis of complete arid partia l
hydatidiform mole'is ma<ie, the patient should be
evaluate.d for the presence of medical
.c omplications, inclu.dit:lg anemia, toxemia,
hyperihnoidism and respiiatory insWficiency. All
,patients should have the following basel1n.e .
laboratory examinations: <
~~
1.' Complete .. l;>lood co~nt with '(lirrereilt!fu count
and :pla.t~fet counts . .. ~:!: .
2. Blood typing
3. Urinalysis
~
~
 - - - - - -- -

536. SECTION V: HEMORRHAGES

. . IN PREGNANCY
.

4. Liver and kidney function tests agents used for prophylaxis inasmuch as these
5. Diluted serum PhCG using radioimmunoassay ~ts .are alsq the ones ~sed as first line ~ents
6, Thyro_id function te.s t in .the treatment of GTN. Since n<me of the
7. Chest x-:ray .$tndies using prophylactic chemotherapy ha:c;
completely eiitJ;!h)ated"theriskofpost-mo~GTN,
. Afterth~ patienth~s been medically;evaiuated surveillance with serial P.CG is still m~dator.r~
and'. stabi~ized, -a decisi.O~n m ust be p1ade Based on the a,.vai4J.~le data, jt would seem that
;~ncerning -the n:~.ost appropriate met~o~ of patients With high..risk factors wm,lld benefit:f~pJ;U
evacuati9,n. SJicl:iop cury%ge is the :F~feired p~pbytactic .C:J:,l~:tn~there,py. 'l':ho -PhiliPpine
method of ~cil.atioil. regardless b(uter:in.e . s~. .$?ci.tt;Y "for 'e Study of T'l'ophocfu$tk:" P.isea~s
.lf the paqent:no :~onger d'e srres t<)preserye:(e~ty, ~ndorses the ad.ministratjon of prophylactic
.hysterectqmy v-illi molt< .iJ;l situ may ~;pe'i.:Co~ed. ch~motherapy for ,patients With .ap.y .o ne of the
:Ilyst~myoffers the. &;dvantage 9f r~~ci.Dgf:he folloWing ~riteria: I
.r..sk of-loCal invasion. How~er.. patients must: br.
. . mformed that i~ does- not'prevent metasta:g.c _ L U~esizel,al:ge'rthanageof.gestatiqnofmor.e
. d.isMse.. Ther~fore, ' hC(} 'moriitoiing~ hi 'still -than '6 weeks
I
~e<lUirC<L the'adPexa ar:~ not removed ~ess the 2 . . Seru.::n ahCG titer more than or equal to
pati~nt .is pe:rimenopau~-~us~ :~e risk for 10:0;0.00 mll:T./;t;ll. . I
. ov-.o:ria:n .m~tas.tases is ,tW-e .and i:!lost. ov.ariart. 3, Th~lutein:-:C&~u-more tha:il or ~to6 cins
.Jlia:ase_s f:l!"~ thee~
. . - .. .. - . . .
lute,in . y~t:s
. . ... tn... .gej::.~tal, . - .'in'.~ .._': . '.'
- """ . . .... . . . . .. : .. .
;.
. .. .
umrverition :i~ ~~-~-ior th~l~~e41 cysts .4. <J)fu.teqlhl,age .~~~than. or ~quaJ)o 35 year:s
. . . . .. /
I
-~;j:_ .DJit..hese:<jstif.sportt!u).~~sly.~:re.S1ye;"4~i~l2:-.. -5~,: ,:Gpt\?dftY or~~~.l~'rt 4._ . _ .: : - . : .. ... _ . -.
;,-;.~-. _:: w~n~ Hjiit~~t.Qmy~aadr1ndu~ti9n'~'of~I.aOOr;.:,by~.. .;6~,.,.,Rt;qlln'ent\~.o)il.r,;~'-fl'.u.""".....-: ..._..- _- , ... ...
;:;.(~- .: -cx:i.:t~~ot~P.rostagl~dliit~to>Allo'>V:!{exp4lsio_ti~are~"'-,.-7.: .:~dic~l- '.: ~~~,itip);~~~o~~: ' aris_ui-~,_ . -ftoin. I
....: .. ~iedWith.~ci:l'il;l.P,le~~eva~tio~~~tv . : -. ~r~phc;>bl~~~~': :prol.if~r~,q.~n: qD.lG-. ;pre-
. :- .-hemo~:~d,p. ..ruSP.f!i:-~ti,P.til~ ,of:~ole.r . : ee~~l>'~ia:-:. 1QiY,rotox.k9si~.. .. p~H~9nw I
.. .. (mk..Pa:f:ien~w~o:ar~Ri;l<n~v.~.sAoulO:z:ec?v~ . ... :l~~ge:AcyJ. ....:. . - '
- : ~Rb-.)~routi~:. glob~li,D., ~~'"' th_~time_. q{-ut~ii~e: .- .a.. :Pisyti;i~;g~pPis~fiori. .. . ': ..__-: __-:: ,..: ..
. evacU.atiOi:t/be~tiSe;-;trPp~cibfu.:s't:-~~~:'RhD::~- .: , : -: .- . . . ::. . , . . . . .... _. I
factOr.':~~ ~ ... !::, . .Chetn:o:thera~iltie:agent:.~l:n.ln'ow~ -ii~ ls

-~;~~~
- - ....
.;;~;~~i~~1?Y -~~~fl~tt.:\~~~T;~~~cf~
~:~}~~~t-A.~~~:-~~en-;a:t~~{r1_:~.~~g/ -
I

Th~ use ofprophylactic -~~emothe~py .at tpe kg ~ay. w(:ight/P.ay :aqute~ "hi :&~.e.,. given I
time of molarevacuati?nis highly crinfu?:versb.l- int:iavasculiini for S days, ~otto'~cee~:J:60(iug/
TJ:l,e con"tt-9.ven'ly.con~ the Wis4om-o'f~sing day. Cheothetapy may be gi:venpre-eva.cua~oil
;all. ~~:erit:S .i9:.pet~p.~! ~oxtc ~~~.t w}len ._otWitJ:Un ~.''iJJ:eeb ,pqste~a~'a;tion. If,~e~~tpre I
~nly .a~ perce~tage of. patie~ts <:Iev~l9p ,persiste.tJ.t . a.~~tiv.~.ly, ~v~cu;~.qqn .is. ~o~~ .q.n .-t..'!e tbird.''day
.:tumor.. .t.:P:proxmrate"J,y :3~ petcen( .of .~ti,ents Of adm.in:istratiOh.. Contra.iridiCa.tions .mau.a.2' I
Wittt: :P~~_.:l~y;da:tidifotm-.~<?le<> wiP ~~-~c~ .. - - . - . . . .. .-
persistdniQ.is~se compared to 20 -per&n,t.witb 1. Heinoglob~~is < 10 giL
complete moles.. K im, et al. in 19.'86. in a "' 2. WBC''is< .3 :b~ i9~/L or > 1:0.0 ;;:1'09/L I
randomized CO.rltrol trial of methot:rex.ate and . 3. Platelet co~I).t < 100,00.0/cm~
f~llrik hci<Lu:se-d:at the. time. of mol~evacuation, 4_ Eleva ted liver and:renal .function .test
-~oun4 :lli~{ tO.e incide~ce ~f post-ni9iar OTN 5: Co.ncurren~ iilfection - I
:deGre~sed fo$17 percent t? 14 pe~nt among
p~.tients with h~gh-=risk criteria. On tl).e other S.~eillanc~.A!ter lr:{olar tva.cuat~.on
b.and-.::,pat.i~ntswitp.l.ow ri.~k did . nqtbe,n~~~ ~rpm
- prophylactic chemotherapy. -Interestip'gly, the ..- _. The mos.f re!ible method :fo'r ~ly. det~tion
incidene<e '{):f toxicity .wa~ .very:low-. other -of:pos.t-mo)M. qrrN_ :is s$-ll serial quflp.titatf.;e.hCG
. ~dc:nnize4 trials h:a~e reported a .decreased risk _leVels. .'Current recoi;l:iirteridat:jp_n i!or :s\.m'e~ancc
of .-posr--'niolar GT.D followi~g ,prophy.lactic .
~er m.olar, pregnancy mcludes ."~~hco 'levels 1
ch~mQthe~py. The .dis advantage pf this practice Wee'k after evacuation an'd'then every -:2 'weeks' -'j
is the possible development of re,sis~ce tp the until the titers become n.ormal for three

Scanned 8y: ~
 CHAPTER 35: GESTATIONAL TROPHOBLASTIC DISEASE .. 537

consecutive determinations, then monthly for 6 '.::Rare C~sea

months, every 2 months .f or the next 6 months.
It is essential to emphasize the import{ulce of
using a reliable form of contracepticn during the
foll~wup period border to eliminate the potential
confusion l:h&.t Q.ri.ses in the interpretation of a . hydatidiform roole was described. Over the .
rising ~CG in a patient w)lo has not been using a succeeding years, a limited numbei of_cases have
reliable contre..ceptlve method.
Preg nacq After a Mola! Pregn.ancy
. ~-tiel$ with molar pregnancies can g enerally
a:pticipat :norm~ futUre_reproduction. How~ver,
the risk !ol' a ~peat ttiolar pre~cy is arQ\itld 1
petcent or 10 times higher than the . norinal
population. The risk rurthet increase_s to :2 8 fainilies.
percent Jollowing a secon\1 hydatidiform ~ole.
.. Fi~ 35.8 presents~ algoriUim sho~g the_ ~oniplete, karyotyping has demonttrs,ted :poth
recotiUlleJ:lded steps to follow in the diagnosis and . maternal 'a..,d paternal contributions; t<r -~eir
man~ent of molar pregnancies.
.....
~
,........ ....
Recurreht/ Familial Hydatidiform Moie (FHM)
Most nlolar pregnancies are sporadic in ~ture.
However, in 1980, e. familial syndrome of recurrent
been reported involvingfamilies cf bOth ,Asian.and
European descent. Affected women in tb,ese
kindreds have~ reproductive history remarkable
for few Qt Jl:O norm~ gestations: Pedigree analysis
has suggested that FHM is a smgle gene disorder
with an ti~tosonial recessive: iruieritanee ~ttei-n:
This is further suppprtcd by -the finding of
consangtiinity in up to so pereent or affected
. . ~though in9~.t ~olar p~~~es ~ FJ!f4~
chromosamal :niake~t,Ip. _l'his is.~ in-,wrect.tii;>n.Jrtst
to: ihe $poradic,oomplete mole~ ;i_~ :which7aisiolely
patema1; chromo.8ome complement ;jti)iJi~t:nt .
. Also, the -occasional partial moles .ii;lentifi~ in
- FHM, are diploid and biparentru rather than--
.triplold. 1 ' .,; ,:: ; ',v,-:i -
. ~ . . -';\:~t;~ F-t(;_~~~~: : -.. .
Genotype~phehotype corrclatiOuSl.;b~~-een
androge11etic complete moles and diartdrlC 'triploid
.. partial moles have suggested . ~!~t the
. oy~r.~~~i<?.!t.,Q.Lm\!~nll!UY ~D;~~~~g~rt~....i.~
. x:e..sp.nn~lQle..fi>-Ltt:.Qp..hablast_prclifcmtio.n.J.t.is.:...also .
thought t.~at. dY,sregulation of normal imprinting,
the process by which . one parentai allele is
-.-transcriptionally inactivated, is likely to 'be the
underlying defect in familial recuirent moles. The
gene for FHM has been mapped to. a 15.2~M
interval on chromosome 19ql3.3-13.4~ 'Th.is ~on
of_9le chromosome contams approximately 60
genes. The function of thi3 gene has yet to be
elucidated, but based on the genetic analysis of
molar gestations as described above, it is likely
that the gene h a s a n important function in
regulation of imprinting.

Familial recurrent mole should be considered

in women with molar pregnancies .who have a c.lose .
fap1ily member With a history of molar gestation.
~mong women with hereditary com~t~te molar
Refer to .a trop~astlc diseas;e specl;flst
ge$tations, no norni~I pregnartcies,~~nd/ or a
history . of riliscarriage or partial moley plus an
. Figure 35.S. Algorithm in the management of hydatidi(onn ability to demonstra te a diploid biparerl:tal origin
mole, . - of the molar gestations would strongly suggest a .

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r-..
~
 538 SECTJ.ON V~ HEMORRHAGES tN PREGNANCY

familial syndrome. More research is needed to. Suspicion commonly arises when an
determine whether ell biparental CQmplete moles are ultrasound Sca.n identifies a fetal pole.along With
associat.eclwith familial x:ecu.n'ellt hydatidifqrnl mole, an .a bnormal placenta. SteUar repOrted that as
and whether all familial roolar. gestations are much as 68 percent of CMCF was diagnosed l:ly
biparental. It is also hoped tha.t fUrther~ will ultrasonogra.phy but as many as
40 percent of
lead .to identification of the .gene defect responsible case s cf CMCF may be missed even by high-
for the famDiaJ.molar
. . . pregnancy syndrotn,e.. resolution \,\ltra$o~o~phy .In .situa~ons in which
the n ature of a multicyatic plaeenta .co-exisrent
With alive, sonologi~y no~ fetus .is uncertain,
.cytogenetic studies ot speCimens obtained .from
A twin pregnancy COnsisting of'- hydaJidiform much
chorionic villou~. .sam..pling will be -of help in
mole with living fetus ia a rare pb.enolilerton, establishiPg the diai:tlo3i9 .in .e arly p~cy.DNA
witb an estimated U)ci4ence .of l i n 22,()()0 to 1 in p6lytnorpb:ism PCR perlorm~ on t..'le products o!
100;000 p~cies. J3irth ot a live fetus from eoneeptl<m bas .$bown .a n :exclu~vely pa~~mal
sue.h a ~stati.(>n is eve~ .~oie rue with l~s t han origin tor tbc molar fissue and a ,n ormal biparental
.fort~ well docl.;Unetited -cases r-cp_orted in origin !6t .the fetus. 'Molar tis$ues obtairied after
worldwide liter~ture. In the Philippines. only 4 evacuation.bas bee~ s'hovyn to be diagnostic for
Ca.ae., bav~ been tep<>~.d so far. Vi)lijr t.eported a paternal unipS:rental isOdisoiny.
.;ca,~ :Q.f::h.~~~m -~le Witli
~~tin& ~~tus
delivered at 3.3 week$ o f .get;Qitlon- .ln ~opo, .a~use of its raQ.ty. the clinical course of
. Me~rewrted twp: a.dditi.Qta~.t~$CS oh:omplete CMCF is _poo(lJt .\Ulde~toQ9. &.sed on pu~lished
~Ple:'Witlt~tinlf.f~t\\3(MCt"t~th:Qf.~tu<$. . reports, maj<).rity .<>f. t;ase$ .t e:s utt.tn therapeutic
. "(lidinQ~{g()~beyon:a~~eJita.~ba'if!.ut.~.rdue;.;. ~.inteN.enti.on : :with . evaua,t;io,n....Qf,.:the., p~ancy. ,.
tc .me.ternal~:c:Qrop}icatioQ:s.< -~ntly,~ ,..-tilstt:ena~. - i.minediately upon dia,gnQs.i s 'in an .attempt .t o
reportedthct:r iat.c ase infu.e : i>JlW.pt)hit~dtfwbith- thwart t;he onset or. mate~ con;u::ili~tions a.ild
the Jl?~ twin. waJJ .4elive~d ~ :~rin .Wit4 no to decre;;.:se the p~tients~ risk of developing
conipUcatl-ons bot!) in~ the pten:at~~. ~nd. persis~ilftt"Qphob"\asti!;di.~9r.Pl'D. Fod.hose
J>P.S~ period. . who ~se. to. entmue :.pt;c=~cy. 60 pex-ceilt
. . wh:~;n.. dc:a ling witb a ~~~c ot .possible will ::esult in citlter llitra.UleQhe fetal des.th .or
.;Jtyct.ti(H{QI1Jl':JnOlc~(mth' # '' ~$tintf~til$/e spontan~U$.- l"~cy .lo,s s. U$\llllly durjng the
,"fil~Ul ~e ~ .to E:h~~: .~f"Ween:.two tondiUons; second trittu~stir.~ on. ~~ ;otb~-~d, near!Y. 40
1:)-a'"i~gl~n :p~e.y- ~iisi8tlri,g-of-4.pa..rt:iat J)ercentot.women.have:Uve,babies,"most of which
hydatj.~:tm:"lri:ble..,(PlfM)-~@.d -a, H.ve c!etu$- With are delivered 'beyon&..:3-2.:.weeks-.,ge.$tation. .No
l:nultiple eongenital anbtnlliies; ~4 2) a . twin elevated tr.equency of f.etal abnortilalities bas so
~cyrwtt.'l;(;)rte placentaexr.:ibitihga<;em.ptete rarbeen de~. DUTeren~tn linical-course
hydatidifom mole.. a,nd the other su$~g ~ depend bn the behaVior of the ,:~~om:panying
riormat-tw:in. In the $ee0nd ease,. .thete-ill ~w.ally . hydatidffonn.mole. Either the tlioltn'part becOmes
a . cl~ .distinction . b_e.t ween .tbe .m:Ptat end.:non .quiescent. alloWing pregnancy to continue or it
Jll.Olat . regions ofth~ plae~ta. ~r"hJs t ype .of . goe"s on .growiri~ ext~nsively,lead4tg to fetal death
.ptc~ancy }~~p:re,-s~:s;i~s a .dizygotic t\Vin~izlg iq and matei;ti~l C()JI)plications. 0.1itcom~ of the
. which . fetlilia'ti<m r~.sult:s. in a . eoplete pre~ancy may be predicted by serum ~hCG
h.ydatidif0pn .m()l~ (CHM) in one twinandanon:ilal levels. A very high (~100,000) titer .at the
fe~$i.I:l :th~ ot.Jler. begihning of the 2Dd tr..mester points to a major
risk of termination. Consequent!y, presence of a
Prenatal diagrt0:3iS bf.a ccomplet~ lilole.With a mil,rkedly.enlargect Uterus, theca lutei.; cysts_. and
co-existing fetus (CMCF). depends \lpon the devdopment of :m aternal coinplicafions such as
p~UeJ:lt'a clini~ signs .and ~~pi:orn,~. physical pre-.eclampsia t:4ld hyperthyroidis.i n all connote
examination findings, .s onographic picture, e~ber!lllt mol~ .p roliferation signif}ing a pOor
abnonp.al blochemlcal data and cytogenetic outcome. On the other hand, declin:ing PhCG titer
. ~tudie$. Jyfost presenting symptotn~:Qf.CMCF ate at the beginning of the.second trimester points to
~~'to 'thos of a .singleton .hydatidiform.mole. a successful outcome With a viable child.
. However, CMCF produces - ~ markedly larger
uterine size and higher levels of ~hCG plior to Cases or complete hydatidiform mole with CO-
evacuation. existent fetus h ave a very high risk for persistent

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_ _..,.._________________ CHAPTER 35: GESTAT10NAL TROPHOBLASTIC DISEASE.....,..._..__~-~-----~ ......
_
-539

trophoblastic dise~se at a range of 50 to 57 Cytogenesis ...

,,- .....
;
:::.~~-~<r'

percent, 40 percept ()f whom ;pr.e sent with

metastatic disease. treattnent"with Chemotherapy Cytogenetic studies ofgestational trophoblastic
i.s ~a successful as in a;ny other case of neoplasias have been limited by the 'availability of
trophoblastic dis~te. Recent '"t\ldies ha'Ve ~howp fresh material. Based on the analysis -o f cell lines
that advanced gestational age doeiS nbt a!)pear to and a small number of tumors, it has been shov:m
be an independeht risk.faetor fordevel()}:lin~ 'PTD. that while invasive moies generally have diploid or
Such nndiilg~ ~ -- con~istet# :with .~e i9-ea C){ a near-d{ploid kaiJ-:otypes; ~horiocarcinoma,
less. ~~ive momi pregnancy in cas~$ ~cllii\g regardless orthe ~~ent p~cy, #.Deriilly
advancecfge,stati6n$. .. .. : shows a m6r~ aberra.."lt kary~type. with m~es in
.. ,. the b}tpeniiploid and 'hypotetrapJoui'rcU.lge. There
Opij.mal . m:anagem~rit of CM.CF is: still . has .b~en, bo,Yeve.r, il.'O sp~c-ific chTOD:l<l$0_me
un:certa.hi 'because of the '~Cant' information tea:rn:tn.gements;as ~o.fnpther~or types, that
avariabie. lri othtr;ci>tmtri~. wedwice is,betWeen have been ide;n?fied ~th GTN.. . . ... ~-
term.hiating.a poS$ibJ,ynt>rmai:IewsandinCr:eas!Ag . =

risk tor IJ1aterrial compUcations at'ld _PTD. suice -~Chorioc.arcino.ma may: follow a n-ormal
a
.we .live in cou.ney where elective abOrtion is not .. pregnan~::y, ilbn-~olar abortion or HM. Using
allowed, patients are lel't with the option. of geheD.:c.:~~~~s~- ~~ is ~o~:)~Q.~ble tc det~e
expec+.ani management. NeVertheless, one -s hould the ge-statlorUJ.} .d r .. npn~ge;$tati:ona! origin
be made aware.ofthe complications th1--t may arise trop}l($mstic..i;i~P.ta~as~ Since ffi.e..gen<mie a of
as<3.--tes\llt.qf_the4" .ptegn\Ilcyand .the n~ for GTN.~.flects.thepteguancy ,from. i\truch'it:~. it
clo~~febil . ii[td materiliii mcmitorip:g CiUlJlOt be. will 'bave ~tern~ a nd tna~emal gep.~~ _:~;j~~s
o:veremp'l;ia~P. from. ~: normal pre~~cy-~~ t>poi:l~.at1eou~~cn,
= . :,.: ,. .; . . _.. or pa~~ genes if 1t Drtgmates fro~ .91.~-P.J.~t~ .
GESTA'TlONAL TltOPHOJJJ..Asnc -.mX>il:'ASlA hydatidiform,mole. T,he presence of:pateitUW~~
,...,.;,._ ' . will ,l;iistia~\,li:sh )t ;fr<>m . a non:--:.g~$tntl9,na:l
.';~Tfie'~tt.rtn::ge.stational ~ph()b~tb 110ptMia . chp~cihorp~ y.r,ijlch_wru.-.~av~~-~~~~;~~at
(G'flffleil~~vassesth.espee~-.of~pl)vh1astic . reflechs.that of the ,h ost. . - ,.., .. . . "'";~..
- dise'as{:s :tht:tt~e: ip~y prolif~tive With the . .- . . . . . ,~~;,;_::. ; _;~~;_,:.
abDit;y to invade normal. tis'Sue and the potential Among GTN s, it bas been quite.;ql~l~-~t>Wn
to .-st?~d l?~~4e (>f lli,~ ~~:--.)~ _.iP,#.ml:.$.~. that the clinically antectdent pre~ is.. not
ch6n~on:ill., ~\ra$lv~ - :Ql<>le, .PJaee*~-'Site always the causative pregnancy. ln studies by
Ti6D'fi()'6)istrc:1;U.P,iorwsm-:ancf"Epif6:~~limd. . Arfui~ et al. and Fisher; et al. the ongm oU:he
Tro~l1ohlastic~.~um-:o~- (EU~. -:~-Ge.st'Ati()nil-.. tumor. was c.firre.re-nCrroffi fhaT of ihe a:nt:eeedent
tn;>phobtasti neopla;si.as ate uriiqu.e .in the ,s ense . pregnancy.
thafone carl diagno~ the presenct :of mal$.gnancy
and in-stitute .chewotherapy even without the . Patholo!fY ,...
benefit of ~;t histopatholo$ic ~o~is. .A,i.tho-ugh
these tumors can tapidly progr.ess to a fatal . Gr~~sly; ~hori~aici,'n.o~pres~n~sa~rlecrdtic
ou1come ifJeft untr~ated, trophobla$tic neopla$ias he#larr4~~c masse~> or nodules.'.in. ~e uterus
are cural;>le evenin case of dissem.inated dise:ase. (Figures 35 ..9, and 35.10). Lutem -cysts in the
ovaries are present in over one third .or cases.
Chodocarcino_ma Mior<:iscopi~al!y, th.ere is: :;m .exub.erant
' tt:op.hoblas~ic gt(>w't'h a nd lack or' Y.lllous
Definition arcblt~ture, 'with a propensity for invasive growth
and. fle~osi~ or. blood vessels (Figures 35.'11 and
Choriocarcinoma is a pure epithelial tu.m or ~5. 1~!: :: Th~s p~iqul,~r .la,ck :of vi}lous patfern
composed, of syncytiotro.phoblastic. and ~e~entiat~~ ~h~~ocar-ciriom~~rc;>iri ..Uivasive mole.
cytotrophoblastic cells. It llla:Y arise. fr.o1J} or -~~r ,c<'Us insm1J;:tte themselves .slnSJy~~: in
accomparty any type of pregnancy. .Th~ antecedent mas~es- am.o.ng host. tissues, sometit}:le~eplacing
pregnancyis hyda:t;idifortn mole in approximately the ~ative, constitu~.n ts oftll,'e o~~- hl ~ch they
.50 pet~nt . of patients, _no.tmf:l} pn;gn~cy iri 25 .arise. The tumor has po int-egral vascu~.:.Stroma;
percent, and abortion or-eetopic _pregnancy iri ~he -it.obtains nourishment by invasion of%atefrtal
other '25 percent. blood ves5ets, and subsequently spreads through

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 !

54b SECTION V: HEMORRHAGES !N PREGNANCY

the .hematogenous route, It may exhibit distant

metastases without a trace of r esidudal disease
in the u~s, wher~ th~ primaiJ':le~iOn: o~ted.

...

~ ::JS.t~ ~~:vii:~ ~~~9n~.SliowiJI~

~~obl.asts m:vadin~;fue;nlrof.?etriutn. .

.....

~ - -:--- .. - ' ' ' -~ , .,, ---- ~ - ;" - .- .. ' I,,_ .. ...,..._ _ _ , -- " '

~e ,35;12; Wim.P<fwci":V.iew.:ofaChb~o~ NOte

the h~~-~~;:.n~d~ ~tl\.ptqinirient n~ .or the
i.qvadingtrophobli).sts. r

.There is a histologic simli~bJ .between fhe

tropht>blastic pattern found at the placental site
in.early .p regnancy and .c horiocarcinoma,.andthls
sometimes leads to errors in diagnGsls.

Clinical Behavior

The mdst comtilon cliilkal .pr~seritati 0 n of

.choriOcarci~oroa i1> irr~gular Heeding which may
p resent as. :uterine subinvol:ution or-.puerperal
blee<ll.rig e 1Y :iri t:he. d'isease.'p tocess: HoweV-er:; ..
. ' . .. . . .. . . . .. . l , the iiiterval mayalso be years from theJastkn.owil
Fi~~s ~lo . .Close-up .\tiew:or .a:chdriocaicinor:n,a.with
.ser1;>3al rupture near the.entry ofth~ left :ranopian.tuOe in.to . .antecedtmt pregnaricy. Curettings ob~ed.ln the
the uterus. . mana gement of such bleeding :.tna:y not ai~~s

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 CHAPTER 35: GESTATIONAl mOPHOBLASTIC DISEASE '541

yield pathognomo.n ic tissue fragments .

Sotnet:iples, these are interpreted only a$ ...retained
pnx\ucts or "sl,lbinvolution of the placental site.

Me.tasta<;~s occurs early :L'l the .course of the

disease. The mos t c<;>mmon site of metastasis is
. the lungs (>75%) (Figur:! 35.13,~ foU6wed by the
vagina.(500~). Other sites 'o f metasta~is are the
Uvef, brain (Fig-..Ire ;35.14), ovaries, intestine~ and
kidneys~ . Hence, choriocarcinoma ,may , :p resent
~an isolate4 fUlding ofdistantmetastatic dlsea$e,
s,gain observed either imniediate ly att.e r a
pregnancy or delayed by a long interval of t:lme.. Jt
- ~9uld therefore be ~uspected in a ny woinim in
t4e reprpductive;year.s .in whom there is a bleeding ' '
. -Y.aginal ms,s s , hemoptysia, or .neurologic
manifestation indiCating~ pulmonary or .brain
metastasis.

Diagnosis
. . . .. .
Clib'r i6carc moma loiown :to a ppeat..Without is
w~~!lnd, to follow a devastating :clinital C()u,rse,
''theieshould be .a high.index cf,s "tlt:piclon to.avoid {~11~ : ._..,.
delay and .e rrors . iil diagnosis. All cases .o f or seems to b'e d elaye.d . . ,The d~agn6,Sis . of
hy4.ijqj,form mole .should. 1>0:-regai-d~ ~s potential gestationtil choriocarcinoJ:Jlla should be eonsidered
o ases''10f chorioarcinoma. such that :c onstant in .the presence.QfE4&y oftheJcillowin~ , ::.;: ' .
follo~'\W: is, mandatory. .-_ . ' . ~ ..~- :.~ ' . .~- .-:~-- .: -:~ti~:_ ;-:~- ~;~~~~i :' -~ ..
1 . Hemotrhagjc nodule in a:piileen.ta;r.i: ~Ji:4>
Jfi1il:ot: preced~d by . a mola,r pre.gnaney, . 2. lnexp~~bly hydropic .fetus or ~~ed
gestaH.tm.a l chorio~ci.Jlotna should . Alw~ys ~ anen:ua m th:e lleon.ate; . . :~ ~ : . .
considered when utetin~invohitiond6es-tiot6Ccut 3. Sotld a v.filous Wph<;bl~st Jound in 'U terine
-~ow.... . , - - - - -, - ~ ----~ ..... .. .... . ~ - - -"-~

. - --------- -- -
.. -- - --

. -- --- .- ----- - - - - - '-::-- _ ,

. . : -

____.,.;.:-- --- ___ ,,_.. __

.e:ureltmgfronowmgaelfver.y;~and
4. Pr.eseni: 'ofViabie aVflioiis"tropliobiaets more
.. than 2 weeks after delivery

Treatment

1. Ch emotherapy

Chemotherapy is the princ ipal mode of

treatment. Surgery is an adjunctiv'e treatment in
addition to ch:m'lot.l)erapy, a nd is performed for
speci!}c indications ;

The .chemotherapy to be ,given to each patient

is b ased on the cla s s ification and s t age the
di s e ase. Ha mm ond fir s t p'roposeq a n ew
categomation in 1973. Hesuggested that the tenn
"invasive mole and"choriocarcinoma... ~~eplaced
beeau se these tenns t ended ;to identify ~parate .
a
and distinct entities what !s truly sP,:~ctrum of
Figure 35.13. Chest radiograph shoWing cannonball lesions d i sease. His Classification treafed lhN as a
on both lun g fields. spectrum o f neoplasia and allowed identification

Seanned lly: C
 : 542 'SECTION V: HEMORRHAG'ES IN PREGNANCY

cf high riskfll.ctor:s :in.thls disease p~s. Thus, the risk factors were repla~d by the :.risk factors
one was able "tQindi~d.ualize th~rap.r:~~; -thereby scoring .system adopted from W-orld Health
treat.a:~patie:ti~ more ;app~p~tely. Smce Org84.iza.t;ion (WHO) scoring system. Thus, the
the~, there haV'e been se-:Ver.al... -suggested basic FIGO staging of disease, Stage I, II, Ill and
mod.ilications ,and staging propo:,;.sls. :In 1'983, a N was .~tained.but the .risk facto~ were replaced
Wot1dHealthO~tion::.t4:4..Y-:gtoup,_:composed by.the mGdified WHO scoring system now known
of sd~nti~ts and
:i.I}ves~gittor-s :mvolved in the as th~ FIGO Rrsk Factor:~co~g System {Tables
st'..1dy of$e U:-op_.4pblast... ~f,id~.P.~d.:a-modtfieatio~ .. 35.3 .& 3.5 .4). Jn this s coring syst.dn~ the
P.fB~gs~we~s. -~-~:iio/~~Q. . ~~:~6sroting . ,ha'J).ges that .w er.e :agreed upon were:
syste~: id.~ntifid :~:ip.~ .:~cto~_ wifu:29 varia"ble.s :1) e~ation riftbeABO blOoa.grcups.r lskfactors..
{scwres) . .~di:y~able W~S -~l"!gJJ~8. -p.\Ull.erical B,pp 2) 'the -~gntqe of liVer meta.stasj_s ~from 2 tc
=scoiin.g:Oi 1, 2 .pr:4~ Tb.e.'tot~:t~,-~d.entified the ."!:he highe-St risk group 4_ the pati~nt~ stage and.
.patfentas.JbVfr~s~ ,{C:it-),)ru4di~ rli:~ {5-1)~ or~ risk score :wits ~ be ~re~sed by ass)gp,ing a
ri~k ,(8 ~:~d. :~~ ._t.;,oW.:;ri.#Pa:tieP:t:J..wre ~en Rottl~ riuin<?Tiil fo tlle s~age J3,nd an Arahic
s~@e :~e#~~~n;W:ther.&PY.~Yihlle ~?,.dk~bi~ nwneral :to the -tisksco~ separated by a colon.
risk p~ti~n'ij .:i{.e:~e. .g~~i). : Jil~tip~e .agent : The :middle -ri$1< ~t~gory was elinllnate<l. Ri.s~
chemoth~P.Y.~. 4~~, Int~~~c?AM Fe4;e~tion of scoring was diVid61 into l<JV{ risk with..a -~re of

r$st&!iflli~ :.:::~:::::::7wmore
W)th ,~wJ:!P..tal~~~gmg;. .' T.Wo ,~osti~.factors . . :. . : .
.. . 'fb.Gii)?'"-~PO;.~ :nlW/inlli~~~~t.fQP.rt>h,disease. ~' ~sTAGE:f : ~~:tothhi~s . . . ~ : .
.... .. ... .. J9.p.~)~en;:s4'c.:-Piont'is..:'fx:';).ri+:"~~tion~'.Of...<th~~:. f:"~'GE'Jl',';)l;k~~a-a~~u~~fllie~:Uter\i'S~btit"_'
~ent,~iegp$q}.._were..~<?ljrd~,cbased~;om: v . :-: . . . ... ,:.~ ~.o,tiie~~:or~il~l'
.Jlle -w...om.menaati~n~ ::of.vnany,:inv~tiga.t.,:r~.., STJ.~.ur ~~~--~~ras~:'' . -:

.
.~~7:.r:t~~~~;~~#~=:~~ .. ;Sf~Q~IV:,~:.:~-~~-~s. ...
~~~~6J:i:li}~t~~ef.~pf1.~1?~sti~j:i0i~ ;~~Ht: . . .. . . -. . . .
i~ .:~S;c4;~?~~"1~~!J:l~~~~;#~~~~:~' Table"!!S;~: : F!:G0'2000..ti$1C.factor seoting sys~

:=;si~~~~~~~:! ~, ;~ l~RE~
_ .. __ - - ~ ~~- - -- - - - a
. . -

Age (ye:an;)
A CQ]l.lP.~,on and. ar).alysis..9f the different
Ant~t
_prognostic fu.ct9~ ,sbowe<;f. :th~f Brew'~-~~ was
the stronge13t of..t heprediqtor,sof.sl.irVival outcotoe
. :Pre~. . ....i:~
.Abortion . ..
wo
"Prcg.n;._I:.~
n-~{ .:.~~~.:_C~::::~
followed..byth~ ~ring:Sy:Stern;: as C;9inpa:red
tothe ~ditio:nal HammO"n&Ciinica1.Classifieation
System ~4 the FIGQ S~ging. .-..Vl.Ull'>
. .....l .: .. .. - .<.-. .: :..
- .,..
._.. -
<4.t.P :<.,7 : . ~t6
.
;:1,:~ :_i :f2
Betah~1Ilt~: .: . . .
. (nliU/ml} '; . :o<:i 000 :1 000 . to;OQO:. >lQO;"ooo
. . S~erhl mvestig3;tor.s, :based on their :s tUdies, . ' . <io;Ooo . <1(;0;000
na:v.e ..prop0~.<il tP:e -actoption :of::the \V:UO Scoring
System; Witn .sey.e~ mQdifie&.tion~:. .On~ :~po sal
was t~ sunp.J.uy the clas~ill~'tio"n irito low" zis k 3 td <5
{1-7) andhighri;k{8and abov:e).<;ategt:>ries.morder
Sit~ of
'to .avoid oveljreatment of .mictd,le:.ii.~kpatients.
. ..:. :...
nietast.ase~
. . .
Spleen; GFtiact .: -..UVer,
kidney "Brii.ti
In S_yptember. 2000, th~ Cance.r Stagir}g-) tnd
Nomenc~atur~ .C{Jxp:m~ttee FIG-0 promulgate.d of ~!i~::_. .l-4~ . S-8 >8 .
. ..
_signifi.~t cAan.g~s to th.e ::c~sifi~tio~ system.
The obj.ectiV'e. was to ~implify . the prev1QUS . ~~Qthera.P.Y. Singl~ 2 'o.r more
agent : ~etitll
anatomic.FIGO staging Wi$ .its:risk'fac~qx.:s .denved
i.rl 1-991 and to re_p lace;this :by a classi.ficaijo~ in Lowris k < 7
w4ich the basic.anatomij: sta~g was r:etained but HighRisk ~7

Scanned 8y: ~
 CHAPTER 35: GESTATIONAL TROPHOBLASTIC DiSEASE ' 543

a.. Single Agent Chemotherapy b. Drug Combinations

In the. Philippin~s. the Philippine Society for All stageOIV disease as well as stages II and Ill
the Study ofTrophoblastic Diseases has adopted high-risk 'patients (WHO scores >7) aie giv?n
a national pFotocol for the treatment of all combination chemotherapy every 10-14 days until
Gestational Trophoblastic Neoplasia, based 6n the hCG titers be~ome normal. Three clean~up
. 2000 FlGO Staging and Risk Factor Scqring . courses after the first negative hCG titer are given .
System. .All patients With a diagnosis of ~rsisten t to ~gh rl$k patients ..
trophobl~stic dlsease and "'gestational
trophoblastic neoplasia should be staged and Several drug combinatibns have been tried.
scored accordirig to the FfGO 200.0 staging and The first drug .combination that WM developed
risk factor scorhig system. AU p atients with .s tage and widely used was the MAC regimen which
I disease as well as stages II and m patients with consisted of met."lotrexate, actinomycin-D) ~d
~low risk Score receive single agent'c hemotherapy cyclophosphamide cr Chlorrunbucil. This is a five-
in the form of Methotrexate given e\Tery 7-10 days day re~eil, with the drugs given in c ombination
or Actinomycin every l0- 14 days, Until hCG titers on ilterna.tirtg days. 'Howe'ler, surVival tate With
beco.m e normal. Two additional C;}'Utses, called. this re~e'n was ohly 20.-80 petcent.' Over (he
clean~up .~ourses or cotisolirtD.tlon. therapy are paSt years,_ several iJ:ldepende.nt inv~stigatQrs
given :after. the first negativ~ titer to en,~ure have <:l.emonst;rated the sup:edority.o fthe EMACO
.ct>mplete eragieation of-.... the disease. Certain regimen over other dt'1lg cotnblnationa {Table
p~\ltlons ~ .ob~rv.ed before e(Jministration of 3 5 .6). It is c;urrently considered the :drug
th~.iQnig.= COtnplete blood oounts With special -com bina.tiori of choice for !ri.ost<high riskjP!t,~$nts .
emphh.sis on hemoglobin, peripheral coutit,~,d . :and one"ofthe most effectiv.etreatmeri~forl:lifug-
plateteF &unt, .i.iver lin4 renal function tests are resistant ,patients. IP. the small grop'm~attents
.requited.b efore jnstitution ofchemotherapj:(Table with EMACO-resistant tU.mo1"3, severel' Ci!pli(tin-
35;:5);...,Chemotherapy .is also discontinued when .base9 have been .used witP, variable x:e~n.);~ts.
toJdany (ievelops; SUCh as When the helllOglOQin, Among these regiine~s, .the EPEMAd!l :tb:~:~!P.en
whit~,:bt()o(l :~U$;'and platelet.count go.down to that has been w1dely used . T:h"hf:~dr:Ug
crlucrul~vel~. or the. liver fu.netipn tests elevate to combination is basically the same as!.the$-GO
mbret:lUuls tunes the norm:al. Ashift:to.a nother regimen, exceptthat cisplatin and etosicre arc
.chem<>th~~u.tic .t'~gim~rt is warranted lri the substitUted for vincristine and cyclophosPb:arnic;le
presen~.. ~L~IL!:~1~~~-~~ . ~i~,~-- .Pl~~~~~Jng ..~r on Day 8. -
risjgg;J!QP leyels for 3 cons~QutiY~Ye!~.l.';t!iiilatiQn.s,
or. the appe~~e ofn:ew ni~ta~tatic sites.
Table ~5 . 6 . The EMACO regimen.
' :
.
.
. DAY DRUG DOSE
Table 35;5. Requireentstorepem'Otherapy.
, . ' Day 1 Etoposide 100 i:Qgfm2 IV drip
Baseline .Studies.Before E.a cli boutse\of Chemotherapy Meth9trexate l00,Qlg/m2 as IV bolus
follQwed by 2 00 mg/m2 as
1. Serum hitman chorionic gonadotrOpin titer in:fuaion over 12 hours
2. CoQlplete blOO<l count with differentiill and pl!ltelet count Actinomycin 500ug slow IV
3. Renal profile- l3UN, Crea Day 2 Etoposid e }.00 r:ngfm2 IV driP .
4. Liver PrCffie. SGOT, SGPr Methotrexate 100 m,gfm2. as lV bolus
fciUowe~ l>Y 200 m,g/m, as.
5. Urirtalysis inf\islon ov~r 12 hours
Actinomycih SOOug l!low IV
Precautions: Therapy is not initiated when Folinic Add 15 'mg.IM every 12 houn for 4
1. Hemoglobin< 10.0 gmsiL doses to start 24 hoUra after
Methotrexate IV horns
2. White blood cellcount <3 x 109/L.or >10 x 109/L . . '":r.'~.
3. AbJ:iormalliver and renal profile [)ays 3 _7 .RE.~ DAYS (No drug ~s given) ,;$'
4. Presence ofuncontroUed concomitant infection . DayS cydophosphaniide 6oo 2 rv. Jri~
mg/rn'
5. Performance statusIese than 2 . . VinCristine l mg/m~ IV bolus .

Scanned 8y: ~
 SECTION V:J4EMORRHAGES IN..,PRE<?NANCY

. .. ~-
2. Surgery titers have become negative. If the uteru3 bas
not been removed, ari.. ultrasound is requested
The s~cBl appr'oach in the p:ianage.nwnt of every 6 moJ;l:fus. Pr~gnancyis avoided for two years
gestatio~al trophqbtastic neopl~sia has always after normal titers ha~e 'Qeen attained. I
.been ctJntroversial. l-J.ysterectoy in.women :who
J;ave no desire for future pregt:la.ncies 1s done more Prognosis
fr~quently in developing countries where the cost
of ehemotherapy c.9.ll ~ pro?ibitiv.e. Rembval of . R~missicn rat<! of low risk G}N is 100 percent
the utetus may :.decre.as~ the number of using single agent chemotherapy. For poor
. cheinot:herapyco~s z:e<iUire9. to bring pafi:ents prognosis or high risk OTN, .several investigative
:to .te.mi3Sion. IUs. hlsqJnilicated in the pr;~rtce .stud~es give a range Of 60:.80% remisSion .iate
.of. pri.IO.duy ~~~arts in the :~}vis, tumor.perforation dependi.ilg on tJ:le .s ite .a ri number of met:a.stru.>es.
leading to.. ~ ,a(rut~ abdemen; uncpntrolle'd ;';
bleed~g. -diug.TeSi.s~ce. '<>r."raih metaS;ta~s. The ln~si-v-e Mole i.
~me :vasculari-ty o f thetumor, :may uecessitat~
:bilateral in~~ iliac at1;ery liga.qon t o :acllleve Definition
..J;l:ernost.asis or to a~oid. ~cessivt1 blood lps~ . .- Th~ . .
a:~.trati6n ~f pre~peta~ve methotrexate or l1;1vasive.mole (IM:)'is ahydatidifoLID mole .t ilat .
:~~~"D -~ aiso-:.Of :S6tue help "in twu~g has..'p,enet;rated.::o r 'irw~d~d deeply into fue-u:teiih:e
fue~~<sCuliuii;Yof'llietumor.-. .. . . . . .,.. wall, or has.:produce<;i"meta;>tasis, :o r bo~ff~e
. . ; . .. ): . .. . . .3.5~lS)~ ..Th~: m.~ority ..of in-vasive m:ol~.s~deVclop
...; ~1Jt9mY.;!fot}-;iuil.g{i!J.tastasht: i~::;~i:fO~ed ' . ..wi'tJ?.in . '6: i:J;l o'nth:~ .;}tO.S t:-til 0lar .::eV&'C'l:.~tion.
.'~-:-ro~:~~eP!;~~6tr1:~~d-:i~~u(}h':~(:. ~Ynt?;ii~~us,~s;~:c~tuioadenoma'(,l:.~trntns'~:
:t4epres~9f;a;spigle~m~$tai:i.C:l~i~.il';:a.n&Iow:.:, .::oi::: m~1igt1_1;\ht: PiPle; ::.but':ll;tv.a~iv:e .. mole:ia.:the .
leve1s.:A>Nl.Q':.: .. prciett:. termf~! u:sev ..

.~ . /~.~e'ty.~fo~~~'-;t~~~;~~:..htaii~has...._., . ::
... :~~~t?.una\~~'otP:Y.rto ~,te~eve~:it\tr.:a~raruaL..: ..
p~~.d.~!a::~~~i ~~~~-~as\a~dia~ijc.,~ . .-.....r
:!)roceaure. Ukewise-,~':va:gipa:l metas.tasis;' .in
tenenu, . ~oilla ~t--i~--~i>t biophled :$:8 this
.a m 16\.d tri"p:rOftrse :i:r:t.ttaetable bleedin'g.

3. Radioth~mpy

Ir.raa.i ation .i~/ctoP.e 'f~H 1iv-er and \>rain

metast.a.~is. at ~ .d os.. .Qf '3;0004-~P:OO <;:Gy in 20
. fractions g1v~n coricoinita-nt~i .viitb. sys temic
cb:emoth.~PY- ~(bri!r'irritala~on, dose of
xneilioifUatd-:is
;:>
mcreB.sea
... .
to t grnfnl?.
Follow-up

'serumor ~e - hGG mortit0ring .is. d one very . .

2 weeks up to thte~- n:egativ titers, 'then monthiy of an invasive mole invading
~gure : 35 . 15. Gro ~~.Pic:tur.e
mor e than hair of the myometriuip. . :. .
for 6 ~onilis, ev.ery_.-2 ~onths for 6 .months to
copiplete the. fi.rst year, then every 3 months for
. th.e..sect>!ld Y~~ then .evecy.6:mo'n t:hs thereafter~
Clinicalexa:mination is perfortned everyfollow: up. Pathology
If at thetime of:'completlng treatment there Is still
radiologlc evidehceof residualtumor .. further This. disease is ch a racterized 'by.e xcessive
radiographs are requir:ed. It may ~e 2 y ears for trophobhi.stic ovetgrowth.and deep penetratibn by
evidence
. of. residual
. metastases . Chest
. to r esolve. .trophobl~sti~ elements, ~eluding whole villi; into
the
'

rad,iographs are r~quested ev.ery_ yeru.- after . the. myometiium

. . . . and adjacent
. . structure.s such .as

Scanned 8y: C
l .
CHAPTER 35; GESTATIONAL TROPHOBLASTIC 0SEASE
the peritoneum and the parametrium. Depth <>f
penetration, as well as the ainou,:1t of molar tissue
penetrating the myometrium 'Vl:U'Y considerably.
Its morphologic characteristics rese:r.'Qle more
t.'lose of 9. complete hydatidiform mole 'thrudhose
of a partial hydatidiform mole. . Micro~oopic
findings feature large fields o.f hyperpla'3tic
trophoblastic elem~nts, with som~ villous st:rQma
in both uterine and metastastic lesions (Figure
35.16). Hemorrhage can occur from Uterine
perforation d~e to massive and deep penetration
or from metastatic lesions to the lungs, vagina
and rareijr, the brain. This diSease is genemny
self-limiting a nd net. as widespread a .s
clloriocarclnoi:na. However .invasive triole ~
prodUce! syti)ptoms which are life-thr.~tenmg.
such that active intervention by the physician is
mandatory.
Flpte 35.16. Low power :view of villi invading the
myometri\lfD. in an .invasive mole.
ClWcai J3ehq~b~ '
: Piti~nts: usul;llly present With pex-Si'~tent or
' irr~gular bleeding after the - ev.~cu~tion oJ
hyd~tidi!orm . niole. :.():ther- sQ.ggestive ~~gn~ are
${i;il~r '~r utet,jn.~ invol,u ijon, an~f plateauing or
mCtea$ing hu.rh<i..~ .c~orionic: cgonadotropiil (li:CG)
titer~ . . 1t i~ difficult to di.stinguish the :cl!'nical
presentation . 9f chqriocardno~ from .that of
inva,sive mol~. They 'can .-only be
differentiat~d by
,gross pathology and histopathology.
DirigTi<>sts
The defmitive diagnosis of invas ive mole can
be. made only by demonstrating the characteristic
Stanned 8y:
. 545
pathology in the uterus itself, if a hystereclOmy is
perfonrted. Curetta,ge may fail to document .the
diagnosis of IM whenev~r the growth is located
deep .i n the myometrium, and not ~ole to
the curette. On rare oQcasions, the curettings may
include :J>iece$ . of myometrium showing
penetration by villi and trophoblasts. Invasiveness
may be stif;;pected through ultrasonography
showing a focal area of altered echogenicity -within
the uterus (Figure 35.17). Doppler scanning may
reveal a focal area .of increased intrauteririe blood
flow.
~.aS.17. Ultrasound picture otinvas'ivefuol~'0wing
.a n ru-ea of.:a.lterW. echogenici.tiy at the fundal tU"Ca o.f the
ruyoinetr.ium.
Treatment
In :m ost instances, treatment is in$tituted
without the benefit of a histopathologic
confmnation. As such, treatment is similar to that
us(!d for choriocarcinoma. Patients are $taged and
scored using the FIGO 2000 staging and risk faCtor
scoring system upon diagnosis and following a
comple.te metastatic work-up. Patient~ with non-:
metastatic di seas~ as weU as those with metastatic
diSe~-s~ With tow risk score are giyen siri~e agent
chemotherapy .in the form of either Methotrexate
or Actirtomycin until the hCG titers regress to
normal levels. Two clean-up courses or
consolidation therapy' are given to ensure complete
remission. Those with metastatic, ~t~ risk
disease are given combination chem6t4~rapy in.
the f~rm of the EMACO regimen with thr'~ clean-
up courses. , Hyster~ctomy is il11itfcated:Jri cases
where uterine perforation with intraati,d ominal
~
 SECTION V: HEMMRHAG6S IN PREGNANCY .

hemorrhage has occurred. Elective hysterectomy
1s .also considered in patients who are of.W.van~
age and/or who have achieved their desired
nUJ.nber of chlldren.
Figure:- 35.18 shows ar. algorithm for the
m~agement of both chQri,oearcinoma and invasive
mole according to stage and .s core of tl)e disease.
. :'
occasional. mwtinucleated giant c ells. Chorionic
villi are present very rarely. It is thought to arise.
from the .intermediate tt.ophoblastic .~ Wbicli
funetions in implantation and esta:b}ishinent o f
the uteroplae:enu-J circulation. The ~jor. protem. .
secreted by thiscell is human placental lactogen
{hPL)~ It resembles .the trophob!a~tic inijltration
of :the myometrium of the placental site du.ring
early pregila'ilcy.

..PST1' can be distio;guished from ge,stational

chorioc.arol~oma by .i ts :monomc>rpbie tell
population, and lack o{nectosis and hemo.rrhage .
~-
(Fi~ - ~5.19 & 35.20). Iinm:un9histoehertlX:al
stud:i~(!.f ~emonstrate varia1)le ~ctivity. Withthe
maJofi:ty9f .cells staining pc>sitive :fo.r bPL (figures
$5.21 & :35.2'2). .

Invasive mole is generally a s.e if-limiting

disease, .although active chemotherQ:peut~t
intervention is iudicate4. Survival ~te~s,so.;.roo
percen~. Willi. the use of sequential singJ.e :a.,gent
chemotl}e~py.

P~c~iittil'~~Jte Ti()phoblastlc T.uxnor

O~finition
Pi~cerital :site tr9phobkstic tunwr (P$'IT) i~ a
rare ttophoblMtic neoplasm With .the pO.~entiaHQr
metastaseS,. arid death. lt may follow .an. abortion,
a molar pre~ancy, or a no:mal pregnancy.

Pathology

PsrJ' j~ difficlllt.to differen,ti~te pathol<;>gically

from .ti.. benigp.. trcphoblas.ti~ irtfuttation. . It is . Flgu~e 3s ..2ci. High power. view .of a PSTI' showing a .
cpMacteriied b y .mononu.clear ti:-ophoPlastic rooriomorphic.populatlon'Ofcells which are polyhednll and .
infiltration o(th~ uterus and its blood vessels, with spiridle.shaped and arranged in sheets.

Scanned 8y: ~
 CHAPTER as: GESTATIONAL TROPHOBLASTIC DISEASE
Ftpre3S.21.towpowermw~iPS1Tsbowingtdls~.~
.pcsiti'fe !or hPL.
Clinical Behaviorand Diagnosis
PS!T may c1inically manifest as a benign
l e.s ion, or follow a malignant course. !t may
complicate or follow any type of. gestation and
affects women irt all reproductive age groups.
Symptoms can appear from we'!l_cs to yea.-s after
tenninaUpn of. t,he pregnancy. Most patients
pre~~nt' with . irregulifr :v..aginaf 'oleedhrg : .o r
amenorrhea 1'\.CCompanied by \\terlne enlargement:
Rare presenting symptoms have been reported,
and include virilization and nephritic syndrome.
Metastases from PSTT occur mainly m the
.lung.- although metastas.e s.to lymph nodes, .brain,
liver, ..kidney, vagina,. stomach, and spleen have
been reported. lt is very difficult to predict which
tumors have the greatest risk of developing
Scanned By:
547
metastases. Levels of hCG and hPL have" been
poor predictors of clinically a~ssive behavior.
Some authors have recommended the use of
mitotic count to predict tumor aggressiveness,
with an increased likelihood of metastases given
a high mitotic count. However, mitotic counts
obtained from endt)metrial curetting,
hysterectomy specimens, or m~tastatic lesions
may vary widely such that using it as .a prognostic
factor for chemotherapy maybe misleading.
Treatment
The difficulty in d.iagno~is and -prc!diction of
the biologic behavior of these tumors lead to failure
in outlining successful treatment plans. A
diagnosis. ofnon-metastatic PSTT should be
followed by prompfhysterectozn.y. Me.ta~taticJ>STT
js om1ne;>us since PST'!' is .relatively insenSitiv.e to
aggressive cyt(>toxic chemotherapy. In su~ caSes,
hysterecto.m yalong with multi-drug chemotbetapy
in the formor EMAco od.!~PE;MA are given;~, ,$ erial
hCQ titers s hould bemeasured ov.er ~ong-perlods
of time beeause metastases have bf>~~r~~d
to occur a s late as 10 years after tlle ~inltial
pecum::nce. of the disea~; However, since little
. hCG is secreted, a . large tumor bur.den ..m,ight
: :already.,b e.present '.b efore :.th hctr'ievei~rare
detectable. .
Until more is known about the aggressive
behavior :o f this tumor, ~~ oppqrtunity fq~:a cure
wiii be O!~d by Pv.tb ea.d.Y diagnosis and
surgi~ excision of localized tumor.
Epithelioid Trophoblastic Tu_?:nor
Definition
The tenn.describes a rare and \inusua1 type of
trophoblastic neoplas ia that is dist~nct from
placental site trophoblas tic n~o plasias and
choriocarcinoma. It has features resembling a
choriocarcinom;)., s u ch that it was originally
termed ..atypical choriocarcinoma". However, it
has recently been recognized as a distinct entity
because many of its morphologic features are more
reminiscent of a catcinoma than of a trophoblas tic
neoplasia.
~
Patlwlogy
A.s tudy -of 14 cases of-epithelioid ti-opJibblastic
tumor (ETT) s howed that 30 percent were located
~
 548 . SECTION V: HEMORRHAGES lN PREGNANCY

in the uterine corpus, 50 percent in the lower :choriocarcinoma, ep~thelio~d smooth m,u3C1e
utrine segmentor.end<>cervix, and ~0 percent h"l tumor, and ke~g sqwuno~scell~
extrauterine sites, incluili,ng.the .s~-QoW~l and of~ cer:v.ix_ D~o?w is based on ~
lungs. Tumor size varied from 0.!) to 4.0 em. All . features and di:ffe;:entiatiop.. : -: . . .
lesions were solitary, discrete nodules tha~ deeply
invaded the ceiVix or myometrium; the cp..t s urface
wa~ dther solid or cystit;:.
. Ava:riab)e da~~~est :lliat llkel?STr:. Jttr'Jna.y
M~cr~pically,. epiti).elial turp._orsc-are npqula:r not~ re~nsive tp ;th~ .~PJ,.dth.~pei;ltic::ege:nts .
and generally weil..:circumscribed:. the tun:lo:rs are Used' in the treatment of otlter .-~ .:~f GTD:
composed ofa relativelY uniform population of '!~y~..erecipmy ~J ~~- .r~op. -~~ye. ~ .
mononuclear trophoblastic ceU.s arrange4 j_np..ests :s aceessful re$.Ults, . Ho~o/et. tb~. ~~~~ of
and cord.. Typically, a small blood vessel is iocateO. c~.,ttett~ge ;alld ch~!hbt,hera:py {<U;_~e- ~ ,of .
wit:lnn the center of t:Um:or .nest"s. early \ci>~ps requites. ftu'ther .6al~ ~ i
.J}"'hCG '1eV-*ls, althQugh -usua,l.Jy lov,r, have bee:U
Chorio.nic-type,intermed~ate trqphobla~t is the used S\,lCC.e ssfuUy to monitor 'tteS:tment for
pred<?lili.ni?Jlt ccli _populatio~ .in the ~pitbelioi-G patients With very low hCG levels. USing the ~
. trophob:~s.tic t_wnor. T~eY contain ro~d:. ~tm core ~ent of the hCG formcnitc=ing titers 'm ay
.n ucki an.4 . e&s-~opll..ilic . or cle~t :ey;to_plasm. be u~
sur.:olind.e.d by .:a. well,4efin~<;l c~il rilerill;l.nu;l~ ..
.G-em:r.aily. .the , ce;Us. are lp,.rger .than ~sfs
~~~:tiop~pyl~~ti~_-:<;~ll~?t $pJ;~l7f.. :Jl?;~.Il:~e: .. . . . .. . ,. .. . .. . . ". ~- :. .. _: ~ ..
unt?~tati0.~$it.-lnt~~tl:Qp~qbla:sP.c.-~U~-' .. -. ~lf.erally;:.Jhe~~l>ce~VJ:O:r.:<:>f~~~.tsl.~!to:
Th~;m.it4tie..ind~~ y.arie~;~P~~-0-Jo :9. ~th-~"pey ': . '~--:1~~~-P~:r:ience'isiW~~~U:&e,~:cl.Y:$5. ~
10 ..hig};l., pwer.fie~qs -~4:0} .:.wi~: an ~ve~ pf, .2 ha.V'e~-~~-,in~~:... thci~~~1y:
mi~:.pe.r 10. J:UgJv-=pow~r field~: . . . . 9enj.gn;. l{:t~stasis .'aJ!.<i ,-d:~~th ..-oCcf.r . in

::~~#.l#:~~~i~#9fhO~~~ti~~}re~j~~Ju_~~- ..:-=~~~i;~cy : ~~-~.::f~;-:.:.:~'~ ~:7~~ -~~~~~~~:.

2

bPI.., hCG .$~(~cl CAM~.cmlY.;f~);~~f~., .. . . . .. . ..

:in the. e.PiVi~dia ~or: "In one..series, :all tjle
tq:m<>rs w~r.e .. P<i~ttivc .fo.r- in4,il,)in, w.ith the
. : pei'.C.e~~ge ..1?f:.~poj>iti~e celis ran;gi.ng fro!il. .20
-~t-;t~-~~&.percerttt
Clini(Xl!Histot:y
Abnor~al vag-inal bleeding i's . the .: IJiost
commonpresentingsymptom . The age .o( p~tien'ts
range;s 'from. IS to -48 y~ars. The. antec~dent
pr~cies ,inch.p;ie full t~nn. 9-:eij.y;eri~:s .(67%)>
'Spdnfan~l;13. abbrt,ions, . (;1.6.~/oJ; and hyqatictiforni
moles (16%]. :hte i.ntervai~~tween th~ antecedent
p~e~cy_.a:nti ..t11~ dia~o $is .o f the t~9.r ~_g~s.
rr9 ni 1 to ta. (av~rage, 6.2) .years. : .i s the 1} subunit .t hat ,is, :actu<i:UY: mea~ anq..
Didgnqsis
:.Se;rum ~-hCGtlters ~e rtearly crlw~ys el~va.ted
-at the time oi diagnosis, although- as with PStts,
th~ levels are ~enerally low. (<2,500 mlU/ml}.
The differential diagnos i;> of. ~pith.elio'id
. trophobla stic w-mor. inch~des placen~al site.
trophoblastic tumoT, placental site .n od,ule,
H~'~ho.(i0nlc ('fo.n:4o~,il~ . . _.
. : :fi~~: cliofio~~-.:gfi.tw~9ttop~ m6~g
hit-vecy1nip9~r:ta.ijt~s~cl"G~I ~-as-<X}.':~yii
sho.hld be iri:stituted in .the pre&enee ofunu:sU.al
bleeding .a fter any-:tjpe .ofptegnapcy~ Ittlcts !l.s ca
perfect t'Q.mor m ar')cer (1:00% sensitivity) fot
mo.riitormgthe trcii.ttnent for :GTDs .for. -d~
H!Cll.I"reric~ of :disease.
. .
H;uman chorio:P:ic ,gt>~ap.ptr.oplil:n. {hCG} is
composed of two .peptides, the.:cr:-and fl ~bunils,
j o4led.non-'Covalently.. TheCtJ _subunit .h as qo3s
reactivity with-.o ther gonadotr.Opbic ho.-mon~ It
clinically Iinpertant in .fu.oni.to@g iropboblasti()
disease patients. I.n trophobW.:stic diseases~ th~
pdncipal SQu.rctofirnm~n..otea~ty in~ may
be the following forms of.hCG:;hypergly.oosylated
arid nicked or non~nicked f ree j3 subunit The
recogr}ized .gold standax:d:for.. hCG testiiig .is, tlie
hCG .~ :RIA.. hCG WRI:a dfective}y pet:tcts all-the.
.hCG breakdown products :Or .glycosylatibn
varianls. In recent"y:ear$, other1aporatories have .j
found that n.ewer .immunometric assays may also

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 CHAPTER 35: GESTATIONAL TROPHOBLASTIC DISEASE , 549

be. appropriate for trophoblastic . disease LOW-LEVEL "REAL" hCG

management OJ;" may even offer an improvement
as a monitoring tool for this disease.
The most coinmon problem enco~ntered with
hCG measurements in patients with trophoblastic
disease is low hCG levels, which i~ .n ot
representative of.the trophoblastic mass. This niay .
be due to the hook effect. ln such ca~es, a rej>eat
hCO aSsa,y using multiple dilutions may be done.
It elm also be due to the tise of an assay that does
not detect nicked or hCG C~lu1nine peptide. This
can account, in certain case~; for a high prop6rtion
of hCG immunoreactivity.
Phantom hCG
Another problem with hGG monitoring i~ the
oceurr~nce of persistent low-level pcsitive
resuits in the absenc~ of any focus of disease.
'IJUs is termed the phantom hCG cr false positive
hCG~; Metastatic workups of these patiei:llS yield
, negative results. despite the persistence of
po$ltlve~ titers, which are usually less tbruf 150 4 . Serial hCG titerswith an assay'tli:iur'measures
miU/ml. out may be as high as 1000 miU/mt'.
. This;l'p henomenon has been attributed .to
. het~rophilic a.nti~o,dies, which cau s,e .fais.e.
_: pQ.s~tive. results. This problexp. is. solved b.y defiiii-Qve .histological or ra(liolo~cai'~gri6sis in
.. determining the urine hCG, which yields
negative (esults, since the heterophilic
antibodies have big molecular weights which
cannot be riitered throug~ the renal glomeruli.
This refers tc>.persistent, usually low levels of
hCG f9dong periods of time. In such cases, the
JXJssibility of a phantom hCG is ruled out through
a negative urine test. Low-level "real hCG is
present in two groups of patients: 1) those with.
quiescent" gestational trophoblastic neoplasia, in
which low hCG titers persist dl!spite conth-ruous
chemotherapy, and 2) those v.-ith !lO histpry of
trophoblastic disease, where an elevated hCG is
an incidental fmdL11g during routine pregnancy
test.. In these patients, work-up includes:
1. Color Doppler flow ultrasound and a.'l MRI of
the uterus and ovaries to identify uterine or
ovarian neoplasm (annually)
;2. CT scan o.f the lungs e nd mediastinum and
retroperitoneum to identify ~ites of
trophoblastic tuiltor (annually)
3. MRI of the pituitru)> and choroid ple.xUs to
identify hCG proch!cing pituitary aq.e norria
(every 2 yeru-s) ' ...... .ft!)c;: ..
all aspects of the hCG molecule (monthly) .
. Patients with quiescent GTD'"Withput . a
the ;,tbsence of hyperglyci>sylated h'C(}~~otild be
observed with 'continuing periodic''''cliriiCa.l and
radiologic assessment and hCG titers~ THEY DO
NOT NEED CHEMOTHERAPY OR SURGERY .

PO!NTS TO R'EMEMBER .

Hydatidiform Mole

Hydatidiform mole is subdivided into complete . hydatidiform mole (CHM} and partial hydatidiform
mote (PHM} based on morpholog!c, cytogenetic, and clinicopathologic features.

Genetic studies in recent years have firmly established that CHM is almost always purely androgenetic
while PHM occurs when there are 2 or more paternally derived sets of chromosomes aM-at least one
maternally derived set.

Complete and partial hydatidiform mole can be differentiated from each other and diagnosed based
on the patient's clinical presentation, ultrasonographic findings, abnormal beta human chorionic
gonadotropin (phCG) titer, histopathologic examination and, when necessary, chromosomal analysis,

Complete hydatidfform mole commonly presents with signs and symptoms pointing to ll)ctrked
trophoblastic proHfe~ation
.
producing high. levels of hCG ' ;';,.: ~
..,:~:.
Any of the clinical manifestations of comp!ete .hydatidiform mole may._be associated with PHM, b.u t
they tend to be more subdued.

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550 SECTION.V: HeMoRRHAGES IN PREGNANCY

While complete and partlal moles differ histopathOlogically, cytogenetically and in clinical .~ha~.
managem~nt Is s(mllar and ~tncludes Identification and treatment of co-existing medical complicatiOnS,
surgical evacuation, followed by close monitoring of hCG post-evacuation~

SUction curettage is the -preferred method of molar evacuation.

Hyster~omy may be p.erf()(med In .Seleeted cases. While this. procedure decreases the.risk of loeai
recurrencelinvas1or,,. it does not-obviate the_
needfor close post-evacuation follow~up.

Hyst~rotOmy and _in<;fuc~on of JabO~ by_o~ocin o{pros~glandlil to allow expulsj()n are associated with .
incomplete evacuation, significant hemorrhage and a hlghedncldence of-postmolai' GTO.
Theca lutein cysts ere not removed as theSe r~ress spontaneously following normalization of beta
hC<?.titers.

Gestational Trophoblastic Neo.platla

The .di~gnosts of _G.esu:l~~nal Trophoblastic Neoplasia is primanly based on the clinical ptesenta.tiOn of
the ~tient_'C()uptedWiUt. a .hlgh'QSta hCGtit~rand typical findir.gs [In pelvic ultrasound.. HistpPathologic
conflmiation is -hot necessary. .. ~.

. In the:pf~nce :o f vaelinaHeslons, ~.io.psy,shou!d not be performed as.-tt)is wlil lnduce1or.rential bleeding. I

.~ . ..Cl~:~bt)tild~~:sl.ert;_t()~Ul~H~~~~~bii~typf;GJN io~ any:.ceprOO.uclive,.9g~ ~inan with: b-~~ .
n~s~~em:Syrt.ptoms;: po$tpartum-:c.:ereprovascularacide'ntsotradiographicev.idenCEi . ofmetaStaile
.... '. tumor of~uilkna.vrl primsry ..eMgin:

eea.~::!lla.ny. :~s.~ ::of.- ~w ar 'id.enti.fi~ :by Ctin!c31criteria an~ no :_paU\oJQSIai~diagnosis :eXistS, .

~. there JS~~ttte'iji$tiflclldn~t>e,~n tnva~: 'rtio1e and:honocarclnom<flrfterms ofthe.way.thattreatment
. .-,~l$!:f>~n~~;;M6.l1Nirtportin\\tliS.nttie~lype-~t- GTN'is 'the'accurilteand~rspidj:llagnosis$0:tbat :.
tteabn~
. . . .. .be.- ~dmlrilst~ted
. ' may . . . :pi:oJ"!'ptfY.
. -.

.All pa~nts.with a :dlagnosisof:ge$~ijonal'tt.optloblastlc neoplasia (GTN), wi~'1 :or Withouthi~topalnolo9~
fim:Jings;'strqutd'be stag~d :an"d~cor~ uslrig-the 2000 FIGO s~glng 'and rtsk 'f~rctorsooring system.
Chel'n()thertipy is the -principal rnode of tr-eatinenl Surgery is an adjunctive treatment in addition to
<;:hemo.therapy. and is. pe.tformed.for specific Indications.

Placental site trophoblastic ltlmor (PSTT) is arare trophoblastiG neoplasm with the p0~ential for metastases
..~nd;.qe?tt:l. Th~ tumorls CE>r'npose.d maiil!y.ofinterme.diate trophoblasts which sta'ln posltively'forhuman
pla~ntal .lactogeri.
of
The:difficulty ln.diagnosis and prediCtion .the biologic behavior of PSTT al0ng with 1ts rarity lead to
failure in outlining successful treatniEmt plans.
.. .
~ ~ Epithelioidtrophoblastic tumor is a rare type ofGTN that is compo~ed opr~c;fominC!ntly of chorionic-type
'. intermediate tJPph~blasts. This is a neWly introduced entity with only 35 cases reJ)orted in wor1dwide
: literature. Pending more experience with this entity, littleis known reg.arding the appropriate management
;_for ~u~c:as.es.
. .
;. Phantom-1\CG -refers to the occurrence of-persistent low-level positive beta hCG results in the absence
f ~of any foctis.of disease. On. toe-other hand,.Jow-level real".hOG is present in two:_ g_roups of-patients:
: 1) those with _qule$cenr gestation~t trophoblastic neoplasia, in which low. hCQ. titers .persist despite
(-eontinuous chemotherapy, .and '2) those with no history of trophoblastic disease,..where an elevated
~-hCGls -an>lncldental finding during routine pregnancy t~sl In bot~ cases;.chemotherapy or surgery is
not warranted.

Scanned 8y: ~
 CHAPTER 35: GE$1'AT10NAtmbPHOBLASTIC DISEASE
~------------~----------~--~------~------~----------~----------------------- .~~
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.app~ tq. pkgno:~ an4tfsatpl'~t. of.gesta.tio.q.&:l
ttopho'}?~c dis6g~:-emr:0pm9bstetOyD.e_i::ol'l9'93; 20~ k9hom.Et, ~e:~ewl-'100 ~O.'st,aging tU+dfiSJc{actor,
:!?{1}:.~91. .', . scorl:r).g,eyst~ .ft)r ~tatipzlal tropho):ilaStic,t:li8ease:
6~ .Dobkih'.GR-lkikowitz:&5,:G9.id_s~DP~~~teix):.~. D~Ption (lo_"l(!. Jihy~ iiMessm.ent, hit J Gynecol
. ,1 :h.:. fo ... ~ean:cc2D:01; U; 73::77. .
et. P.Jt: .p.up1
b
. -
l-i
. . D01,1 _~.;4traaqno:gp!p:.L;J: r:;~t.~t.. , .. ,....... :. .... 1:. . ;. .. -., . , ...-. .
. .. -!t?tl~b~. n~p~.J-~~p~:.~~-i99~;.;a 6 ,flj: :2l:'cole,M.nco:its :fi.ee;71ftib~and."-iu'lti~!ites..
..'14-16.' ~ . . .. : . RO~e5;in.~apd_troj>ho.b1a_<>tic~>.f'l~eprod
1, : ocl~ bf..Ges~<i~ ~;>'llobl.a.St,i.:_nceo:P.l!lsia t. Med 'l998l 43: 3-10. ..
... W t-~~6-.. :Yalf;J Biblt.lWt19:91} .{6..):}639~1:. . . . . . 22. Fi~ AA. 'et':ifu Ge~ .:~p@b1!i5i:!e di&:e~3e: .
8... tJi:aaia:~P.; cr
..~ ~a.sman w_.. ~s~n.~04ii .t:r'oPl:l
. _.. ohlasiic:: . .I!lOl~.and ~:Sti;@k'a. ~J.:Rep.roa-:M6a.;I998; ~ .
. 0JiP ~oo.l' -Pilb01;1\~:93; 1'2 '1.0.,::255 i :.';., :. ~ .. . 43~ 87-97.
, ~n~pl8.4iL. ..
23 .Cole >LA, et } i:L t!t$o/ of.-Co~ly.~:used_-con:le::ciat.
.9 .:~i!&-~~y:~%M4!1B':il>:.:~sm~w.
P.ro!.~ti~".ffl:ctoP~ .iA.;!?l:Tt.f: }.., .ptopo.Sedc ~ .stonncg
hl,lirlali~t:hlinom~,~'ddtct>:Plh~un~iri' thc
~~;~.~ti~m.~ar;Ui~ ~e:n~a: AiziJootita -ci.4tgn~sls--an4~h>ftr9pho1;i~c-:diseases.
oYD:eeol-lWJ,: .15~ :(2}:~11,-()lp. pllii'h~ ~Ofii: 47'{1): 30~3t5.

1t!. Dub~6<~fr;;J;_~~,t .S<@a~rlb:AA;Mortow~P. 24'. ~FihlieiAA,et a1. ~pus 4ydaqdlfo~ mok'lde:itified

,Mefaa,taqe :gec~tatl'!)~: :ti:oi)h:otilsti(; '<li:3eaa~: A ru~ the ?lu~yregnancy,of Ch~om:a.following
. tomp.8li.~6n' o( pi:6@:.ost!c c}S:&;~IDlelition )y~tei:na. F birt4.of D<;Jrmal. twins. 'Jnt J :Qynecol Cancer 1995; s~
G{'llee:Otoncof 199~; 45 '(1): 4-Q:-:45. 6'4:-7~- .

H -~-~ Y ar-0. l'J>erdd!>-Kiahi.scl:R ~miaiiion 25. Fj..~h,~-f~ -~r :a1. tk:s~poruil and n o~~g-p.tational
iat~afia:sr~~<ir.~~~t;e-fu.~itj k~rii4 tt;o:p:hob1asti.9~.~ dhtingu4h.ed by. D1fA II.i).E}lysis.
trophoblasti6 tumor. J R~roa ~.etl 199.2; ~1 :(5}: 461 - ~cer 1'992;, 69: 839-84-5.
465.
.2 6. SiJ.~ T, d al: .rd.eri:tifica,~pn of':the :J>tegr;tancy
12: Smith .I)i3, Holden :~;-, Newlatu:h ~:$ , :Bagoha:ve Yill. re~sible' for gestat;ion tro_phoplasticdi:seaseby o NA
Correl~~-.ti~m. .b etwe.en -clinical et~& '(F.lG0.) and aruU,Y~- Obstet.Gyn.ecol.1993; 82.: 629-634.
. .
. pr.~gnoetic g:r:p~ps with ,gest-f,1.ti9:na}. tr<~phoblast!.c
dise~ . Br J Ob~tet .Gynecoll99:); 100 (2); 157-1.60. 27. Ari;nilT, ~.t.e.l MaJ,i.gn.a,httrophoblastic neoplasms with
. . . ~~ent modes of.origi.il. Cancer Genet Cytogenetic
.13,. WW!jC Jr, Hunter VJ .ni.a,g:nosis and management of 1995; as: s-1s.
b~ ~eta.s~~ts for g~s.ta.ti9nai:tropho~ia:s~ disease.
~togyl99J~ s (6J:.48~so": 28. Roberta DJ. et liL Adv.ancee in the molecular biol ogy
of gestatiorial .trop.hoblastic &se.a se. J Reprod. Med
14. Surwit &\.Childres JM. High riSk m~tasta.tic. gestational 19.9~; 3o: ~01~2oa.
trophoblastic disease: A -new do s.ein~ensiv.e, .multi-
agent chemoUlerapeutic :reginiel,..J . Repro Med 1991;
36(i)~ 45-48. . . . . ..~ .. . . . .. : .

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 36

PLACENTA PREVIA

Definition

Types

:,,,. Incidence and Etiology

Pathophysiology

Signs and Symptoms

Differential Diagnosis

Management
General Principles
Methods of Delivery
Complications

Prognosis

Seanned 8y: C
 SECTION V: HEMORRHAGES IN ,PREGNANCY
.IJEFINITION
.. .,
. Placenta previa is a conditicn w herein the
pla.c~n;ta is implanted in the lower uterine
'se@llent N9rmally, implantation of thi! placenta
,~'in t;.he fundal portion of the ute~e cavity.
. Th:ls positi.on protects the pla.centa from
,m~cal forces that accompany retraction of
. :j;p~. ixlrometrium from the pa;ss_i ve into .th:e .active
.~~t bf t4~ l,iteftis.~U:iing pre~ey an4-'4tbor .
tli)l.s :per:n:,itting th;e piicenta to fun~tion
: i.mdiSturbed: ' . . ~;
.~~
.. .])~nclio.g
.on the r elation of the .p lacenta to
: :Uie;:ci!fvi~ .!Remal 9s, cases .of piacenta
previa
. ' ~~~~~ subdivirled into fol.tr Ga,tegories:
"i~~; .!;.if~tal placent;t . prev ia; T.he cervical os is
~::!~ :ili(>vered.-tompletely by1.-placen~ ' ...
. :. 2~>P'artial-~placenta.-: previ13.;, The''internahos', i s::, mUltipar,ity; Inilltlple
.....:~iiilly t.Ov:ered: b y-:plac.enfu. ,
. . ..
: :- ..~ .~_.
. : :...:. ~3~:~J4arginal.placenta -;pre~a.~ ... The edge..of,.the.. . Th~ str.o.ng ..a:S$ociat'i~n. bet'o/e en: plac~n4,; ..
. :.> :~ ::-:::.;.:fp 4icentais'i2cma a:w:ay.:from: 'tl:leintemaFos. ,
'. :. ~:~.....:::~!: . . . . .
.. 4; ~LoW-lying plac::enta. The pli;tcenta is unplanted
: . :.jp~ tb.e -lower uteqne segrilent such that the
: > ::ptacen00 edge -.~oes not r each th"e irtt:ema:l os
ouns:-:mao-sepr-oXimity t o it_ (Figure -3 6. 1)
.. "
,. . Tab~~ 36,1. The cla ss ification of pla centa previal. Total
~ . -."~ . .Parti3.13. Marginal 4-. Low .lying. . . . . more com mon iti. women over.35 years.
Although some distinction in outcome may be .
made among the different degrees of placenta:
previa, all are associated with possible life:_
threatening hemorrhage during pregnancy and. r
labor.
INCIDENCE AND ETIOLOGY
The true incidence of placenta previa. is difficult
:to detet.Jl'i41e With any degree of certainty hut
avera.:g~ ,approiitnat~y op.e in 250 births or:0~4
~~n:t:.~ . . . .
. . .
~~ the Phmppfn~. in. 19as,' phcenta pren~
was ~gnosed once.i."'l. every 360 deliveries or 0.27
percent. In 1991, plac:enta.previa. was diagnos
once in 93 births ot 1. 07 percent. This was .
attributed to theimproved .accuracy :)fult:rasoP.ic.:
.technique s in detecting; the placental site.
Tile etiolDgy of _p~enta prev' }.sl. js unknoWn. :
However., there are ~vernl {actors that infhieilce
the Qcc:linen..ce. of;phi.~rtta pr-;vJ,a; Th,~~ 'in~iude . ..
2
inqu.eq.abo:Iti9ns.~previ0#~ ..
~e<;n ,section.4 pueiperni:endometritis,5 ~~e.
6
p1a~enta and.aavanci:rig}natetnal age. 7
. . : ,
....
. pr.eVi:a an~ muUlp;tY''SU,gge!?'t8- .<tluH:previou~ : ' :
ptegnande$ "Pe~anently d~mage' :th:e
endomehium un..der)yi~g the pJ~~~n'tal iit~,
maJc;I.ng e-v..t::r.J su~b: ~ea. an uris:q:itable l.Ocaii6n .
. f9.r~lli~~ia~!!~~ -~~s~~i.E~ci~_:ru~_ .
vi~wis ~pported by t;heob.s erv.ation.fhat xtn1J#p1e
induced abortion s hav~ the simila;:- effect of
increasln.g 'the inclden:Ce Cf'placenta previa. :. .
. . . . ~
Singh and as~oci?tes itl~n:tified platenta ~,'
in 3.9 percent of women who had und ~r.gone.
ces:ai-e,an delivery:, Compared With 1.~ perceritJ:or .
the whole oqste.trial population. Defec.fi:Ye .:
:va scu1ariiation of the decidu a s (possibly a resu lt . :
of inflammatory or atrophic ch anges) appears to
be a major contributing factor to the developmen t
of placenta pr~via. Pa tients with a his tory -o f
puerperal' endometritis and lower uterinesCa.rs
are at ris k.
A large placenta, occurring in multiple felu~$
and fetal erythroblastosis, m ay s pread towards ~e
region of the intemal cervical. os increasing the: :
incidence of placenta previa .
The incidence of pla centa previa is' 3 .tim~s.
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 . CHAPTEft36: PLACENTA PREVIA 555
--~--------------------------------------------------------------------~.~.-

Two theories have been advanced to explain during the third trimester of pregnancy. Th;;initial
the occurrence of pl~centa previa. The first episode of vaginal bleeding occurs without
suggests that the primary implantation is at the warning. The patient may wake up in the miqdle
isthmic area of the uterus. The implantation s ite of the night and find herself in a pool of blood.
expands as the placenta g rows and various The amount .o f initial hemorrhage is relatively
portions of the loweruterine segment may become slight and rarely fatal. The ble.edirig generally
involved, including the intemal cervical os.
The ceases, only .to recur at unpredict.able intervals,
second theory is that the implantation site is
at which may be increasingly severe. The earlier in
the uterine fundus"' but because of damage done pregnancy the bleing ~pisode occur!l, the more
in this. area because oi previous pregn~cies. there serious is the type of placenta previa. Fifty percent
is ur..idirectional growth of the placenta towards of patients with total .placenta previa will have
the istlunus. episodic bleeding before the 20m week-of g~sta:P.on.
Marginal placenta previa and lo~-):ying placenta
PA'1HO?IlYSlOLOGY may not ble<;:d until the onsetof labor..The bleeding
in placenta previa is almost entirely external, L~us,
As t.~e pregnancy advances to tettn or at the its amount can be assess.e d with a rea~nable
onset of labor, the lower uterine segment is degree .of accun'l,cy.
retracted ot drawn upward. .As tllis r~t:ri:tction
takes place a.t the time ofdUa~tion of the infertial l>IAGNCSIS.
OS, there is SpontaneoUs premature ~paration of
the.pla~U;t from the spcrrgy layer ofthe declduas. A-presumptive. diagnosisof. pl~cen~ previa
The set)ar.a:tion of the placenta teat'S into the should be made with any episod.e ,o!PJ'Pnl~~!hini
matero~iJ~lood sinuses with resultanthe:ntorrha,ge trimest-er vaginal 'b leeding. Usefui'\indir:ect
from the spiral arterioles in the decidua. infcrtnation may be()btained by carr.UJ.bd,o,tg{~!ll
examination. In. placenta ptevia, the. 'liietus j3
After delivery, by either cesarean section cr usually soft; easily patpab.le, non-tend.erand~on
throughthe vaginal<route, excessive bleediiigfrom . contractile. in. 3 5. percent of case~...J:b~~ f~~~- is
the ..pla.~iltal' site may continue~. ThiS isc:tue to either in breech :or:. sh(:)ulderpresenutt;Wli;.'nf.i;the
the fatUhat the lowel" .u terine :segment; which.is vertex.is the presenting part, it is often.bj.gA~~ve
the more passive portion of the uterus, is the pelvic brim. Hearing the p!acerttal .soU:fiie,via
incapable of strong uterl,ne contractions. The the stetho$cope o r Doppler tranSducer j~st-above
interlaciligmuscle bundles cannot *choke. oft" :the the ~Jvi~ prim ~aY .~ ab.elp_ful findit!gin pJacenta
~~: y:~~~~--~t_ili.e .~it~ 9~.RiaC:i.!ii.8.1:1m!?~:ikt!9.n. p.n~Yia.... . . . ... ..... . .
$ome investigators indicate that the placenta in the past, the double set-up examination has
in placenta' previa tends to be :flat and to have a been considered the final diagnostic step in the
surface area 20 to 40 percent larger than.usual. management of placenta previa.u However-, since
In the placental areas overlapping the. cetvical.os, place:n tal localization ..can be obtained . by
. area3 of degeneration are ue~Cribed; ofte-n in sonography, it is rarely necessary. The
contact with old Clots that F.epresent the r em.nan ts . exa.nllp.ation is tarried out in the operating room,
of preceding epjsodes of hemorrhage.9 with preparations made for immediate cesarean
section because even the gentlest examination
. Notbeing covered by awell--developeddecidua, can cause;severeheme>l!ha,ge.The set-up includes
the lower \.!terine segment apparently Cannot limit the p resence of an a nesthesiologist and the
the invasion of.the trophoblast and in about 1 operating room team. The patient is already
percent of cases, deep penttnition into the prepared and draped for cesarean section. Digital
.underlying tissues occurs. This pathologic entity, vaginal examination is done . and the cervix is ;
"placenta accrete", is one of the most formidable ~xplored in aider to estab.Us.h the l~tion of the
complications in obstetric practice. 10 placenta. Double set-up e,xamination .should not

. SIGNSAND SYMPTOMS
be performed in women with immature1'etus in
whom delay in delivery is advisable.
. :1f
I
The classic syrnptotii of placenta previa is Placental .lo.c alizat.lon bjr t~ansa.b'do mi~al I
painless vaginal bleeding that usually o<;curs . sonography has become a .s tandard feature in the 1
I
I
I
1

Scanned 8y: ~
 556 SECTION V: HEMORRHAGES IN PREGNANCY

diagnosis of placenta previa. 14 It is best achieve procel:fure to compliment trai)sabdominal

by direct visual~tion of the placental edge in sonography in the diagnosis of placenta previa rutd
relation to the futernaJ cervical OS. The rates of it helps to exclude false positive cas~s.32
accuracy ,are as high .as 93 percen~ 15 to 97
perw-.;;ent. 16 S.!.rice there ar.e no markers. to locate Plcu:er.tal Mlgra!ion
precisely tne i.Tltemal cervical os, occasionally,
both positive and negative results pave been Plac;:entas in the secpnd trimester.are low-lying
reported. The false positive results were due to in 45 percent of cases., b ut by term, less than l
Uhiilary bladd~r <Uste~sion. A full bladder :brings percent r~ains low-lyit}g. 1.9 Se~en pe~t of
theOerVi,x into clo.~. proxinllty with the placenta. placenta previa :ar-e .a~)'m:Ptomatic, being found on
Therefo~. ul.tta~otrlc scru;.s in app.a rently positive routine ultrasonic scans .fc.r other indications.
c~ses sbo1lld be 11'ep~aled after emptyiilg the Placentas that lie close to th.e internal o.s ~uring
bladder. The mos t co.mmon rea:s ons for false the s,econd trimester usually will migrate up-Watd
negative resll1tsa:te positions Qfthe fetal head that towards the fundus as pregr..ancy advances
obsnre the region to Ute ~....I'V'ix andla:Uu~ to scan causing ~o clinical obstruction to the descent of
the lateral utez:lne walls. 'ti:mor..;'fritsch i;lnd the fetal presenting ,part. or the 26 patients
associates repqrted the, accuracy an~ safety of ~nea at an av~~ge ~f .29 weeks gestational age
t:ransvaEiruU sonographic placentall~tion.H when i ..~e placenta~ lay between 20 Jlllll ~~yfrom .
Several studies s'Uggest that t,he tranSvaglfl8l:route the intetnai os .~ ~o rrim of overlap. on:ty 12
is sa{~, ev~n ln women w~th placenta previa. pe.r.cent .required ce$&-e~ ;section, :for Pbwenta
De$pite the . J)Oten~ for ptob..:.iJiduced ~uma pre\14\ at~liv.ery. An 9vedap;pf >20 mm after 26
. to ~ the plaenta. .t hiS appro.a ch ha$ been weeks was :predictive:mf th,e need 'fox .c;:esa.~an
' d~~nsttablf':saf~: 1ti :'~r-ienee.d-:hands~;~The sectiblii~ " ; : . :. . . ' ~-
tn\.4sva~ . a,~p.roaeh {)tferil superior spa:tial
re~On.sb,ipbf 'tbC lower .p~~n:tal . margin: to the DIFFER&NTIAL PU.GNGSIS
mterrtal!eetvi(~al:d~ ih4be<~t'Uey ot Farine.eliit29 . . .. . ..
, t:nulm~,ul~una~e:s 100 pe~n,~:~nsitiVe : .' fhe.';differePfial :dia,gr;rosis :'it:lclude$; abruptio
::m, 1th~ .di~gt$tli ~f,: phiC'eliU~:, prev-=a.., J..n!rttu~ld . placenta.. }~,lpatheldgicle$.10'n$>in'the va~and ' -
and eolleaglie$'.bad~~~ ~ro~t1!*>$iijve ,prictive :. thettrviX/ ahd ;vasa previa. - . .
vruue:.for tiri~dWgnQsi;ng pbi1:1t'a:prma and
a .n_,~_g~'fur.~_:prtrllc..~vj; >YM\1.~: !d .~~ ~J:"~e.P~ 'f~t . .'l;o tule ou~:.~~R~~~~ . ~Sions. -in the ;Y..,._~tla
-..:-1 ii.,-:'"''" :"'':<cf>'H...,...d
~ , u.w,6 .U:.! ~~.ms.._... e~+' .. l,<:sl..m
-...!i9..!.UL:H. __, g
.....-..
H.~~ at .
~4. o~l_~m.~..g_~~ ~~.!.JE.~~J ECE!!?:~
.... $- ~-
oono~pby as the gold .s tandard for f ue diagnosis lesions, .v.a,~at lacerations, ;r.uptur~<J varices,
of j>'iacenW. :pr.eVia.30 many practitionen ~dv<>eate . specuhun
/ exam,i,nation on the va,glna a nd cervix.
~sabdotnir)al and transvaginafapproaches . .
should com-plem~nt each t>ther. h.t gl.'iem1~ Vasa .preV.i'a i~ a nu-e ~pm~yofthe uml;illical
~sabd~~al sptiograp.hy is petiorm:ed nrst. If cord resmting:from vela)ri.et<>~s insertion; in which
the platentil. is f Undal if.. t~tion :Of a pheerita the uD1billcat:V.ess:els ~~te in 'Ute m,embnmes
~ lS ct~y secil,, trailSY~at examirtatiqa ~.$edista;tict.:tc)rci !Qe .eclgeoHh~ placenta;23.the
is unnece~sruy. However, il:there is any doubt tp. fetal blood v~ssels cross the internal cervical os
theJelati~nsl:}ip ohhe lower plp.cental margin with and prese~t ahead of the fetal :presenlipg part.
the'ifiterhal 'cetvic:al t>s, a tdmsvagir. .al scar.. may 'i1le fetal.vessels may betom when the metnbi<!Jle
he done. . ruptures or by pres~ure from the fetaJ .head.
Vaginal .b leeding is bright red.and painless' and
Some authors advocate tr:a nsperineal coincides with ~e rupt:u te of membranes. Fetal
sono~phy.31 .3l Positive l"r~dictive value in U1e heart tones may be slow .and i.rTegular indi~ting
diagnosisohnmor degree l'l~;tcenta previa wa~ 8p fetal distress. Ab~ent fetal heart tone~ indicate
percent W ith ~sa~omirtal compared to 100 fetal. exsa!lwinations. A s.ample of the vaginal
perd:ntwith transperineais onography; though for blood clot is sent to t~e laboratory for
major C;legree Placenta previa both are in determination of fetal heinoglo.b in and blood smear
agreement.
. Transperinealsortography
. .. . .
is a valuable . may reveal fetm nucleated cells.

Scanned 8y: r-.

~
 CHAPtER 36: PtJ.\CENTA PREVIA
---------------------------~-~------~
MANAG;EMENT
General Prt~ciplu
.Women with placenta .p revia may ~ assigned
to the following groups:
1. Those in whofillhe fetus is p retetm but there
is no pressing need for delivezy. Expectant
manageme~t is ret::ommended with a Wget
date fot delivery at the end ofthe 3Th ~'k.lt
includes hospitalization. admi.ni$tratlon of
corticosteroids.. replacement o f bloOd loss.
ke~pi.ng crass-matched blood .J1Vaiiab1e for
emergency and bed rest unde.t ~lose
.obsemtion: Once the .bleecfulg :bas -su:~ded..
pa,tient may b roanagtd at home. pro;,ided
that .the pa;tient aild family fuUy. un~~~t:l
the nature"of her cortditio:n and that sb:e ltrust
..rem$ at' bed re~t with bathroom~$. ....
.ffhe;.AAtient ~howdlive nw ;(Jl.e~hospital and .
'. mus~'have reSources to ret1,ttn tO the ho$pib;ll
.inm1ediaie1y. In properly ~elected pati~ts.
outpatient tnanagem.ent of ..$ymp.toxnati<;:
.plae.~l}:t.a preVia ,apt*ars to be,a~ptal;>le
. alte~ative to traditional conservative
-~t mpatient .managemen.~ wmg. ~a!.
;..iha~om~th~o~tiottiia:l'$ho~no ~tfit
to inpati~nts as .oppo$cd .to outpatient
-:rtanagement.34 In their study .of 53 pa~s.
the~e Wt!t~ j)o d.ifferc.n ce. in nu1tc;~td and
n~f~~ :._tn()~~~_d!!-)' ~~~~~ -~~- :~,tLS!2HP~,
lP11?2an~:~~<?.Q.~..~i.M:\ien.!~L~e
24 and 36 weeks gestation .have reeurrent
episodes of bleedhtg wl.U\ .52 percent reqWrtn,g
expeditious .cesarean delivery~ . of a living viable fetus. cesarean section is 'the
2. lfthe pregnancy has re~qhe.d 37 w~.ormore
or -l ung i'I1aturity has .b een do~uthented by
amniocentesis. -cesarean s.e'ction is indicated.
3. Tho.se in whom labor is in progres~ and the
bleeding is minimal. Twenty percent of
patients with symptomatic placenta previa
have uterine contractions. Tocolytics ;may also
be considerfd in cases of minimal bleeding
and premature fetus. Sharma. et .a l. in a
randomized controlled trial showed the
advantage of administering tocolytics in
symptomatic placenta previa. The used of
tocolytics. was as.sociated witJl :signifi,cant
prolongatio'n of pr.e gnancy and increased
1n birth . weight without . causing' adverse
effects on the mother and the fetus. 35 36
Scanned 8y:
'557
..
Tocolytic .the.-apy in these cases d~.. not
appear .to have an impact on frequency or
severity of recurrent bleeding. 36
4. Those in whom hemorrhage is so severe as to
necessi~te evacuation of the uterus d~spite
of the imm.aturity of the .fetus. Blood
transfusion should be giv~n to keep the
patient's hematocrit to a minimum of 30
volume P<!rcent and one .s hould proceed with
an abdominal delivery. .
.
PLACEHJAPRE'v1A
Min!mal bleeding .
I.
...
'EJq>ecl.ant manag~nt Cesat.olan $eC!bn
, hOspital~ lion
. .
C9r'OcO<sieroids
.replace~nt a. blood Joss
bed re$t
..~ :: 2:.,.::.~;_';~;-~;f~ ' .
f J~; -1!..-'t.~i;~r,: ~:.
Methods of :petivery
L Ge.sa,r:ea:n. s.e ction . has -replaced- attempts. at
vaginal delivery for all but a mnall minority of
pati~nts with placenta: previa. In ~e presence
delivery_method of. choi'ce. The choice of
uterine 'incision can be made .finally ori!y after
the abdoni~n is o pened. If the fetal' lie is
longitudinal and ultrasonography doea not
show the placenta to be implanted on the
anterior surface of the uterus, a lowlransverse
incision may be selected as long as the lower
uterine segment appears to be well-formed. In
all other circumstances, a classical cesarean
section affords easy, atraumatic extraction of
the fetus. Ifthe placenta cannot be avoided. it
is generally best to seek the edge quickly and.
gain access to the amniotic .sac apd the fetus.
rather .than cut or tear 'through the placenta,
himself. .
2. In cases of marginal or low-lying placenta
previa. the need for cesarean section is
~
558 . SE:CTION. V: HEMORRHAGES iN PREGNANCY

predicted upon the .o s to pla'c ental e dge been successfully used m

dlatan~e and clinical features. When the
placen:tal edge lies> 20. mm aw~y 'from the
internal os, wcmen can ~ offered a trial of
'labor with high e;q;>ectation of success. A
distatrce of.~ 20 .mm Jr;om the os is
as.sociat~ with higher cesarean !lectiun
. 11tte .(4&A t;o .90%); altho~gh V?-ginal Miiv~ry
is still pp~~ible ~ependhig oil the Clinical
drumsta.P,Ges. In gener,a:l, ~ny degree Of
overlap after 35 'Yeeks s ep. irtdia:ti.~n for
t::e;sarean :~tion. 37
CPMPLiCATlONS
.PlaCenta. a.ccreta
This is ~trongly associated with pla~enta
prevla, occu#ing in up to lS percent of t ases.24
'Vbis aS'sociati~!l is .due tp th~ thin, P.oo:dy !otm~d
d.'eciflu;_ off.~ low~ ut~rihe ~gment, vihieh offers
little .r-esistil.:;tce to Q:eeper ' tnv~sion by. :t he.
~cptJ:pblast-:~~:u~uf$..Y.~~~W;!in,there;iS>.a , -l :~~-d~g\theJAs.t;,deeade:.:.-Indew;.~pJ.acenta-,:
ptevious :c~.sar~n -see.t:ion scar .. }'be d~k o.f
p'la.een~ac;;reta:ln ;thep~ce .'Of'ip,la~nta-~~~ ri~:~~stimce ~t .pe.rrriits t:b.eubstetrlcian
.in~~~- witn_lll~ nuirt~t .ofpreVious . ce~x~
~??n.. ~s,w,cenHor .04~1>riot~~~?~
and. ~o ~nt !or tw~ .ptiot"ce~:~p~:l&~
WJiCii :t;h~;-~:.P~tion.,:!3(th~,P.1aceP.ta is..:~Cit
and :it-iS.n:aitt6.,.cq~t:iol b1~gh.y'can~~liVe
measllie~, ~ .'hyster.f;Ctotny i:s 'u$1,lallJ' r,eq~
. teim. -~'pprQach:es;
Pf>st~;#~orrh:c:tr,.e . . m~ge~~iirhey(Jt+d'-fh'~-rtim-e -a-re-.boD.nato
~ ~O'Od' :to~'S m~y co~tim.i.e aJte.r -d~liy.ery
.follo:Wll;ig pla~W.removal. .Norma:lly, t:p.e ~1~
v e-sseb ~uP.p}y'i:ng t .,h 'e ~nter-:<.11lo,us .s:p a.c e ar:e
occluded. w -m.yomC:ti:f.d t:;Ot;tttac.fiot;~.$: The lo~.er
ute$~ :s~~~~t 'is '.o:rrl,y wa.J4y C9~traetile ~d
~y be m~ff~qye ~: heti:l,'0,S~si~. Oxytocin .arid
met'h:yle~gohld1/i:t;le m.ateat ar'e . . giv.e n
parentenilJ.y..2.3. fr<Ys:q :tglanain E; !iuppository h a s
controlling post~
hemorrhage due to uterine atony. 23 25 Ultimately,
hemostasis may be established .b y overscwing the
Placental implantation site, bilateral uterine or
hypoiast.ric artery ligation, B-ly:p.ch stitc~ or, a
total ab<ionllnal hysterectomy is done.z:J
In:tr:a:uteritt.e .( lrowth Res!:rictton
B~. etal. have-indicated tha t pl:acentaptevia
~:~Ol,Ult .for m~uterine groWth restrictiim.26
Bjetre, et ;U. reported in fheir series, that.t;he ;nlost
comip.on cau.se .<>flow birth weigQ:t infants was
pla~~ ~l'T .~rial .fetal l?ipmc.tcy pef.!G!Pled
f;VY two weeks .may be a
reasonable rn.etbOO of
scr~- for- 'thisj:>oten~ -complication. '
. .
PRQG:~OSI$
. Withi:p.tteasjng ~phisti~tion of rna.n3:g<;:.m ent, .
Itl.atetna.f.Pii>rta.iftyrS:tt$ :have been .redil.~ea from
25:~ent'i~.t .the ~ ~fthe century ~ le~s:-ilian.
.~~if~g~pro~tly~cs~mallrhaternal
tot;QJ:een~ on :~rlriatat ix;l~rtality. ~~~furity..
i~ .. t~~-. <Dil':jpr c:~u.s_7 .of : .p'erinait~. -.deatp..
Cl,rU:~tlm'~-s ;pe.r..JI!,.itt!n,g . it. is. :de~irable. .to
.. ,po'stt.9Ae ;;ij~ii.vezy. ~til.aftei- ..fe~..maturity is.
~~On t:P.& other.h~d, ~ee $-e proP,a.bility
of ~f#i' :h 4ptf}lage ~~r~s si~gmti~- fl.S
the ti~k of expe'tartt-
outw:eigh w'itl:l th~ bene fiis 9f <;;otithiiied
intrauterine. ~Stene. Wtth fue of :m~eniuse
neonatal tci;:hrtqlbgy;~-m:orl,ality ra.~ with
phit:e.n.ta -previa ct:iu1a be reduced to l es.s than ten
!J.erP-t: \>y ~owing the<p.Eegp.ap.cy to -cont4lue
u~til, t~~ :~$th to ~~th week or g~sta:tiop ?tld
r>. ~~tm~Jb.e P.r~cr. :J:nmti:d~~Lation
of th~ amniotic fluid .for fetal lung maturity' has .
been donf!.

POINTS TO REMEMBER

PlMerlta previais a condition Wh.erei.n the placenta i~ implant~ at the IO'Ner uterine segmenl
' .
Th_e etiolegy of placenta previa is unknoym.

Eactors that Influence the'occurrence of placenta previa'are tnultiparity, rnuriip[y-lnduqed abo:rtions,

preyibus -~sarean -section, puerperal endometritis, l9rge pl~centa and advancing maternal .age.
: ' . . . . . . . .. . .

Scanned 8y: ~
 .CHAPTER 36: PtACENTA PREVIA - 559
----------------~~--~~~------~----~~--------

Classic symptom of placenta previa is painless vaginal bleeding.

Fiftypercent of patients with total.placenta previa will have episodic bleeding before the 20" week of
gestation.

ln the past, the double set-up examination .has .been considered the first dia.9no~tic step jn the
inan.agement of .plac-enta previa. However, since placental localization can be obtained by sonography,
it is r:arely necessary.

Placental Joca1~tion by transabdominal sonography has become .;:1 stand<;1rd feature in the diagnosis
Qf placenta previa

The use of trnhsvaginalsonography has improved the diagnostic -accuracy .of placenta previa

Expectant management is reeommer.ded with a preterm fetus but with no active uterine bleeding.

hi patierits with uterine contr-actions and minimal bleeding, tocolytics may w considered.

.o ut patientmanageme~.-ofpreterm symptomatic placenta pte\oiaappaats lo ~ an acc~ptabfe.altemi'itive

. .,...,.to.tffiditionai.~Otl$ervatiVe expectant inpatient management.in car~fully. selected ,patients. , ,., .. :
. ; ,:: ~-;. .. ~-. .. . . ...~ , ....-~- ---- ...-;-. ;;.:....-~ .. :-:
;.,;~!>Mtl\e pregnancy,.~s reached term o; lung maturity has .Qeen.documentedby amniocentesis; -cesar~:~it'.t....:
:, ..::- section
... . is. ..:.d
. ~ 1ca
. . ted
.. . ,
.. ....~"""'-~-... ,~{~.,,-;;,::
.... .... -.\...i.tl~-~tr .
...... . ~:~ -~ --i--:-

: ...,,.,_-;.; 1~ ; .: ~- -~=~: _:.- . ,~:

_:,... ,.:;. -i:~-; . -- . -..
~-:;.: . ... .
. .. . . . - . . ;. . . _;."':; ;-~; - ~JJ.':'f::..;f.>":..':~

. -~ '
~:38 9. Greenhill P, Friethlu!.n EA; 9irilogical.', ~J)Qpl~s .&n~
Modetn Practice :of Obstetrics. Ph:il{jd~iplitil:~.WB
'

Saunders CO. 19'74; 415. . .,

1. Committee: on Nationwide Statistics, PoGS: Annual ....
H>. ~t'to.ll R~. ..~~~- JJ,., Paql RH, QWJligan-EJ. The
Reports-: 1986,1992.
.'' . .~n~~~. m.@~K~c:At<>.f riJ4q;l\~prey:ia.
.Am J Opste~ Gynecoll980; 137: 687.
2. Hibbci:rd LT. t>l.a centa ptevia. ln Selarra JJ .{ed)
Gynecology and Obstetrics. Vo12. Ne;v York: Harper &
11. Creasy RK, Resnik R. Maternal-Fetal ~~!iicine.
Row, 1981.
Principle$, 'Pnlctice. Philadelphia: WB Sa~n.ders Co.
19.84;542.
3. Tay\or VM, Kramer. MD, Vaughan TL, Pea~ock S.
Placenta previa ln. relation to induced and spontaneous 12. P ritchard .JA. MacDonald P, Gant NF.. Williams
abortion: .a population-based .study. Obstet Oynecol . Obstetrics, 18"' ed. Norwalk, Connecticut: Appleton
1993i 82: 88-91. & Lange; 189: 712.

4 . Singh PM; Rodrigues C, Gupta AM. Placenta previa and 13. Bowie JD, Rochester D, Cadkin AV; Cooke WT,
previous cesarean section. Acta Obstet Qynecol Scan Kunzman A. .Accuracy of placental localization by
1981; 60:367. ultrasoun~ R;idlology 1978; 12 8 8: .177.

5. Kruppel RA, D~kker JE. fligh Risk Pregnancy: A Teain 14. Gotesfelct KR, Thompson HE, Holmes JH, Taylor ES.
Approach. Philadelphia: WB Saunders Company, 1993. Ultrasound placentography: A new method for placental
localization. Am J Obstet Gynecol 1966; 19: 538.
6. Hellman 'LM,-Pritchnrd JA. Williams Obstetrics, 14~~> ed.
New York: Appleton-Century~Crofts, 1971. 15. WiHiamso!l i:>,
Bjorgen J, Baier 8 , Worman M.
l)ltrasonic diar;;,vsis of placenta previa: V!il\ft:
!-:c.~r.-
of post-
7 . Caldera R. Placenta previa. J Obstet Gynecol Brit Emp void scan. JCV 1978; 6: 58. ~
1939; 46:531. . t*:::
16. Jdfrey RB, Laing FC. Sonography of th611'ow-lying
8. Iffy L, Lnger A. ferinatology Case Studies. New York: placent a: value of the Trendelenberg and traction
Medical Examina tion Publishing Co. 1978; 309. scans. AmJ Radio! 1981; 137: 547 549 .

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 .. :560 . . V: H~RRHAGES
SECT_JON . .
U~ PREGNANCY

l7. Trimor-Tritsch.IE, Yunnis RA. Confi.rmihg:thesa!ty-of 29. FarineD, Pers hir DB, Timor Tritsch IE. Placenta previa:
vaginal scnography in patients oSus~ted pi placen:ta Is the traditional diagnostic approaCh satisfactory? J
previa. OhetctGyneco.l 1993; 1:742744. Clin Ultrasound 1990; 18:328.

18. Wexler P, GotteSftld KR. Early diagnosis Of placenta
previ.1. J Obst~t Gynecol 1979; 54-'231.
19. We.XT;er P, Go.tte;>feld KR. Second trimest~ pla~enta
previa and appai-t;ntly r:.o:tmal p!.a,centation. Obstet
Gynecul 19~4j._ .50: 705.
20 ..Cavanagh D. Obstetrical Elllergencies. Sprinifield,
Thoro~. 1961.
:21. Brenner WE, Edeli;llan DA. Hendrick~ CH.
Cbru:acteristics of pe.tie.ut:l with placenta pve-Jia .(Ulrl
resuluof!~t oi.anagem:ent. Am:J ObstetOjnccol
1978; 132:80. .
..
22. Pot D. Vasa previa. Am J Obstet Gynecol 1979;
134: 151.
23. Cuiil'Up~~ .FG, U:v~.no .K, Bloo.m s .. :H~ut-b J,
. Giistrapp, L, WenstrOm :te. 'Q:bstdrleil Bemohh:a,ge.
william..s.O~tetii(;s 22"".Edition, 2,oo~: 809.
:.
. :~, :,2<f-.,,.-B~9.l~~r ~Uj:~c~~.t-<R,;<~t:eg~~~.eA,,F~.~E-, . , .. . . ~~qii.. f4m.'~"(;Yb:;t:et;.Qy:ne<>cl"lS96~.J75.: 806~. .. :
~centa 9teta, in,creta.Mdpercieta:. SurVey .Of.4D
~- Obstet'Oynei;ol I9P;'.'4;3'-:49~
2:5. Hc:rtz .R, SaJW~R. bicker L. . Tre:atmentof ~~-tu.in
.-cu.te$e ,.anatomy .with prqst~glBn.djn E .faginal
. . . ..8up~t;qri~'3: 0bstet.Gyr+ecol''.l980;
.. . .
56:t'29~
30. ~tue1d RA, Gilber.U EC, Arnold MJ, Wladeniiroff
v":N. A..--curacy and safety of tran:;v!l.gi;:lal pl&cer.tal
lcca.lization. Obstet Gynecol 1990i 76: 759.
31. Daw-&00 W, Dumas M; Romanow, et a.L Translabial
ultrasonography an;d' .Pla{;enta previa: Does
measurement of the o3-placen'ta distanC::C predict the
OL\tcome? J 'Ult.rasound Med 19 96; 15:441.
~2. Rani PR, Haritha PH, G.o v:ri f<.
Comparative study of
tran:sperineal and t:nmsahdomi..."'lal sonography in the
dl,agno* of pl.acen~ previa. J Obstet .Gynaewt RetJ
2007; 33: 134. ..
33. Oppe:rib:cimer L, Holmes P, Dabrowski A. p iagnosis of
low lyingpla.Cenqi! can w gration in the third trimester .
.predict:'ml!cmne? U.Itn;!.S<:>und Ob~tet.Gynecol 200 1; a:
i6o. . . .
34, VIm; nA. ~:ul ~; Milla:r LK. Management of the
. ~p~otn~:P~~JJtcv.ia: a-x:~l!omjud controlled
. trlal :of..ip.p.atien:t versus cutpatient expectant
.. '
3$. s~ A, Suri V, Gupta L 'rotolytic..therapy in
con~....tntti\:o.~ent of symptoma tic placenta
--~ IntJGyn.e:<:Ol Obstet 2004;:84: 109.
.36. . &..ssiP.~ RE; Motililk CW .Paskiewicz LS; Fischer SG, ,
' .
'f.om.~ch .'Pd. Th~:~ect oi tocoi)r.tic use 'in the
~eJ;Lt of Sj=pto.tnatic .p lacenta previa. Am .J
Ohste:;t Gyn~oll99S; ri:2: 1no.

3t. 9l!ll.~h~.!:P?::~!:. ..~" ~-c_i_cjstx.~PJ Q.!LlLtet'x:i~j.a,n_s .a.n.d

Gyn~logist of ~da. Di.$osi;.s and managcinent
Zl. BjerreB, ~Jetre L Sigriifita:nceof<>bst~trjqu.factotsin ofb.l acc:nta .previa- j O.Pstet G)'n.aecol Can :;mb.7; 29:
progp~ :o f'low birthweigti qhlldren.. Acta ~ed,iatr 26i.. . .
~d 19,76; :~5: 577. . .

28_ B.r,cn:ner WE, Edel.m .an. DJ\, Hendric~s CH.

Cl:Wl"act'erl$5cs of pa tients With placcn.ta. ptevia :a,nd
. .reml}t:sof exped:aritm~ement. &n..J O.bstet:Gm~
. . .1975;. 13Q ~l.8() ;

. .. .

Scanned 8y: ~
- - - -
 37
ABRUPTIO PLACENTA

EVELYN P. PALAYPAYON, MD

Definition

!ncidence

:-- Etiology/ Predisposing Factors

classification

... ._,J,P~thology

.-~'--!'Sym:ptomatology ... .. :.
Signs and Symptoms
:t.. 'r.

Diagnosis _
Retroplacental Clot Formation
uirrasonogriiphy
Color Doppler Imaging
Magnetic Resonance Imaging
Non-Specific Markers

_Differential Diagnosis cj

Manage(lJ_e nt
Maternal Assessment and Management
Fetal Assessment
Expectant Treatment in Term :Pregnan-cy
Expectant Treatment in Preterm Pregnancy
Delivery

Complications

Scanned By: ~
 . -~~':; .
------~--~----~S~E~CT=.to~N~~~.H~
.E~M~O~RR~HA~G~
- E~
- S~l~N~P~R~E~G~N-AN~.C~Y------------------
562

. DEFliDTION 10. Maternal hyperhomocystinemia increases the

risk by three to sevenfold.
.A bruptio placenta .is the separation of a 11. Short umbilical cord late in labor as the fetus . .
.norinel!y implanted placenta before th;e birth of descends.
: th~ f~tus. The diagnosis is most .commonly made
. . in the third trimester, but the term may be used 12 . .External o r internal version .
-~te_dhe 20th week of pregnancy when the clinical 13. Sudden decompression of tht! uterus in cas~s
~d pathologic criteria are met. Other terms of of over<iistention, loss of 9...L-nniotic fluid or after
. . .. abrt.tp.tion placenta are a6cidentaf bemorrhag<:, delivery cf the first twin.
_, .:- p_rem.ature separation of the placen ta and 14. Uterine anomalies or tumors Uke in,
:: : p~~tal at>Qplexy. . !~troplaeen:tal myoma~ .
. .. . .. . . .
. ....
.. -. . _1s. CbCaln,e a,b~~, duri~g- pregri~1cy :m.crea.~~.the
.ltfCJDJPN.f?t :_ . ,

risk .()labru.ption.. Ei.t~ts ,appe.QJ:" t:Q be n:lated

-: . .. .
. 1-n~: ~rt~ incicienct; <o.t'abrupti~~ P.Ja,ee~ta to.- c6oain~..itiduced hypertension~ ...Cocaine .
:Yiiri .\Videly.mpublished series aceordit)g tO the pr~vents the re ..uptak.e ~~ nor-:epmep~~ i .
epinephrine at the nerve ending thus
pP,PW:!ition studied and the diagnostic criteria
increasing its blood level which ca,.use.s
*p.pbed.
. -. ~ _:_, .. increased peripheral resistance and inc$sed
blood pressure.
,~. : . . .. ilncldenee in the Philippl,."les varies, from 1 in
"'-..
' .---:.:1 .:.200::3bop~gnancies. Worldwide incidence is the
\~: -:~>~~~;~~~~
.:.:.~~:..~.-. .,.~4-i~~:_ -~-
. ...
... . . . : . . . .
CLASSIFiCATION

. ... ,~ ~JtriOtoaYl. PREDISPOSING:

.. ' ~ .
~ACTORS .
.
As to extent:

.. . .~<.,;Nmne~\lsfactors iu~.ve been Guggested to play 1. ~- a part has separated

.Q; frq~,in abi1tptlo placenta but a ~g etiologic 2 ... Total - the whole placenta.:has separated
_., ... ;:~~ is -stillla:ckirtg. ..
.. . As to onset:
.:Theaepredisposing factors are:
1. Acute abruptio- sudden on-set of signs_~d-:. .
; '1-.~t~~m~ l).yp~rten~ion.
:bQth cl).Fonj~ and symptoms .__ . . ~-~~: . .
; ,:. ._'l)r.egriancy:;mdUeed, 1s a major risk factor for 2. Chronic abr:q,ptio- shows hetnorrhage "with.:.
.. ,-plaC;ental abruption. retroplacental hem~totna f9rmation ,be_ i ng . ::
. ~.Matern~ cigarette smoking is associated with arrested completely ~~out delivery
. :the finding of deciduai necrosi~ on .p athologic
' ... -elc$ination Of the placenta. W6men who
. ... smoke had a two-fold .increa$e irl placental
.. ~bruption than non-smokers and this risk
:; :tnere~ses fer each pack per day &m()ked.
_. 3.-.11ie risk of placental abruption is increased
:aignifi.canUy in women with premature rupture
.br membranes.
4. Chorioamnionitis.
: . ,!?.~ere Cetal growth restriction .
.~. 6; Advanced maternal age and parity. . ;
'
.. :1. Race or ethnicity.
:8 Women with previous abruption have been
reported to be 5.5% to 16.6%. 'After two
,consecutive abruptions, the risk ofa third rises
. . ' to ~5%.
-9~ irauma. Figure 37.1. Sonogram s howing a large retroptacental bleed ..

Scanned 8y: ~
 CHAPTER 37:.ABRUPTJOPLACENTA
As to type of bleeding:
1. External - the bleeding passes between the
mezpbranes and the blood escapes through t he
ce~.
2. Con~ealed -the bleeding is not seen externally
but is retained between the uetached placenta
and the uterus or may extravasate into the
amniotic cavity. The fetal head is closely
applied tothe lower uterine segment that blood
can..11ot pass through. 'i'he extent of bl~ding
may :not be apparent and may pres~nt as
matemal a~ock that i~ disproportionate to the
- . amountofbl!)<)dlmJs. theuterus'maybclatger
than age of.gestation due to the accumulation
of .r etroplacental blood
3 . Marginal sinus rupture - the placental
separa~ion is limited to the lilargin with
minimal bleediJlg but without uterine
tenderness and pain.
Pathology
The mai.-. pathology involved is the formation
oi decidua! hemc;~.toma. Abruptio placenta is
initiated by. ~bleeding in . the decicht.a .- basalis
splitting the .layers and leaving_a thin layer
adher.e nt to the myometrium which causes
separation, compression and destruction of
placental function adjacent to it.
Small arterial vessels in the bas al._layer: of
the decidua or the .decidual spiral ar.~ery which
are pathologically a.ltered and prone to rupture
may be the source of bleeding. In some cases,
Scanned By:
563
bleeding may begin from the fetal and:placental .
vessels. As it expands, it disrupts more vessels
in the process of separating the placenta until
it reache.s the piacental margin . .Compression
by the expanding hematoma leads to obliteration
of the overlying -interviilous space which
ultimately destroys the placental tissue in the
involved area. The uterus, being still distended
by the products of conception cannot contract
enough to compress blood vessels. For the ft;tus ,
th~re is loss of surfac.e area for the exchang'! of
respiratory gases and nutrients.
There can also be an abrupt rise- m uterine
. venous pressure which may be trartsmitted tQ the
intervillous space resulting in the engorgement
of the venous bed and separation or' all or a portion
of th~ placenta. This is seen in vasodilatation of
.conduction anesthesia; Gi'ossly by looking at the
maternal sudac~ of the delivered placenta,. ::o,
cir~umscribed depression containing &ark
partially clotted blood depending on extent of
scparotion denotes a.b ruptio.. ThiS; chruig~_takes
several minutes to materialize. A .very -~eJlt
abruption may not show any differen~;e from a
. norm81 placenta at delivery. The causes of vaginal
bleeding at times may reinain ' o~scure 'a.fter
delivery. ::;- .~
Extensive or massive placental separaiibn is
typically associated with little gros's or llistological
change in the placeflta.
. Large hematomas result in immediate fetal
distress, necessitating emergency delivery. A
large fresh clot behind a floating detached
placenta.observed at the time of cesarean section
is the only sign of an acute retroplacen:tal
hemorrhage . .
Mkroscopically, retroplacental hematomas
consist of red cells and fibrin, the proportion of
fibrin increa sing as the lesion ages and red cells
degenerate. The basal plate decidua may be
normal in instances of acute ret~oplacental
hemorrhage. An acute inflammatory infiltrate may
occur in the decidua basalis adjacent. to early
clots. An infarcted placenta overlying the
hematoma is characterized-by necrot:iG,Y.illi widely
separated by a markedly enlarged an4:~ngested
intervillous space. Retroplacental hem.atorilas are .
composed predominantly of mateq1al :blood, but
in some cases, th(!re may be significant fetal
component.
~
 564 SECTI_O~ V: HEMORRHAGES IN PREGNANCY

' ~

SYMPTOMATOLOGY DIAGNOSIS

Sig:D.s and symptoms may vary depending on In ~evcre cases, diagnosis is generally obviou.s
type nf bleeding, extent and onset. It may be i:hrcugh its. signs and symptom~, In ~der and
classified: as mil<i, moderate or ~ev~re. External more common ins~ces, .it. may be difficult to
bleeding may be profu::;e an.d yet pla<:;ental recognize y.rith certainty and diagnosis is often
sen~ration ma,y not be. so . extensiv-e as to made by exclusion, clinical inspection and
cotnpromise the .ktus, or there could .be 'no ultrasou:nd examin~tion .. There are no +aboratory
external bleeding but the placenta ;may be te;;ts or diagnostic meU;lodS'that wou).d accurately
completely sheared off.resulting~ fetal 9-.~th. ln _show lesser degrees of plac~ntal ~paration.
conceale4 i;l.bruption, sho.ck will be
disproportionate to the amount of blood loss .. Suspect abruption placenta in ca'ses of
Vaginal bleedbg may be ~u~den or intermittent. abnormal. fe'tal heart. ton~s of unknoWn. cause
There.may be crampy orcontin.ous.abdom~al or accompany}ng signs. of labor,. unexp'lained
back pain of'va..-iable. intensity whicl): may be bleeding m pregn~~y' ultrasorucally vi'sualized
genec~ or localized- - liquid or dark area behi_nd the placenta,
portwine colored amniotic fluid during
UsuAlly, there is in.ereased uterine .activity .or amtiiocentd;is, qecteasing serial hematocrit in
h~n~~... 0teD,lS may be. irritable lllHi th~r.e. . prc:gna:n:t wom~n. and retinal detachment in
~ay .f>e,contra.c.tions with slight .marup)llat~9n. pregnant woreen.
.Fetalheai:t:ctones ar~ auP.ible :ubless.inor.e than
. he.lf.ofih'e!p).accnta~has~sepa..rated:9.lldr.mayt.sho:w... Aside frvm its symptomatology, to diagnose
~ifycardiaJcirtdeceie:r.atio~sr: The:r~r-~v~b}e. ,.. abr::uptionw~:can.also.m~e.use;of; ... ....., .
. evidences of hypoY:olemla-. :with ;~hy~dja; and. . . '
sh~k. :An;J;nioto~y 'willshow; b~oody.ru;n:nic'flc a mot fonnation retroplaceb.taily
ftuict- ':I"k.mostfrequent-~dings:are bl~g and .:b~. :VJ~~nography.:ana D?pcple'r imaging . .
abd~rrrlnalj)ain... , . :a,gnetic
c..
.
. r~nance _imafdhg.

. ..

L Vg,W.al' ble~ding - ha~.~m~k of ;;tbruption . .' .

.placenta. ..O.nly 1_Q%_Qf.!:IJI~~!i -:wom.~P i?r~~_n;t
with concealed hemorrhage.
2. Abdomimil pill - may indicate extrayas'atlon
of ~lood :i nto the niyorit(!tHu~ .or pe.inful
hy.Pe~tohi.c <;:ontrac;~lons induced by. :the
abruption.
3. Uterine .tenderness - may be generalized or
l~d to the site of placental detachm~nt
4 .. Utcr:ine hypertonus - uterine tonus is ekvated,
or
fe eling r;igid boardlike.
5. 'Fetal distress
6. Idiopathic .preterin labor.
7. Dead fetus
a!~:.:~'r~,t~.~~fi_b_~...,~eelljg~Jhe.:.~a:t~mai
surface of tlie
=placenta or extrayasatlon qfblood
may .be. $e~n below tl).e C;}:1prion at the fetal
suriace: : The vol1l,ine or blood Clot .is only 40
percent .o'f the amo').lr it o'f blood loss and
ertravasation of blood il)to the uterus, ligaments
and retroperitop..~b..m ma,y be considerable.
Blood pf.essure may be. maintainf!d in spite. of
blood loss of two 'liters.
Ultrllso.no g:ra p hy
Pltras~mpgraphy rules outplacenta previa and
may 'sho~v retroplacental blood clot. Negattve
findings th,ough do not exClude abruption.
Diagnosis of abniption is frequently difficult
de.Spite ultrasound. The p resence or an
ultrasonically det~ed subchoponic hemorrhage.
ipcreases the riskof abortion, stillbirth, abruption
antt.preterm labor. -

'

Seanned 8y: C
 CHAPTER 37: Af}RUPTIO PLACENTA
. ~ ...
Color l)oppler Im.ag!ng
. "- '
.lts 'introduction 'a nd use ofthe notch to defme
Jnabonnal wavefonn()fbQth uterihe arterie.s was S> Abdoininar. pregnancy .wi~j~~~9..i:ninal
..,sfu'dida ~a:t l9..,2l weeks. Its p~esence could be -
.used to identify pregnancieslhat are at hi.gll risk
for pregnancy_:.induceQ. 'h ypertension and for a
.. ";pb~sibl~future a:br:uptioti.. This group pf patients
nee.d'incr~sed surveillance and niay benefiHrom
pxPphylac~c :therapies.
Magnetic -Resonance Imaging
This is helpful in e<taluating unexplained
bleeding when a transabdominal ulttasound has
failed to identify a definite source of bleeding.
Scanned 8y:
S65
Non-specific Markers
Serum CA -125 could be used as a marker for
abruption. Maternal serum CA 125 is ~lieved to
,be._denved from the decidu<i. and is elavated in the
flrst trimester and immediately after delivery when
placental separation occurs.
Thromboroodulin is ;:t.1 endothelial cell marker
and was. significantly elevated in 8 women with
abtuption compared with 17 women without
abruption.
..
.
~.
DIFFEMNTIAL DIAGNOSIS ..
These differential di;lgnoses iriclude:
l. Placenta previa .
2 , LaQ<>r a!XOmpanying placenta previa
3. Labor ~ .
4. :Uteripe rupture . .
hein.Orthfige ' . ,.,:: c. "}i't!\;)::"- .
.6 . Ruptured hemangioma ... .,.:: ~.:: . .. : ;~ l.'>'~ "
7. Hepatic ~ptl,lre
8.. J.Jterjne-vein. and . splenic s..:-t:ety.r:Uptu,re
9. Sickle ,c ell .crisis ?_ :, . . ,,, .... ,
Placenta previa is usualiy .p~:I~~~~ 1y,aginal
. bleeding and can be seen by ultrasound. Labor
accom,panying .placenta previa m:;ty ~us~ pain
spgg~~1lve of..abmptio.n. Abruptio place,pta may
also.. Iilimic.,normaLlabp:: or. it.J:nay ~use-no. pain
at all particula~ly in a posteriorly implanted
placenta:. Other intraabdo~al c6nditions may
mimic abmption and may necessitate immediate
laparotomy.
MANAGEMENT
Managemen~ of abruption will depend on
gestational age and status of the mother and the
fet:~.Js. Assessing matern.il and fetal condition is
of utmos t importance.
Maternal Assessment and Manage~ent
Th~se consist of tnonitoring blood .Pressure,
fundi~ height, pulse rate, resp'iratory.r ate, fluid
intake and urinary output. . Patient isiityped and
crossmatched for at least 2-4 units ofw.llole blood.
Immediate correction 9f matern:ql . hy;,vplemia,
anemia ahd hypoxia should be made. Whole blood
is superior for treating clotting deficiencies and
C
 566 SECTION 'v~ HEMORRHAGES IN PREGNANCY

replacing blood loss. No o.p etative procedure .is

done before replacement therapy of blood is
started. Inti-avenous fluid .w ith DSLR -or DSW:ater
using large bore needle is immedi~tely started.
Hemato~rit. should be maintained. ,at 30% or
slightly higher 1111d urine out.flow is a t least 30
m1jhour. Request for immediat~ _ CBC inciuding
platelet count, plasma fibrinogen, fibrin
degradation produ~s and patila}. thrpinboplastin
thne, id:e ally, every hour until delivery. An
obsttridan s hould be -alerted to a po:ssible ore if
t:h.ree out of four laboratory values are -abnormal..
Clot obseri~tion test is made and if no clot is
formed within 8 ...... 12 . tninutes, d-i1igno$"ls .or
e:oagulati<m. .iailure is made. If no clot is formed
within :30 minutes, this may -me~:fibti;nogen level
is less t;han 100_mg%. lf plas~~ \evei _i~ crl.tical
and bleeding iS 6tcessiye! . ad.J;n~stet f ibrino_g en
by intravenous :.rt:lu~ using eryop-recipit:ate. With
$toted b~lack-ofhemo:s~siutsultafronifa~tor
V to vni:djillciency~ Ifpl~telef~t:mt :is lees$ than
so~~m.li:.there:n:lB.Ybe~trou,bl~~me,~ftom
ilici$iow:s itt$. siX-t o<' elgnt;?p1~tel~ttpaeks,:-,a.re .':Si~y:~--.: J$0xupr.in;~:py::itselfl:Jnayt:prbduce'' ,_.
transfused ;,.. Coagula:ti:C:ni.!i:. ; deft;ct.&; ; rep_air- .. . 4ypertension :a rtd ta"Obyc.atc:Ua..so . that it :i.'l .not
-spQntan~OU3)Y within twejtty foUr ho-ur . or SO;
P.,.stelets;'if~vct)r. low, taketwti'to tour-clays to .r each
n._o pnaban:ge;
U the djQgnosis is Unctrtamand the fetus is
tili'le Without eviden:ce-:Or fetal ~lres$, very close
o~tiori may"bt: made.lnunediate in~
i-a ;d~ne if .the fetu-~ $how.s ilistrese or :if. the
diagnosf$:of:al>ruption-is ~rtam. Platenta;prev.ia
is ruled out by ultt~soun~:t The paUent is
. ho~i~fcr about48 h~llr$lU1d.blOod is~
FeW moiUtoP1lg is ~on~ serially and mother is
Clo~ observed for: ~er Pt~,.- pabl, 'U1c:rlne
~nt:IactiO~~. increase in -~ of ut.Cii.Qe flindus,
seticil.-h~tologic ~ eoagulatio~ p,ro!il~
Elq)eetu,t T.reatmeJtt-.in Pretertn
. P:epaney
.
Sctnet.hnes, delaying delivery m~y prove
benefieW when the fetus is immature. If there
are deceleratkms. oUgohyd.rammos or maternal
deteriomtion, th~n deUvery "is made. The 1,1se' of
tQCOlyticsis ..stiU controve.rsial ..M~gnesi~sulfate
ls . no~ able .t o decrease ute:rjne hypertonicity
ad~ble :for USe in abruptio. . .
ne!J\t~

Ce~tr~Jvenou_s;pressure<:'shoi1ld:.\>e!~oJlitored-.:. , Dclivryds .:either :by t:es.are~n . s ection or.-

. in modtm.teto' $CV.re.cil~; 1m. tX.~s of:.twelve vagi :d:Vel'Y~ Va.,gin~l.Q.eUvecy is p~qmi if
~~:P:t!m~,t~r.~ W~'*t .i:n~_<tJ.:i.!~$ .o.Y'~.rtt.tm:~f!1~!9n. 1E~J-n!.lt:i~~:g~~.. :.~r ~~!~.tt-..~~ -~~t~.~~f
'U--:.,.;;;;;; . "1"'
~.!<Y~:.,;yg_:Uygl ..... 3..;~
.,~:--- Jl[~UJ. ,y,; ~,., ""'
J.Hi0fL4 d
an~ .AI}__ _ .-
b'li:le&il17.jamtnimnl-witlfol:tt.&rm~H)f.fe~1-_>'t
Oll'- - -~~ _ ~ ~~~ : --.......
- -- ~.

cardia,.:: -overload. Although U ~ay riot detect VatfhaJ.tieli\tery.t::attetiiptedoU~ifdelay:is,Ndged

pulmonary :t:origestion, the patient sqauld be saf'e ii-b?th ~other andfetu'~.' . . .. ' .
obser::ved tor dyspn~. cough ~d - rals. The use ' . . .
ot furose'riiide fpr pulmonary. bnge$tion is b~en :r-u1d -~i,lt~
It ,pi,ie..e-nta .previa ha$.
'beneficial. . . amitiQ.to:-r :may :be :(tone {ot q~~_ek ddivery.
P,r-evto.~~y., ::itwas beli~ved th;;tt .$tiiQtQn.:tY
Fet :IJ Assessment (l~:hl~dL'laft:Jlh
. -. - . .. ."" . . -.th~fui
.. "~-f.;;u<)iisi!
PJ.CU;l.~_ t:.-:
a.n d
t~d\tee.i :~n~ :i,nfu the-. matetn:al :CircUla tion .o f
This is made by e stinia ting t.he size .ofthe fetus tJu:9;;p~p~stin- and ;activate ~gUiation factor-s
and moriit0ring fetal heart tone~s using a .fetal fr9b) ,tl)~ :,P)a~ntill :cto~. ..a.t present, this ~s no
monitor. JUeW: distr~ss i~ qetected, immediat e evidence. .
delivery is accomplished for fettis'!s w:ho have a
. chance of .s urviving (:for example , 24 --wee.k Oi!o/l Piri p\ay..':b e- :~Yt:n: jf~nP crhy~nliC
gestation and above)~ The .effects 0n the fetus contiactiot}~ are
rioted" wlien vaginal ~eJjvery . is
would depend on the effective area for placental:. decided upon even it there is ho hypertonicity.
maternal exchange dU:e to -maternal _.h y.potension There is no eviden ce to -s upport the fear that
or shock and as a result of frequent and intense oxytocin may enhance the escape of
cOntractions or teU\Jly or. iricre~sed .intrauterine thromboplastin :into. the-maternal-circulation and .
r~sting pressure. Anemia would. aiso affect feto- enhMce -consu~ptive coagu1opathy or amniotic
matemru o:lo/gen transport. fluid e~bolism.

Scanned 8y: C
 CHAPTER 37: ABRUPTIO PLACENTA
Cesarean section is done for live fetuses in the
following c:Onditions:
1. Fot-unsu~...essful induction of labor
2. Presence of fetal distress-
3. For other obstetrical indications
4 . Failure of.labOr to begin within fbur houts
Even in a dead fetus, cesarean section is done
if:
1. Continuous bleeding is moderate or .
heavier
2. Progression of abruptio shown by an
expanding uterus with a concealed
hemorrhage
3 . If fibrinogen levels progressively fall
In cases of mild abruptio with term infants or
mQderate or.se_vere abruptio regardless of age of
gestatio:n~i~prompt. delivery controls hemorrhage
and save~ the life Qf the fetUs. Prolongation of .. percenthad.rei1al failure, Renal,necr,o.~i~~(t;Ab_ular
tim~ --~Qd worsens the CO!ldition.
Maternal complications and nepnatal outcome
ere d!rectly related to the length of tUne between . and inay:need dialysis. : carefully moriitor hitake
the on:set.o fabruptio and delivery. It-is said that
the int.en'Sl should no.t ~ceed six l)o~. although
this may""not be so when the fetus is dead or
previable. EXperience at Parkland Hospital shows
that outcome . depends on .the adequacy of flui,d
and ~IC>Qd r~Bla.~~~~p,t..
The a.'1esthesia of choice is either general
anesthesia or p udendal blotk. Conduction
anesthesia is not used because hemorrhage may
be profound with persistent hypotension.
COmplications
Complications of abruptio are hemorrhage,
coagulation failure, acute renal failure, acute cor
_pulmonale, $J:leehan's syndr.ome and post-
tra."lsfusion h~patitis. Maternal oliguria and shock
ma)' &~'ttr. .F;~t@ S,Jl>.U".t;,.~~ -m.a.y. ~nd in-fetal .de.ath.
Couvelaire uterus (uterine apoplexy) is a
severe.form of abruptio in which the entire uterus
may undergo bluish, purpie or copp.e r
discoloration-due to blood extravasation into the
myometrium and into .the uterine serosa. This
may also be seen benea th the tuba l serosa,
connective tissue of br-oad ligament, subs ta nce of
the ovaries or free in the peritoneal cavity fro m
Scanned By:
' 567
tubes or from serosa, These may interlere with
contractions though most would respond to
oxytoxics, ergonovine or intra myometrial
prostaglandins. Couvelaire uterus is not an
indication .fer hysterectomy. lt's a rare and non-
fatal complication and can only be diagnosed by
direct visualization or biopsy. Therefore, this
condition is often underreported and
underestimated . If the uterus is severely
macerated or atonic, a subtotal hysterectomy may
be done.
Acute renal fallure is usually transient and
may be seen in severe forms where there is delayed
or incomplete treatment of hypovolemia and
anemia. Reduced cardiac output and int:rarenal
vasospasm due to massive he.morrhage and
coexisting ac~te or chronic hypertension impairs
>enal perfusion. Oligqria and azotemia ;may be
seen. Pritchatd.and Becker shO\vec-thet in severe
cases, 48 percent. had ,proteinuria...~~t: only 4
or. cortical) may .be. seen. Fibxi.n.: xniY-.occlude
glomerular capillaries causing tissu~iP.~I"osis and
renal failure. Complete cortical necrosis is rare
and output. Abruptio placenta iscne.of the.most
common predisposing .factors . of . con~umptive
coagulopathy in obstetrics. Oth~Jrq~dnditions
associated with it are amniotic Uuid ~mbolism,
hemorrhagic shock and sepsis. .
- Co.nsum-ptlve - Coag\l;lopathy .. Overt
hypofibrinogenemia (l~ss than 150 mgf dl of
plasma), elevated levels of fibrinogen-fibrin
degradation products and decrease in other
coagulation factors are found in about 30 percent
of women with' abruptio placenta -s evere enough
to kill the fetus. The major mechanism in DIC is:
.thromboplastins from decidua and placenta enter
the maternal circulation and incite intravascular
coagulation. Severe hypofibrjnogenemia occurs
and levels of fibrin degradation products are hjghcr
in serum from peripheral blood ~an iri serum from
blood contained in the uterine.cavity. The patency
of the microcirculation, though, is maintained by
the activation of plasminogen to plasmin which
lyses fibrin microemboli ..
Diagnosis of DIC should .b e indiviciualized for I
.e ach patient since clinical manifesta tions and .. '
labo r atory examinations are quit~-variable
depe nding on the underlying disea se. Elimination
of underlying disease is necessary, In abruptio
C
56S SECTION V: HEMORRHAGES 'IN PREGNANCY

placenta, prompt removal ~f the products ..of but-does not rontafu clotting factors. Concentrated
conception, replacement therapy with fresh whole plasma can al be used. A q~ad.ruple strength
blood. 9r frozen plasma, .general supportive care plasJlla contains 4.4 gre.ms of fibrinogen/unit.
and antico~gulant therapy, if needed, are .done. Initial dose is 4.6 graJ.llS and as much as 20-24
-During active bleeding, the transfusion ofpiatelets grams dependL'lg '.)11 response may be given.
is the best practical means of counteracting. a
clottingdefici~ency. A platelet .p ackcontains abOut . In the presence of coagulation def't;cts, the
20o/o fewer platelets than 1 unit fre.s h blood. 11rls more extensive the surgery, the more likely the
.is satisfactory for immediately replacing blood loss nemorrhage will be.

,.

POINtS 'TO Ra:MEMBER

AQruptjp ptarenta is the separation .ofa normally implanted placenta before the birth of'the.fetus from
!he ~Oth we.~k of-.pregf:lancy onward.
InCidence ls tt)e ~a.m:~ .woddWide, frcm 1 jn-.,20()-;300 deliveries. .
:~. .There,are nl,unerous:p.redisposing faGrors::ma.temat hyPertensiori. m~temc:l cig.arette smoking .. trauma,
,....:~~noamolonjtis.; fetai':Srowthr~~~on; .advanee{hnatem~:ll age end :parity, race oretrlnicity, previous
, ,~~~Ptioi throm~philias~ 'Sh~rt umbineit.co.tdl ~xtema1 or internal version;uteiine anomalies, ,~ine
:abuse. ;me::1sed.~vel$ ohdpha fetoprotein>premature rupture of membrane~ ar.d:previPus cesarean
seCtiOn;
.Cia.s~~d as tO .extent as totaL{whqle piaceht;3 :ha$ ~par:crted) or partial (onlyaparthasseparated)
,al:)ri!ptio \placenta.
, ' ' ''ClassifJe<t=~"'l!l:onSet -as ja~.Jt~.{~odc;Jen:on~et-of siQn~:andsymptclirls~ and cbronlo.'(hemot.rhage;ana~ .
!': . ''"reti'~tcn:hemato~ a"rtest~'OOtn'J)Ielly'Y{ittlOUt'deliver-y) ra\)rtlption. : :. .
~ a~1o-~>pe~~~xtemai,(bl~dlog:~~s betweeMh~.mem~nes and the uterus Md e.~pes
th~W9h the:~rVi>c).,. cancealed '(ble~iilg:is ,:hot seen~extemalfy butis:tetalned l>e.tw~~l1. 'Ul.9 4:.m~~s.r .
pla~ta".andlthe-utei'u$},'<!rn;t~ma~ina~slnus.rijpture- (placen.taLseparafion isJimited to.the.margin With
. !ritnlmai':b.i~eding but witnout iJteiioe teno.emess and pain).
The m~ln pathology involved isthe formatl0n of a.d~idual. hematoma
Signs and symptoms may vary depending :on type of bleeding, extent and onset It m~y be class'lfied
aunild, m9derate or sever.e.
: Vaginal .bh~edi~g :iS the hallmc;~rk .of abruptio placenta. Only 10% of affected women pre sept with
~led hemorrhage.
.The djagnpsis is.usually mar:le on clinical grounds, in moderate to severe cases; dic:~gnosls .is generally
obVious throt.~gh its signs and symptoms, :
lr\m!lder an'd_more rommon iiistances, if may be difficult to recognize with certainty, and diagnosis is
often .made. by exclusion, cliniealinspection a11d ultrasoul)d.
:
examination.
~ .
:
There '<Ire .M labof(itocy tests or E:liafj'nosti.c methods. that would accurately a.ssess lesser degrees of
plaeental separation. .
Retr.oplacental clot formal1on.Js ?een in the maternaf surfaC'e of the placenta or extravasation of-blood
may..beseen.belowthe chorion. at the fetal surface.;
. Ultrasonography is not a sensitivemethod for. diagnosing .placental.abruptiol} but .it is useful in excluding
placenta .prevla.

Scanned 8y: ~
 CHAPTER 37: ABRUPTIO PlACENTA . 569

Color Doppler Imaging is used to d~fine an abnormal waveform ofboth uterine arteries was studied at
19-21 weeks.. Us presence could be used to identify pregnancies that are at high risk for pregnaney-
lnduood hypertension and for a possible future abruption.
. Magnetic ResOnance Imaging is helpful in evaluating !.lnexplained bleeding when .a tran~bdomlnal
ultrasound has faned to !d~ntity a def.nite source of bleeding.
The use of serum CA.- 125 could be used as a marker for abruption. Maternal serum CA 125 is
~lieve"C~ te> be d~rived from the decidua and is elevated In the first trimester and immediately after
delivery when pt.acental separation occurs.
Differential diagnoses include: labor accompanying placenta previa, labor pain, uterine rupture,
abdominal.pregnanC'J With intra.abdomlnal hemorrhage, ruptured hcmGingloma, hepatic rupture, .uterine
vein and splenic .artert .rupture and .sickle cell crisis.
Management options wou'ld depend on Us severity, associated complications, gestational age and
status of the mother .and the fetus.
~cific measures .in 't he manag~ment of placenta! abruption are: Immediate delivery, expectant
management ~lid maoa.Qement of romplications.
.... - )~~~ asses${flent.ls m.ad~ by estimating the s~e of the fetus and monitoring fetql heart:tori~s. using a
.. ... tel.al monitor. If fetal distress.is detected, immediate deHiery is.accomplis.hed foffetusesWtio ha\ie .a
. ,, ., , )~!lance of:Surviving (forexample.24 w~ek gestation and above). ''~'":'?~:':- -::.::~:;
' - . 'lm~ediate interventiOn is done if .the fetus shows dlstre~s or if the diagnosis of abruptio~"f~.: ~in::
_ .T~e need .for immediate delivery depends .on the severity of abruption and wtu~~ther the fetusis anve
- cii dead. -

. :i<:i1 :~...~irtal deiiv.ec:y:.i$.'prefeiTed

if the fet~s is dead or:delivery ls: imminent or if.:bleedingtisHninirnat ..
.wftno~t signs of 'fetal distress. Vaginal delivery is attempted only if delay Is judged~.s<~~)for;;bOtt'l~
mother :and fetus. . . .. .... : '...

Amniotomy:aea:ease$blein9 frOm the implantation site and reduces entry into the matema!'circuiation
of. thrombopJastin aod ,activates ~~~~~~.~~~-~~~rs fr~~ ~~ .P.~a.~~.~!C'I clot
'cesareaii'sedloills'dbne for'iive fetuses in the following,conditions: uns~~ssful induction of'labor,
l presence Gf'fetal distress,. obstetrical indications, failure of labor to begin Within four hours.
Cesarean section j~ donefor dead fetUses in the following conditions: continuous bleeding is moderate
or heavy. ,progression of abruptio .sh.own by an expanding uterus with a concealed hemorrhage, and
fibrinQgen levets progressiv.ely tan.
The anesthesia Cif choice .is either general anesthesia or pudendal block. Conduction anesth~sia is
not tised because hemorrhage may become profound with persistent hypotension.
Compli~tions of abruptio are hemorrhagic shock, coagulation failure, acute renal failure, acute cor
pulmonale, Sheehan's syndrome and posHransfusion hepatitis. Maternal oliguria and shock may
occur. Fetal distr-ess may end in fetal death.
Couv.elaire uterus (uterine apoplexy) is a severe form of abruptio in which tl}e entire uterus.,may
undergo biuish, purple or copper discoloration due to blood extravasation into themyometrium .and
into the uterine serosa.
The major mec~anism. in DIG is: thromboplastins from decidua and placenta enter the maternal
circulation and incite intravascular coagulation. Severe hypofibrinogenemia occurs and levels of
fibrin degradation products are higher in serum from peripheral blood.than in serum from blood contained
In the uterine cavity.

~
I!
Scanned By: ~
 57:0 SECTlON V: ~!ZMORRHAGE'S JN .PREGNANCY .,

'%!->
RultrutNCES 14. Hubbard JL, Hosmer SB. Couvelaire uterus. jAm.
Oste!)J>ath .Assoc 1997; 97{9).

1. Creasy RK. Abruptio pla~rita. Me::ernal .and Fetal
Medic:i.J;le1 Fifth&ti~6n .2004; 713.
2, Pala:yp:ay~m EP. Apruptio placenta. In: liB Panlillo, et
~L (ed11.): TextboOk ofOb'stetrics, First Edition, Ql.l.ezon
City: Aasociati~m of Philippine Medical Colkges
Found;atiop., .1,9.9S; 317+322.
is. Aitokallio - Talbe:rg A, Halmesmaid E. Motor ~e
accident during. the second or. t hird t.Jimester of
pr_egnrulcy. Acta Obat et Gyneco! Sca.'1c! 1992.
16 . Bruce SL. Premature separation o f the :placenta.
.M~ent of Common Problem~ in Ob-Gyn. Mishen
and Brenn~ l988. ..

3. Rasmuuen S, Itgena.r.M, :E>elaker K. 'Ih~ effect 9n the 17. 'Gliclcm~Jr.PhantomNote.inOb-Gyn.TlJiro~

.~')ib.Oo4 .bffurthet: ptegn~cy of ~~acental a:bruption
and the roe of its ~nee. Br J obstet .Gyria.ecql 18. Fr-eeman RJ, et ai. Int~rpretirl.g Fetal Heart Ra~e
1997; 1'04(1ll: i'292-'l395. . ~ -and M!!Jl~.gement of High :Ri.sk'~cy.
~rtd.'Eatiun . .- .
4. Ananth CV, S~iliz DA, Williams.~MA. Pl'acentiu
aO,ruptibn and fts as~oclation with hypertension and i9. Tal>erl3Z. Plaenta:l -ab~ption. Ma:_TlUalofGynecologic
.prolonged tu~:orm~nrbfanes-: A m.;;:th~1~ vi~ Emer.gencles.
'alld~ta-B.4alySis. O.bstet Gy'ruiecoll996; 88 (2): 309-
. 318. 20. Ball RH. Aide CM, et al. The. clinital sipilliea:i:lre of.
'illti.a:~ortogr.A:p:Q:iqt.~~y-f:(et.:~ t.~d . '3ubch oriop.ic
s. 'A::umth.CV, Saritb%'E>A. Bow~s WA~r, et al. Infl.u enee hemorrha,ges .J Obtet Gynecoll996,
.on;.~v~ di:sot'll~pi ~d cii;;:;r;e~ ~~19n& on_
phii)eli~l "abru:ptU>~. atld ut~ri,ne 'bleeding .i:lu !ing 2 1. ~n ~ et aL .Dopplerultr'asouPd of i:he uterine
p~. Br.J 6Q~tet"'Gynaeco1 T~7;'tt04)s;:S7,2 ... . ;ftrt~ . the ~portane .of bijatenu not~g:iitth:e
. ... - ... 57~- .' . . .. .. . . .. :pridi~n-of.,~psia,.: pl3,~.,abpiption,.crc_ .
' 4cllyezyi;ifa sma.ll:ior gestation-a! age
bJy. Ultrasound
;6. uiniin s,' Cha.uahucy :jf, D"amal K, ~t. al::.Qu.t~e ei .obstet Oynecol 19'9.6. .
abrup;tio ~ctp:t~.fu. rgtm~6isi;Ve at:i.P:)>.JP.et;t;ensive . .
~ta-m A&a Kha:n:Hosp,i W. Kaiachi, ~taP- .2~. }kili,a ;,r:t. c~~o~Delga.:d(:; R, Arce F.. M~~ serum
. .alpha.f~toprOt$ 'in p~cental abt;uptlohassociatcd.' with
7. An8ntb:~ct,;~p;A:. :Lutl:t~~ER .Mat~cig~tte. .: : . : ~labot; IiltJ;Gyilecol O~tet:l9.97-: l .
-'an.i~t~:a.:n:a.c ~ct-or.'.for: :P~~ental.~::upti:on. . , .
~ta~~dut~e'bl~ed.iz}g:in;'p~gilancy. Ain 23. 1\a.)' HH, Spi~e:- CE. Pi~J.in:i.ina:ry"~perie:nce with
J Epidt;:in,ioll996; 1'4~(9)::881:.8~9. ~~~tiC. reSo,na.;J.ce imaging h,. patienia 'with t?W
. - ~ester blee<lll}.g' Obstet Gynecol'.l~L --- -
8~ enatt.Pi~.s s, Milis .J~C,Yu.enJ~ --~t :~ -.~~~:0~ -~~- -, .4- ~~ ---,- ~- -- "' ~ .-. ., - ......
:etrec ot mi:jol&g jn,pteeFEi'iDp'fiii'P~aD:8~: :S'iii0lailg .24~ witt :g~~l'{nes K;ec ru: C'kr2s m ioPij>t:io ~m..
teau~ 'tbe ~a~~. Of.preecl~psia.l)ut '~ase8 . Ani ;J'Obstet Oyn:ecol .l991 .
.fr.e ta~~ o(~~Ol't'il#.ty\ ~ptio ~.nta,.and .
WQR Amj o~~ rG:Yn8.~6i -1997; l.rl{l):l$6-l61.
7 '25." Dong .J:r.... cf.ei~C. Analysis of
65. a11es of a1miptio
' .iJhi:centiL Am J'O!Js.tet Gyiiecol f991 .
9 ..M~~tU;i. ()=B, Wps,mah.I:;E. Premature .rjl:p~ pf
. the ' metq1i~~s: neonatal con~eql.tences.. 's ~i:nm 2&. Cunningh~ GF, .Ma c ])Qnal!i 'P:1 ~~t IF, et al.
: . .199oi
Perlnator .. 2' ots}:s75-3eo.
' . '
Abruptio placenta. Williams Obste'tr'!cs.

10. ~denderJM, Cc)x'S:t-L C},lniC:?-lcou~ ,ofptetilB.tute 27.:RU:bUi RN, Colman RW. Diss~ate4 intra:Vasctl.laC
. tuptwe of menibr:a r:ies. &min Eerinatol :1996; .20{5): c9agulation: Approach tc Treabnent. 1.992.
369-374.. . .
, . .
:28, 'T,aka..Shi.H. Principle~ ;of Therapy fo.r Pl.C Statu;s and
U . O~derogr.l LS,.Kabukc}.l A. Elevated secondtrimester . N~7. T rends.
HCG k vel ~ated.with adV-erse pregi'!A!lcyoutcOme.
Int Gjne~til O'Pstet "1997;.56(3):245~249. 29. Bruk L. Abniptio placenta. In <;).bstetric;:ll Decision
M~g1 21>4 ed. .
12 . 'Krame MS, Usher RH, PoUack R, e.t al. Etiologic
.detennin:a.nb Of abruptio placenta. Obstet Gynecol 30. Borld .AL,. et al. Expectant management of abruptio
i.99"ti'69(.2};221.:226. . . p}.acenta. before 35 weeks gestation. 'Am J Perinatol
. -~ . 1989.
13. Goddlijn-Wessel TA,. Woute;s MG , et aL
Hypethomocysteinemia: A risk factor f~r p lacental 3.1. J-ienderson CE; et a.L Ritodrine therapy in the prcsc:nte ,.
abrupclon or infarction. . . . ~fdironic abruptio placenta. O~stet:Gynecoll992.

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CHAPTER 37: ABRUPTIO "PLACENTA "571

32. Nathan L, Huddleston JF. Acute abdominal pain in 34. Clatk SL, C~tton DD, et al. Abruptio placenta:.~'Critical
pregnan(fy. Antepartuz;n and General Obstetrics Care Obstetrics 3...s edition 1997.
Ei'nergencies.
35. Konjie JC, Taylor DJ. Bleeding in late pregnancy. High
33. Granite TJ, Pircon RA. Interpreting fetal heart tracing Risk Pregnancy Management Options. 21><1 ed, 1999.
In: Queenan JT (ed.i: Management of High Risk
Pregnancy. ~999 .

... .: -
... - -~:., .- .. ::-- ....

..
.-: ~~ .: .-.: ... :.:l "\' ::.:- .'
- . :-: ,~ H

..-~
;; ;:.:
,..:,' ' ~ --~.:

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 -.....

. . : .. ,

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 38
DISSEMINATED INTRAVASCULAR
COAGULATION IN OB_S.TETRICS
CORAZON 1'. LIM, MD
CARM$N T. NARCISO, MD .

Etiology and Incidence

Pathophysiology
Endothelial Damage
Abnormal Platelet Activation

Fibrinolytic System

Clinical Features

labOratory Diagrio~is

Management
Principles in the Management
Specific Condit!ons
Abruptio Placenta
Intrauterine Fetal Death
Amniotic Fluid Embolism
Septic Abortion.
E~lamp~ia

.....
.:s.

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 574 SECTION V: HEMORRHAGES IN PREGNANCY

Di~seminated in~svascular coagulation. is a PATHOPHYSIOLOGY

dreaded problem. ~ ~e practl9C .~f obstetries .a:nd
i$ seen in wide range. of eomplications such as Norm.a lly there exists a pelicate bal~nce
a'b tuptio placenta. s~ptic ~b~~rtipn, c.hodo ... between: low-gJ;ade activation of coagulation:
ai:D:ruonii:is, amruotiC: nwdembolisn; pregnancy-. ractors "and -platelets; and neutralization of
induced hypertension and intrauterl.rie fetal death. activation products in the circulation.
The term hypofibrionegenemia has beeu used
for many years to describe the disorder. in 1901, Continuous unobstructed blood flow dilutes.
. Oe ~ reported a state of "temporary hemophilia activated coagulation produces while humoral
:n -e;pa~ent with abruptio placenta and in another inhibitors neutralize. them, inactivating stable
~th :a .lllflcerated.dead..fetus. ...Since then
in~rest coagulation f~ctors. The reticuloendothelial
i.n this mala'<iy led . ~cO the di'stdvezy :llf :.a sy~tem elears the ..cir.Culati;on .:of activatdrs.
coilflumptlv* :.thrombohe~orrha;gic..dlso.rder inhibit.o rs . and . qisi.ntegrated ptoduct11 9f
;c1utt3C~enztd b.Y an . ex~J;l:taiv.e :ge~eraUofi cJ ~~on~ P}a~letadhes~on ~dagw~on are .
thri)rttb1 leading to sy.ste.mic 'Ves~el obsti'U~~on, regU'lafe<lthro'\lgh the .ac;tion ofpr.Qsta(:yclin from ..
, ~naumption of platelets and clotting factors, endothelial cells.6
s-eecndllry fibrinolysis, and microangiopathic
h~tnolytit failure. Defibrination syndrome, When the balance is tipp~d throughan
.~o~surnption coagul9pa~hy, di$seminated intensive aCtivation of :hemostasi:s,~ a .
fuitavascular coagulati.on, and con.sumptive hypetcoagulable state characterized l;:ly Yilassive
;t:iut)i:nbohemorrh~c disorders have been used to thrombosis With diffused fibrin depo'sition jn the
idJ'itify.,.the condition, bU:t the latter is preferred microvasculature ensu~s. tesq!fu\g.~ i:>bstr:uction
hecause . it b.e st describ.es . the clinical . of the i;n.icrcci..~1,1latitm. CcnsequenUy, coa~tiort, . . . .
~estations~ factors' .sncl -platele~ afe. consuroed .leading:to a
hypocoagUlabl~ state .characterized this time by
.. Disseininat jntravascular coagulation (OIC) . massive bleedlngwhi9h may further be aggravated .
. js...~.~Intermediacy" mechanism or. disease by se1;:onda.ry fibrino~y~is.. {FiiD-tre..38:.-l)
. ' eo.mplic;ating:a,:multitude of diseases~?:..: .

- Its complex clinical presentation,

jjnptedictable course, and the various the~C~.peutic
'
Extensive Activ<!tion. of Coa.gulation Pl~ess (various diseases)
. .
Endol}\t:licil damage
. .
~ -:.

~~woes in i ts . management make it extremely Tissue lr.)'-!ry

Platelet llCtiYation
. -diiiicult :to conduct clinical trials to compl~tely
~derstand its prob1ems. 3 1 ....
Massive thrombosi~Fibrin deposit .

'E'Ji:OLOGY MID ffiCII)ENCE

1 ;"A'~
. .: .. The overall incidem:e of this syndrome ia not
.ye.t:)!:nown in the Philippi.ties. It is not a common
.entity but ~me large general hospital in Ll)e United
Activation . of
ficrinolytlc
sy~tem
1
Hypercoagulabmty

inf3tction Hemolysis

:Stattsclal.ms .o.n e in 1000 admissions. .In most setodary

fibrinoly.sis
ConsurilptiOn of coagulation
f<lC!ors and platdets'
st~dies, the prevalent cause is infection. Jac~bson
~ports that 50 :percent of c;ases i!l h~s institution ~ .. 1' .
~ Hypocoagulabilit~ M:~ssive bleeding
. are brought about by .obstetrical complications.5 t
The incidence depends largely on how much effort Death
is put in pursuing the diagnosis of dissemina ted Flgure 38.1. Tipping the hemostatic balance .
. ~travascular coagulation (DlC).

T.ble 38. 1. Maintaining hemostatic balanc~. The mechanisms triggering these catastrophic
UDC!l>atructed blood flow dilutes activated coagulati.on factors
events are:
Humoral acton in activate S table coagulAtion factors
.Rc~lOendothellal ayatem relflo:o-cs prc><bc.ts o( coagulation and 1. Endothelial damage .thr<;>ugh the intrinsic
clot diaintegration .
- Proatacycliri from .. pathway" as observed in septic abortion and .,
e~othcltal ceU inhibits abnormal platelet aggregation chorioamnionitis.

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~
 CHAPfER 38: DISSEMINATED <JNTRAVJ\~CULAR COAGULATION IN OBSTETRICS . ,51.S

2. Massive tissue injury with entry . of INTRINSIC P~THWAY

procoagulant material in the drculaticn Endothelial damage c.-----~ SepUc abortion
through th~ extrinsic pa:thway" 3:3 in abruptio
ChorioaJnioni:is
.plae:er-.ta, atiJ.niotjc fluid embolism, retained Contat <~ctiv ation
dead fetUs al)d saune~iriduced. abQruon.
XJI
3~ Abnormal intravascular platelet activation as !
.in thrombocytopenic purpura, malignant XI
hypertension and pregnancy-induced !
hypertension. IX
!
Endotheliall>arn4ge VIII Platelet
factor 3 Ca ++
,
DiSseminated .jlltravascular coa~tion {DlC). .t.
X VPF3
.frequently c:Omplicate$ severe Wections because Ca ++
of potent endotoxins that damage the 1.
endothelium~ The pathologic fmdings resemble
1 . Thromt>i~
those .seen in the gene.r alized Savarelli- .t.
Schwattanatm reaction iri . rabbitS; Mccllilfurs of Fibrinog~n Fibrin (clot) .
eit4ct.h~lia1 dam?.ge which -h~vebeen . i<feritified Figure 3!l.2. Initiation of DIC by endothelial damage
.and. fQW).!t:to b. increas.e d dur.an;g s.epsis are the thtough the intrinsic pathway.
int~lel'i1ih1s; tumor necrosis fact'QrS tTNF'), platelet . ,....,. _ __ ,. ~~-'l .,

E~;ctiV.a:~tl-~ .f.ad~r-s .(FAC), teukotriep:es tind - . :.;~!:':.; .....,~.~~~--~

tli...:0Jrib6.~~ Ni." Damage of:the V..essel wall.and Septic abortion may result in ~an;J;tc.ut~
w~ent~sure ofco~gen ~ctivatesc<>ntact fulminant type of DIC through the above
fa:tor '91 ,J ni't iatihg the -coa,gulation cascade n:1echanism. An ,~ray of aerobic or. anaerobic
leadfug:~{'(;o:~lot formation through the intrinsic bacteria may: be c~u,1sative .age.n,.~s.-...;$.e;ver~ .
. pathwaY:'(Fj~re:38.2) . .hypo.tensiori~ ~d .;shock:.character.i~;:,tli;e:,.}4lica,l. :. .. ~:

a:
This is :tiow pi"QCess, in which the .coagulation
facto-rn, which normally circulate in inactive form,
3I'C sub~cn.tly .activated. The C()a g-&ati.on phase Massive tissue injury with ~ntry. ofproco~l~tion
begins with etfdoUienat<niliufge -:With c.o.ritact mci(f:fiiliin the clrculatton may ihlticiieDIC tliiough
a<ffimtiQii or .ci>Uageii ~Willi ractc>-.rxrr '{Hageman)
and h.lvolves the activation of f actor XI {plasma
thrQm.b<>plastin antecedent). DUring contact
~tctlvaUpn, bradykinin is pro.duced and also
activates !actor XI. The activation of factor XI
irii.tia-tes tbe activation of factor IX {plasma
thromboplastin component) and :factor _VIII
(antihemophilic glol;>ulin).
Together with calcium and platelet factor lll,
facto~ IX and VIII are involved in the a c tiva tion
of factorX (Stuart-Power factor). Factor X forins. a
particwate complex (pr.o thrombinase) .with factor
V (accelerator globulin) and calCium.
Prothrombinase (cotnnion pathway) then initiates
the conversion of factor II . (prothro;;nbtn) into
thrombin. Thromb'in reacts wit}). factors II
(fibrinogen} bringing about fibrin ('c\ot). Septic
abortion and. c.horioanmionitis initiates OIC. by
picture' and.
nlost cases may be refr9.ctory .t~
therapy. . . ~ .: ' ~'.;.~;-;
fhi ..irtillnri$iiPQlliWai?': - -..
This inv.olves a rapid process in w:hich
procoagulant materials come from tissue injucy
a.hd is not ordinarily present in the blood stream.
A funCtiona! identiCal prcthrombinase .cari be
.produced ii:l a matter of s.econds by activation 6f
the ext:rirtsic pathway. The pa,thway bypasses the
activation of factors . .XII, XI, IX arid Vlll. Tissue
thromboplastins released by the injury interact
with GaldU1Jl and 'factor VII (ser:um prothrombin
conversion acceleJ;ator) and th~ resulting complex
causes. actiyation of factors X, V, and platelet
phospholipid into prothrombinase (common
pa;thway). Under the effects of the prothro~binase
complex, factor ll (prothromt:?in) is acti_y ated to
thrombin._T~s then reacts ~th factor i (qiF<?~eX:_) i
to-form fibnn (dot). Abruptio placenta,;_jpmtotlc iI
fluid embolism, reta_ined dead fe.tus.;tsaline~ I

endothelial damage through the intrins'ic pa thway. induced abortion initia te DIC through. ~xtrinsic I
(Figure 38.2). pathway~ (Figure 38,3)
!I
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576 SECJlON V:HEMORRHAGES mPREGNANCY

.'EXTR!NSIC.PATH'NAY Saline-induced abortioo causes DIC through .

entry of disinteg:tated placental tiss\le mto the
Abruptio pi8Cellla
circwat,ion activating the coagulation sy-stem.
r~ injury
Amnl6tlc 6~ embolism Although hyPo~brinogenemia, tlu'om~penill..,
.L R"tained dead. ktus pt~sence of fi.b dn dt:gradation pri:>ductS12 are
Throm bop/ astin
Saline lnduced ~botil9f1 featu~s of the conditio.n, excessive bleeding i3
1 usually not ~n as :~e tn~uced abortion removes
VII
the underlying cauSe.
l :"

XV PF3 Abnormal .P latelet ActiVation

C!!++
Abnormal platelet aggregation 1~ known to
1 initiate the pxocess of nrc: .Among f~.cto:rs
il ~ Thr~rnbin
r.e ;$ponsibk for.,.platelet i;tctiva:tion leading to
ab,p:pitnal aggregation in.. this s pecial entity ar~:
tl)e iel~.of platelet activator factor {PA.f) as seen
~ .t'hrqmbQcy"topenic I>:!.ltp'\ira, ~d UJ,e. dcficjency
:F igure 3B.'3. :initiation of PIC by e ntry of p~ant
.~~teria:l il;1 tl;e ~tion through :the extrinsic.pathway.
of i_:m)~cj.clin.,. a regwator a;r. pJ,at;elet a<::ti.yity.13
Pre..,ec~hipsia m:ay tclgge,r DIC throu,gh this
~e!;jiiUijs~. PAF and d'ecreased prcis.t icyllne
. ~u:se:s :ia.ctiv.it:y off~ct: ~ V .a;-;a. piat(!tlet :factor.
_., '.T.P:is .meQh;~]lh~ i~ .~n:v:ol.v~:ttin. tas.es:-:o f UJ ~:tQ~ .p.rothr:o:nlbin.a se CO!J;l,plex. (coJil'mon
.iori1puo;pl.a.'6e}}~ -;:ir~ttauterlrie~,feful'de~th'.,Qn,Q.; ..... pathwa.y};\Wn~~!' t.:he, e(f-e~ts ' :of>;in=ofuroinb_iliase-
. ret:ent?.!>r~~ ;~t>:'P.~ 0fl.trid ;.embOlism S;llG':salifie- .. cOr:npi~ =fas~or ,II ..<Prot,ht:ornbin): is. activl:t~e~ to .
induced ab9~n-;;. . thr.-ombin.. T:hrorn.b io react~ with fa:ct.or 1'
(fi~og~j_.to..fc:irD1 fibtih (dot).(Fi~e '3'8.4)
' Th~ ,p'la:P~nta-: ;~ttP. . e$1'dua:s are
ri~h. .. 1n ..
iliiOii:rb9'P.\il$nc;sulistaD.~ .im.diilie:Jatt~f3 ien.t:tj .
iti;t;(; .t:h~:~teb:t~:ve~s~~::~l~tro~:;fur9\1~. :
ga.pingu~eifue:ranu~~as .ateci- s1i4d<m ~t;ioil . . PlATElET AtTJV.(:tloN
cif.the .pW.~t:a~ ~te DK~-
_f.>lat~je~ ,~~~,_ ~~~.. g~i~~9... 1!{~;!~9nl ~-..

I
.
.
_Foilowmg a~~tb ::Qf.:th:~-4e.tu;s.J,.h.:..U~eio..::t,he .l;.,c
"
,-~.a:,~ ...-a;.;;;r;;.;,:~~.
;,.ou = ..,~ - ~ :Se.v~e
.
Pre.,
ru;t:.n,i eti.o;: fhiiil deve1ops Wo~bqplas'4l:: activity
W:illeh . ib.crea~s :-m.th Iohger J~ta~: re:te:P,tion.9 In <oo '"" ~- "'"'P'''
additio~ :p~iigillro;tt mate:r.jhl fro~ We. dead
:fettt.s is :~'l~tl;nuously . ~bs.Qibed :tes.uitin.g to
p~grssr:o.n :i:ri~ .'acute::PIC. J:l31~~ .is +tiild.to.
. does:~n~t U$lially
. . . .arl:d
:xn.aaemte ~ ' .. lead iter. ~ous
.
X \J PF3'
ep!n,piicafiotl~- C.a -+-+
~. 0 -~

AtUnio:ti.c fJP:i,d <;:on~ahiiil,g f.e'tal d.e b.:tis

o(m~hiuirt., ~e~, .lany.go) m~y.'fmd :.it,swa'yinto
I
~--'-_.:_ _ _ _ _ Thrombin

the matet:nali;ircula ti~rn . a-rr(il su.bs~qu..en tiy

Fibrinogen-....- ' - ' - - ' - - - - - -::> Fibrin.(dot)
opstruct th~ p)ilinonaty art:e~ries l~dihg to w:hat
f$ known., as anunotic. flui<;l etri~lis~. the e~t,i.ty fi.gure 38.4.lnitiation .o fDiC by plii.telct activation.
is':rate l:iutis.u~llilly fatal,. c~cteriied"by acute
re~piratou: faih~.n!, cyanosis, cor pulmqn?:le,
profciuJ14 shQck :and 'h~inorthage.' Although t4e
s~G patho_ gehl.c .. mee~sm.;i~,riot known, it THE.F~RINOLYTIC SYSTEM
-is 'pqstulated that.m~hanica.i obstructiorr <if .the
pulqtonacy~Cillation-Cap: a~vate'tl~e c6a~~ltion While .theintravaS.Cular 'GQagulation is. going
.s ystem aii:a. lead' to. sev.e re consumpti0 n .With on,. there is a tendency to thromboembolism,. so f
secondary .fibrinolysis and severe bleeding.1i "the activat~on' of the ' fib ~inoiytic sy s tem 'is .a

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 CHAPTER 38; DISSEMINATED JNTRAVASCULAR COAGULATiON IN OBSTETRICS .. 577

protective mecha,nism. Pl:S:s minogen exists
normally in the plasma .It can be cp_n verted in its
activ~ fcnn, plasmin, by tissue activator, plasma
acijvator and uroldnase. Plasmin :s plitsfibrin a nd
fibrinogen into progres$ive1y smaller fragments,
which are referred to as -fibrin split products and
fibtinogen degradation produds. (Figure 38.5)
Plasminogen
Tissue ~ctivator __._......_......._.~
<-
Pia$1rifn
.t
fibrill-Fibrlnogen
-~
Fibrinolytic spr.t procll~s
-~~gu~f~3'8fs. The fibrlnolytic.$)'stem.
. ..:.CL1NlC.M Fmt'I\URES
. . . :Gene.rany.;..'the-clini<::al~t:naili('esta:tion:n>f :PIC.
. ccan-~ea.tegorize.d ~g to the ~dea of ~ts
.that oceuriUter thediSQideT is initiated. :S~ptoms
of tl\e.underlyil!g p~ di~ WID.. he ~vid~p.t
followed by efutica:i:sigris ofo.rgan dysftlJlcti,on.due
to -oos-tiuctron . . :or di:e ~:mtcio'ClrC:iilaltcii.
Hemorrliaiic- ~athesis--Slibsequ~tJ:Y:-:occ-ux-s.:a:s
..coa~ation fa:c tors :llld platfilets arc t;Onsumed
at)d hemolytic al):eltlia witlt jaundl~ ~P~ :f;i.$ a
cons~quence o'f red ceil A.estructio~. Patients
generally l\ave frank bleeding or a tendency to
bleed -from mucous nien1Qranes, irttravenous ~line
sites, injecti(j.n ~ites, 1;lnd -surgi~al incisio.n s.
Abnormal bruising, purpura, pet~c}:liae, and
ecchymoses frequently are noted. Melena,
hematemesis, h em9.turiaand vaginal bleedit;lg are
noted often in severe ~ses.
. The quantity and character of -\}leedjng .are
dir:ectly related to
the seV;edty and ~plosiveness
of tb.~ disea~~ pr9<:;es$ . .C.~ftaJn,lJ, jn a,I:l . a~ute,
uncontrolled e.p itode of DIC, .a patient ca.h suffer
irreparable dainage seGQndary. hypovolemia or to
iritracranial ,or intraperitoneal and anemia is .a lso
a Ufe threatening event:in atiY patient with acu~e
. fulminating Dlc. Table 28.2 lists.the early a nd late
ma."\ifestations oi DIC in general.
Table 38.2. DIC: Early symptoll).s and late seq'J-.71ae.
Early symptoms
1. Generalized microvascular obstruction
In$ulficient tissue oxygenation
Shock
2. Microcirculatocy damage in various organs
Myocardium: Arrhythmia, -shock
L-ungs: respiratory distress
Cthtral nervous system; tachypn~ fever, c!:)nvulsions
Kidneys: .renal insufficiency
Skin: .infmttion
Adrenals: shock (WaterhOuse-Fredirichsen syndrome)
Plasma Activator
.3?- Consumption of coagulation factota and platelets
Generalized bleeding
tate seque1at .
1. Organ dysfi,lnction
!Gdp.eys: uremia
Liver. ja~ndice, liver ~sufficiency
R~ 'cells:j~undice1 anemia
. The sy:mptom,atol(>gy ofDIC d~~~!9.,f:>P~t~:trical
coraplications d~pends upon the ~ecl).~sm. :and
processes involved in the specific;,;.aisor.-der in
question. . ----"' .. ,_....._..,~
Abruptio ..
J)~acen~ presents 8:.?.fi4~ ~gec~
:of.mariifesta:tion~? J.11Aglpgfrom':niP..~;~01;'nl~rate
bleeding, to excessive hem6rrhag~~A~4JP.~~~t;r(mg
u te~ine contractions, .abdominal'.'.'pa;in S.. and
tendeme.~s, . and fetal death.H.In severe ~~es, the
renal f~nction is compromised and the
d~~-a.~~-~~~t h . . ~rav~~e<i -~i_~hQ_~Jf.: &u:~ _to
excessive bleeding. However. it may follow a
favorable course if support measures ate adequate
and if prompt_ emptying of the uterus or
hystere~tomy is pe.r.fonned.
Amniotic fluid .embolism is ushered in by a
sudden onset of acute respiratory distress with
cyanosis and profound shock, usually seen in a
multipara in labor. The course may be rapid and
fatal. Mortality is 80 percent with 2S percent dy ing
shortly . after onset of symptoms. 15 Excessive
bleeding is seen in 40 percent.
On the 9ther ha;rld, a compe_n sated chronic low
~aqe PJC is.seen in fl!~ed dead fetus syndrome.
Hemorrhage after delivery may be expected but is
usually mild arid responds to replacement therapy
alone. :$r
-~
Bleeding . duririg saline-induced ~b~)rtions is
usually mild. If exc~ssive bleeding occurs after

Scanned 8y: ~
. 578 . SECTION V: HEMO~RHAGES IN.PREGNANCY

abortion due to decreased fibrinogen levels and hour, it will not withstand inversion of the test
low platelet count, replacement therapy remedies tube :several tiine:s.
the-condition. The induced abortion curtaUs the The elC)tting time, a!i determined in the dot
clinical course. observation test_ provides evidence of fibrinogen
l.:ve!s. if the clotth~g ti:ne is less ~ 6 minutes,
Septic aoortion ca."l be complicated by the most the fibrinogen level is probably more than 150 mgj
fubninant type of DIC in obstetrics. "'Ill'e clinical 100 ml. If the dotting. time is more than 12
course is similar to the_t seen "h1 sep$is. Endcto;xi.n minutes and the clot is poor, the fibrinogen level
shock w;..th .a cute rcmtU failure har.a<rterize the is probably 10()..1!)0nJg/ 100 ml. Iithere is no clot
condition. l3leedin:g is oten excessive .and in 30m inutes, tbe fibrinogen level "is probably less
generalized. Residualrenal dY:$function may be a than 100 mg/100 ml.
late sequel -i ft he patient survives~ Many tases are
rel@.etory tothe~py. A -struidard blood amear, stained with Wright's
sum-.. can be u~ .to lllake a rap.id diagnosis: If
li1 severe pre-eclampsia-edampsUt.. ble~<Ung f~ than four pla:telets per high power field are
frcm thrombocytcpeQ.ia predominats Md ~ay be seen this sugg~st -thromboc ytoperila . .This
aggravated by moderate hypofibr}-no.g~nemia. suspicion CAA ea-sily be (X)~J.riPed by perfon:nirig
fu.~rebral heniortb~e m.ayalSQ eoxnp.licate the a platelet count. thrombocytopenia is
condition in pati-ent-s with S;Cvere hY'Prten~i(:;n. characteri.stieof.intravasctila.r ooagul9.tio:n bUt is
Co.~:-~Uhlons .and coma are -accom.p anying not found .in a pure fibrinolytic s.yndt.op::te. I~
mar.ifestatibns. Jal.Uidiee Wi~ anemia may :later -Qi~sem.inated :ina"Va$c ular coag).ilation the
set'ijfbetau$eof.::rnicto~~opathlt"mee:t>..anjcal red . pa:s~e ~f th~ i'~'!;l bJPQd eC:lls through fibrin
' dlr!J.Y~s; ..-..' - . : , . -m~~~- clU$.geJJ<thit-:Jpa'; :8J,ld ngni~ted
ted blood cell$ {setrls~~s}~
l.AlJ.O RATORY. DIA(lNOSIS
Wb~"E~'lalrator:yJacllitiesare a~ble."
:i'ile rabbratoJj. 4e'Sts Jor. dis.se:m inated-.. :m
the. ~t.et. ::I>I il'lclu.d~ protonsed partial .. .
itltri~ 'ci>agtilaiiPn, ~: - . . ~'bQplA*tiji lbnc 'IU'iclp'i'Qthrotn'bin timedue.
to,a.ct:tv.atiotJ ,()_f:~ '~tion l i}"$teliL "VepletJ,on.-
:L etot _61).~~~~- ~~t t>.f'~ril.:~g ,lt.bQ)lt~JOvi'Jn>ri.Jlqg~ level as.well

. 2. P-enphetat smear
~ r=:o~r~~-~ tlt.ne
5.. fibrinogen
a.~ .:4~~:.'!~~!! .~f .f~.t.Qr..YfJj, _Y,. !!ndII.
~!lU!.I:YJiibm,:_l1l _~ __rus~ 19~ ,Q.t. J;J.Men.t: JYh.e n
~~fibrir.ol,y#is &etsi n, ep~i;Qulin lysis titne
$ $h.o1Wi'l~ d. the l~v~1$ of .fibriri degrac;lation
.'6.FaCtOi":assay.8 ..,... VlU, V, ll pro"d'Utt$ lri. tlie 'circub'tliln "becQm~ elhtated .
7;Antithrombm IU Mi~_gib~llerii~lytic anemia 1!1 tnanifested
8 ..PlM-el~ts .. ~s fiagnient~d . i:ed ells in the Peripheral blood
9.. 'Eugto"bin clot lysis li.rne $lle;a~ a.nd:. 'i rireaSd taef\c dehydrogenase ievels
ro. F_i~nn :dJ~g:rndation products L'l'.lh~ .-~ (i'abl~ .ss:3,.
11. sem~ bili...:.Ul:>irt
12.Le."ctic acid dehydrogenase MANAgEMENT

'The .t;teatmeilt -Ji).f DIC"'in general is one of the

In the absente-o(goodlabcratocy facilities, the
Clot observation test and examination of a
peripheral smear ar.e valuable. For the clot
observation te~t a s-$1 ;sa...-nple ofbl'Ood is ~placed . '
in a lS~ml tes.t tube a.-11d inverted four or five times.
Thedottingmechahl$m i~ --~bnotmal i(there is no.
clot within &-12 mm\ltes. or if :a dot that forms is
not solid and lyses withi,n 1" hour. The dot size is
abnonnal if it .:OCcupies. less than 4$ pe~<::ent of
. :t he total volu,me"of the blood .sample. the dot
stability is abnormal if, after standing for half an
.mostcon.ttrivers~:fu the pMl,ctice.ofmedicine. The
process jrtvolve<t in the disorder is complex, varied
m1d c;liipticated. The dinieal manifes.t ations vary
acPrding tolhe:primary triggering disease .and
the state :Of.the_patien~ upon-diagnosis. Labo.ratocy
panUneter$that.m oilitor treatment ~ many and
fr~ue~tly :Chan.g e -4epending on Ute prevailing
CO~gulation ":defett Md the patient's response to
the-rapy~ Antrfibdnol~iGs, .~ticoag\l~ts. and
plasma products can correct only certain facets
of the d,i~ase and cannot be u~d all at the same

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 . CHAP'n:R 38: DISSEMINAtED INTRAVASCULAR CbAGULAT!ON IN OBSTETRICS 579

of fibrinogen and 100 anti-hemophilic fa~tr units

~ ,

Table 38.3. Laboratory dia,gnosis of DIC.

of Factor VIII per bag, given at a dose of 1 unit per
Hemostatic ~feet J.a,boratory paramete."'S
kg. body weight. Strictly speaking, its use should
Peytdk>n of.C0;1giilation Prolonged prothrombin time be restricted to cases with significant bleeding dl.le
facron to factor depletion. Fresh frozen plasma, when
. Prolonged activated partial plasma fractions 9,!'!! not avauable, can ~.lso be
thromboplastin time effective and can also be '..lsed as blood volume
expander. Although factor replacement brihgs to
Low .fibri,nogen
n;1irtd the theatric3.1 dictum that his ,may ." add fuel
Decreased Factor ill, V, ll to the frre, .no eVidence eXists tO show that the
giving of thee blood prodpcts has led to adverse
Antithrombin m iow or absent .. eff~ts on patients with DIC 16 Platelet concentrates
are indicated in severe thromoocyiopenia. The
Tbr6mbocytopenia LQW.plaldet count . d :o se is 1 unit/ 10 kg body -weight. However,
Abnormal clot observation test
precautions should be taJcen to mi:ri.i.rnked di~ease
.Acti~tion of f1brinolysis Shorteraed euglobulin lysis time transmission. there is no genera! rule as to the
Elevated fibrin ~gradttion exact indications for the use of thes e products.
produ~ in serum One should be guided by. the severi,ty. and duration
of the coagulation defect arid underlying
Microa..1gipp~thic hemolytic Fnigtnerited RBC inn periph.:'-:U circumstances.17
. smears' . . ''
an~~~~--- : .... - .
Eleva~ unconjugated ~.1m Heparin inhibits protcolyti(#:e~Hl'.'~and
'bilirUbin' thrombin in the presence ofarititliiombiri1iC There .
is no <:pntrolled dinicill trial regardi'ig the dl1eacy
I,.acticacici dehydt-Qge~ of heparin in P1C . . }{ov;ever, jn C.ases where
~d
ronstimption of <:oagulation factcrs conlues:and
the cliilical.cond.itionwo~ns, :the'itli~tion
{;~-~~~:-~} ... . . . my be' hidic.ate.d. A .bolus; of''TO;~otr}iriitC:s
tin,le..'fhe ;postDIC clinical s equelae are a set of intravenously flowed by continuous-:iiifu:$ibn of 10-
probletn:s one hasto deal with when ~e emersncy 15 units/kg l?OOY weight is tecO!iunended Until
m
is ()vf. short; there is nohard and fast rule nor clinical and laboratory. parameters -stabilize.
set p rotocols that will ..be -etf.ective -- tn- -its S Ubsequeril pra:telel an'd coagulation fa6tor
management. Good clinica:ljudgmertt;recognition
and treattn.e nt of the underlying disorder, prompt
repracement snout<nonovi. Anti~fibP.lio1ylC: a:gen.ts
like epsilon amino caproic aciq may be given only
decisions, and adequate supportive m easure are if secondary fibrinolysis is present. Otherwise,
necessacy tools in the therapy of this very complex they can exacerbate the . thr.o.mbohemor~hagic
disorder. One has to decide the program of complications.
treatment on a case~to-case basis.
Ma~gement .o f Specific 'Conditions
Since DIC always results from .art underljing
disorder, t.'le comerstore of therapy is correction Abniptit;; Placenta
of the primary pathologic c.o ndition. In obstetrics,
this generally -indicates termination of pregnancy. A major feature of DIC in abruptio placenta is
O~ce . this goal is a~hiey.ed, the DIC may be hemorrhage leading to hypovolemic shock and
eliminated by facilitating a return to control of the renal insufficiency. Replacement of'blood loss and
coagulation mechanism by intact hemostatic .prompt evacuation of the. uterus dramatically
pathways. On the other hand, if .the underlying corrects the disorder. The admini'stration of
pro~ss cannot be eliminat~d or if the DIC .has cryoprecipitate to replace fibrinogen an<\ factor VIII
progressed beyond the point of possible and pfatelet transfusion to correct
spontaneous, compensatory r.es.ponse, thrombocytopenia may reduce the hemorrhage.
replaceme11t therapy is essential. Replac~ment Hc::parin is n.o t indicated as it may exacerbate
t herapy restores depleted factors and platelets. bleeding in a case where the coagulation defect is
Fresh whole blood restores blood loss and volume. self-limiting. Patients will have to be closely
Cryoprecipitate contains approximately 200 mg. pbserved after the emergency is over for late

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~
 :sso SECTION .V: HEMORRHAGES 1N PRE:GNANCY

sequelae like renal .. insufficiency and Septic.Abartion and O.bs~etric ~psis

thromboeml:?olic complieations' lllay oeco/.
Septic . abortiol). and other cases of obstetric
bitrauteririe F{!tal Death ~epsis ~hould be tre~~ promptly and vigorously
\l.ith appropriate antibiotics. Heparin ma,y be given
The :eourse t>f DIC is low grade .in this entity~ if evidence of PIC is fov.nd ever.. before clinical
Hqw.ever, elevat!!d levels of -f ibrin liegr:a datio.n manlfestatious :become evident. However, in
pri)ductS in the plasma a nd lowerihg: of p~~t1ets severe'cases ~th afulminant c;:.li.Ilical course, the
~t:l :fi.br:ffiogep. hco.in.e eV:i~ent: on t.he third :to the 11se of ~eparin has not been very effective.
trl'th week. of retention. ln t ...~ose cases' 'w here Antifibt:inolytic agents ate withheld unless organ
delivery ;Of the iet),ls i:s .!>UCi:essfully .irtdu~d. ischemia is a ccmplicat.jon. Prompt evacuation of
bl~ed~g is rn.}.p.iJ.lHl.l~ lio:wever. if operatiye tb.e ut~t"l.ls in sept;.ic abortion and adequate
mtetventlcn becbti~di 'necessary,. and lal:x)ratory replacement of depleted fa~ors are ih order. Many
pttra).Jlet~r~ 4l.hrw a t~ndency to pr_ogx:' sslve ca.Ses are.refr.actory to treatment.
.cqns~pti~m.,. heparin .should :b e a~stered13
. beferi..iw:gerr .ana: replacement tl).erapy so:o uld
.'f~llo~:~. ; .
Tl:fe .p roblems of DIC in severe eclampsia .a re
simHar to lho.s:e . fou nd . in thr-ombotic
~m~pe~:Hi. .p~-pura where symptoms -of
This. etl.tity .h..s very poor sUrvival rates as thrombocytDperrla, microangippathlc hemolytic
.eapicr::staf..~RGW:ev.~t~m .tho~;..whQ;.S~ve;the . . -anenlia .~.d hy_pofjbr.l.nqgenern'ia .dqmi.nate the
diSQrl\~;~,hcnlox::rh'agem6y:~~"Witll;W~wo ..... pi~fure;:.OpstV.J:dion:;of . the. microvasculature.. of .-
'nours.aht..tl:t~Qn:.set.~t-s~.P.tP#l~nula;~oly,sis~ .. tlle kidney.S~ :$\rer: and central nervo1,1s system is
P:omiM.'t~"th ..iire~ .<>f. :p~C. 19 Asid~. 'ft:itii -.~e c.o l:tibn .~e, -use: .o f h .eparin...is of no benefit in
.gene@}::~ fi? ,~iTt#. b.~--~ii._shockf .. thi.~ cliS6idex= ~s:dang~iou int.~cerebral bleeding s
~:ll_:i,o{,)i~iitd~f:ti'-:~bit.irwlJ:tk :a:ge_n;~~ve . :lit.~y o:triur .es:pd:a.lly -ip tho se wi(h :severe.
~ .~rin'~nded:.buf $e: risk 'ji~ted mth .liypeitcil.sio;n. Control ~f'the .eqa.m:ptic state and .
fhi'=ir: -~ ~h.ii:vytO. ~b:e::v.teigfi~a~~t~thed:~enefits l, -ilyPertensionv an"d-r:apid~termination:ofpregnancy.
:f;t:erl,v~edi_~-r-.a~-~iao/~me~i. ~th~a~y:~ s.h~u-ld :be . ar~- v~ry: -iw~r~t:: ~-~ ~~~r~s. ~r~~.h frp~en
adim:riistett;d '1 mt hils to be mmiltored to a-;oid p~sma . r:~th,.e:t th~Ii pia;telet .cpncentr.a~e s is
.~$)!! :~f~ii~4}~ . . -. . ... ... .. . . .. . . . -
.:iecpiriili:~!i<Ifff:.

Consumptive ~a!Ju.top~thy or defibrination .syndrome happens whe:-~ the balance betvteen the
cO,agtllatioh :ea~de .and fibri/)qlysis t>ecome.s a~normal. _
Proihrombin time '(Pi") le~l$ fu~ integrity of. extrinsic r o.a gula'tioh system. Howev~r,.it is -recommended
that tl:le .international n.ortnafized rati.o be :used, inst~ad- o f the .grea't variaoility in the results of
pr9.tl)rombiptim~_. Normal value for INR is 2 to:$.
PaftialtfirombQplasti;'l time {PIT) examin~s :intrinsic .coagulation pathwaY: The normal value~ is 25;-
. 4-1 secon9s. . .
~e rill.mber of .f)late1e.ts that wiU indicate bleeding tende~cy Js <30.;000/cu fDffi.
The:normal valpe of:fibrinogen i~ .1.5-4gmJL but on the iirst trimester, i:t becomes 450gm/J,_. A value of
tess :than 300mg/dl ~i~nifies.the.presene;e' of abnorrm11coagulopathy. . . .
~ '9iot ~ose.fvation .test: is a poor man'fibnnbge1_1:assay. lf no clotis observed within 6 minutes or it
show~ tysis .of clofwithin'-30 minute~. there may be eoagolation defect and possibly. th e fibrinogen
level':'is < 150mgldL.

Snanned 8y: C
 CHAPTER 38: OlSSEMINATED INTRAVASCULAR COAGULATION ,IN OBSTETRIC$ ' 581

0-dimer indicates the severity ofintravascular fibrinolysis and is also very specific for D!C. The normal
.value is <4941-lg/l. If it becomes> 5001lg/L, it is an Indication of OIC. .
The normal vaiue.af fibrin de-gradation -products (FDP) is <10 )lg/L. If the level is >100 )lg/L, it signifies
ex~ssive fibrinolysis, a featur~ of 01~.
Antithrombin is the main physiologic inhibitor of thrombin and .factor Xa. It indicates accelerated
coagulatiQ..n.
Fresh !tozen plasma (FFP} and stored RBC supply all the necessary eiements such as fibrinogen,
factor V, factor VIII and antithrombinHI except platelets. These clotting factors in the FFP will remain
active. for at least .12 months if.it is. eorrectly
. . kept.
. Heparin ls eontrainciicated In hypovolemia.
Earl'j and sufficient fluid replacement will avoid renal failure and assist in the clearance of high levels
of
of FDP from the cliculation by way of the -liver, helping in the restoration normal hemostasis.
l
lf"the patient faRs to improve With blood replacement, maintena-nce of organ perfusion and oxygen.
temo\lal of the c~use, it is better to refer her to a hematologist.
DIC is a global problem as.sociated with abruptio pfacen-~. septic.abortion, chorioamnionitis, amniotic
fluid embolism, PIH, and llJFD.
~ . ~ .t. .

A:del!cate balai1ce exists between low grade activation of coagulation factprs and~:pJate.l .ets ;-..a.nd -:-:,
(letitralization ofactivation products in the circulation. : ...:: -::: '~. .};,1::,: '
The mechanisms triggering events of the endotheiiaf damage is through the intrinsic pa"ttiway;~;massiSie
ti~ue injury is through extrinsic pathway, and abnormal intravascular" plate~et activation.
.. ~-.J. -,;.,..-~ -

I
I ..
..:: ..:..

Th~~ymptomato!ogy of DIC depends on the mechanisms and processes invo!ved,;J.n.:Jhe sp~Gj~c

.c!i~SJ.~.!'!rs. . . . ".:-:-:: ; ; .-. ~;_,. - : ..
There are varied laboratory tests that. may be employed to diagnose DIC ranging from~tfle?periph'er;al.
smear .al')d clot obsarvation test to the more confirmatory fibrin.degradation products and lactic acid
dehydrogenase.
The :treatment.of.DIC. in -generalis most-controversial and directed towards specific conditions like
abruptio, IUFD, amniotic fluid embolism, septic abortion and eclampsia.

5. Jacobson RJ, J a ckson OP. Erythrocyte fragmentation

1. DeLee JB. A case of fa tal hemorrhagic diathesis with
premature detachment of the placenta. Am J Obstet
1901; 44: 78 5. . 6. Lee L . Reticuloendothelial clearance of circulating fib rin
2. McKay 00. Disseminated intrava scular cOagulation: an
intermediary mechanis m of disease. New York: Harper-
lioeber, 1965; 493.
3. Mardar VJ, Martin SE, Francis CW, Colman RW.
Consumptive thrombo-hemorrhagic disorders. In RW
Colman, J HirSCh, VJ Marder, EW Salzman: Hemostasis
arid Th.l'ombosis: Basic Principles and CJ.itUcal Practice,
eds. Philadelphia Lippincott, 1987; 975.
4. Siegal T, et al. Clinical -and lab9ra tory aspects of
disseminated intravascular coa gula tion (DIC): a s tudy
of 118 cases. Thromb Hemosta t 1978: 39: 122.
in defibrina tion syndromes. Ann Intern Med 197 4; 81:.
207.
in the pathogenesis of the generalized Schwartzm an
reaction. J Exp Med 1962; 115: 1065.
7. Bone RC. The pathogenesis of sepsis. Ann Int Med
1991; 155: 457.
8. Graeff H, Kuht:l W (eds.). Coa gulation disorders in
obstetrics: p a thobiochemis try., pathophys iology,
dia gnosis, trea tment. Stuttgard, Georg Thie me, 1980/
9 . Pritchard JA, Ratnoff OD. Studies of fibrinogen and
other hemosta tic factors in women with intrauterine
dea th and delayed delivery. Surg Gynecol Obstet 1955;
101:467.

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 582 SECTION
~- ..
v:HEMORRHAGES
'. . ' . lN PREGNANCY
. ' .

10. RuS3el WS, Jones WN.-Amniotic.fiuid enibolism.Obstet 14 . Graef 'H, Kuhn W (eds.). Coa~lation disorders in
Gynecoll9&5; 26: "479. o b$tetrics: pathobitJcheroistry, pathophysiology, 0

d.iagno.si.s trea~ent. G.eor~ St\lttgard, Thieme, 1980. .

11. Brozman M. Hemorrhagic disoraer:sfollowin:g im.niotic
fluid embolism. Clin .Obs.te.t Gynecoll964; 7:.361.
12. I3eller F K, Rosenber6 M, Kalker M. D ouglas GW.
co:nsutnptive <:oagUlc pathy .asso-ci.a ted with
iritraamniotk fn!usion:ot'hyper:tonic salt. AmJ :ob~tet
Gynee9l i912 ; U2~ 534..
13. Fuster V, et al. Assay.()"( -platelet factor IV 'in plasma.
Mayo.Clin Proc.1:97.a; 48: ~03 ..
15. RussclWS, Jones WN. Anmiotic 'fluid embolisxil. Obstet
Gynecoll965; 26: 4.79.
.. .
16. Pitney WR. Disseminateq. intrava scular coagulation .
SeininmHem.at 1971; 8:{)5.
17. Beiler f,K, Us zynski M. Dis5eminat.e d in tr~va scular
coa:gulaticn tn preg'r..ahcy. 'CliA,Obstet Gynecol 1974;
17: ~so.

~ 18. Belle:-FK., et aL The fibnnolyticsystem in a.rcniotic Jl)lid

~. embolis m. Am ~ObstetGynecol1963; 8'1 :'48
. !

I
j.

..,....
.

..
: ~

. ... ~ ..

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0

.,.

Scanned 8y: ~
 .-
--.

...... ..

., . ; ' ~-

. .

L.

...--. ...

...

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 39
HYPERTENSIVE DISEASES
IN PREGNANCY
WALFRIDO W. SUMPAICO, MD

Introduction and Epidemiology

Definitions and Classification

Hypertension
Proteinuria
Gestational Hypertension
Pr~lampsia I Eclampsia
Chronic Hypertension
Chronic Hypertension with Superimposed Pre-eclamps!ai Eclampsia

Pathophysiology
Pseudo-vasculogenesis and Placent~l Hypoxia
Changes in Various ~nd-organs

Diagnosis
Risk Identification
Clinical History
Physical Examination
Laboratory Tests
Ultrasound

Preventive Management
low Dose Aspirin
High Dose Aspirin 0

Ant_i~oxidants

Definitive Treatment
Control of Convulsions
Control of Hypertension
Optimum Time and Mode of Delivery
. . :!it
Management of Mild Pre-eclampsia : .~-

Management of Chronic Hypertension

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 SECTION VI:
. COMPLICATlONS
. . .
IN .f?REGNANCY
' ... ~ ~.

INTR9DUCTION AND EPIDEMIOLOGY Protein.u rla is defined as urinary protein.of.at

least 300 ;mg/24 .h6u'ni urine sample or .a tk:a.St
Every year, 536,00'0 w.omen 'die from. 1., 000 mg/ ranQc m sample of urine taken 6 hours ;
pregnancy~related causes. Mor.e than 80 percent. apart. Qu-alitatively, dipstick VC}lues of 1'rcite3 to .
to
. . .q'f maternal deaths worldwide are .du.~ five d irect 1 + signify mild proteinu ria wh.ile-2+ to 4+ signify .
Causes: h.emorrhage, sepsis, unsafe abortion, heavy proteinuria.. The dla.gnosis of pre-ecJ.a:m,J>#a
op:>tructed labo.ur and hypertensive disease of is suspeet in the a bsence of proteinuria.
_pregnancy. 1 The latest repqrt from the Conijden.tial
E:I:l.quiries into Mate-r nal D-eaths (YK) 'lists Edema is s-qch a coromo~ finding tlia.t its
eelimpsia and :Jrr.e-~~Jampsia as the -seco,nd most. . p~esenoe doe;s not valic}ate the presence cf pte-
. common ~14-~ .and stiowed-:an ip_q~S :'fr:cQtl;l tP;~ ~c!~.rnp$.la. ..
pre\jo~s; ripo~~:'fb.e l~tes~ -st;Mislice 'fr<?~ fu~ ..
Pt.iU:Jr~ Ol!~te:tf.icai anq :G_yne.o~cill. $oc.ie.g Gelltatio;n,al_ ~YP-~rtenston. is hype*n:s1on
'{2-006Histca ~ens~o~n aii ~sitl..g :l ~3 f .54.5 Witbo~t. pt9tethuna' occun::mg after Qb . wee~s
'={~6.~4%) inateirtal d~aths. Flirfuer bro\refi do-wn. .g estatipn. or
.po~tp.arturn.. It is a terrrp<>raiy.
}l~rtension d~aths were preecla:rnpsia (SO), P.iagnosis during pregn~ncy whi ch has :to be .
. -e1iw+.psi_a '(66)., pre-existing. hypertension (8), confirmed 12 weeksafter'deliver-y. If}l~~n
:~clc- hyperten:;ion with .p re--eclampsia .(8) a.n.i:l re'Pll'Us to nortnal .lev.els: the final - diagi;l~-;ls
;$ p;P s)':p.drom~- {11).3 C.le8.1'ly, fueref.ore, any tranz~ent .b~rleri?iort. If hypertension -~Sl.sts,
;atfipt,:fu c:urb ma1;etnal and peri.n'a1;.al mortality the final diagnosis is ehrc!liC kyperten$on. : '.
'.aha morbidicy 4 ue to hyp-at~nsive states will
. :res~ noto~ .in1ess.1o~s :of.llvesbut:8.:1Sb in l~sS . Pre-eclamp'siR-i:> tae:pre~ce.ofhype~oP:
-'de~ation:of.:finimdal,and;}J:;.ateri~-reS?lirce~. and prQte~u.ri~: oe<:;u.rpng .}lftet the 200, w~'.of.
geatatidn : except fb: c?;ses of ex:ten.aive
:l)EFINITIONS AND C~SIFICA'TION :tmpli:opl?-stic ptolifetat19n. Preeclamp~.hti.s~
. . . as
:..~. futt}icr C:fuss'if.ed: .sevete .in the p~6e .
:Numerous cl:assificati~n she:mes- h~ve be,:ln . :of. oni or 'lhore of the following signs :.and
.p:ro,posed bP.t tb.~ c.upim.t ezlass.ifi~tion -ad.cpted symptcms: '
.:~: :~s--hapt.er .,_tep'resents the. 20Q2 :m?difie'd-> '
. ~~J!{p. offue Am.eridl.n Colle~e 6f (:)bstetrician's 1. -J3P.cifatlep.st 160:i:n.niHg.eystolic or 110 mir;Hg '.
-~ 'QYnecolo:i;ist~ a nd the ~QPP .~-~ggrt Qf ;the &:astoE.~.. . . ,... ,;;:.,- : .
:, :fra"ti,<)n3f~J~l~ ii~$.~J:!t~ W~t~G:r.oup. on . :J
~]ti&h Blood rre~sure in Pregnancy (Table 39.1).3 2. Proteinuria of at .least 4 grams/ day .or a
,' persistent qua.l.itative 2.f or m,o:r e on dipsgck
With severe rei:lhl involvement, the sdu.m
creatj.nine will .be ~oted.- to rise. . ..
. _.- hb.te 39.1. Cla,ssi,fication of hype:rt~nsiv~ disoniers '.
. ..~.rt;plicating pn.gq.mcy (Am,erican Qollege ofObstctrici.;:ms
... : .. ;~d Oynec610gi~ts. 200~}. . 3. OUgu;ri;:t of less than 4:QO -ccfday siglliffjlfg._ .
decre.as~ renal b)<?od . flow an4 dim:ici*~
.' i .;G:estatlonhl.HY%rtep.sion glQmerular filtration. rate.
2~ Prc;-lampsia j:EGl~psia 4. Severe headache or vis;Ual disturbance~- .
attri}Quted to ~er:eb.r}:U edema. .
: :3. Chronic Hypertension ... '
-4.. Cb.ronic.Hyp<:rten.sion with Superimposed 5. Pulmonary edema or cya.r;1osis . can oe due to
. Pre--ecl.atr\p ~ia I Ecla:;np;;ia hemo.dyrta,mic changes, predominantly i,ln.:
increased after1oad.

6. Intrautedhe growth restriction (IUGR) is

Hypertension is .dia,gnosed wh.en- tbe blood caused by diminished Utero-placental: blood
. pressure is at least 140 omHg :systolic or 90 flow. .
mmHg diastolic. The previous definition of an :
.. i,Ucrease of 30/15 mmHg. over baseline val~es- l:tas . 7. Abdori:rinal pain, epigastric o.r RUQ iri location; . .
t.een .e liminated. . . results from distention of Glisson!s capsule .of. . : .

Scannec18y: ~ . .
 . CHAPTER 39: HYPERTENSIVE DlSEASES IN PREGNANCY '587
to~''

the liver due to hepatocellular edema and/ or 'rable 39;!2; Causes of chronic hypertension in pfe!nancy.
necrosis. Rarely, this symptom may presage
Chronic Essential Hypertension
liver rupture from a subcapsular hematoma.
ChroniC Hypertension due to Renal Di:>elise
8. HemoJyeis-is e~ent as increased s erum LDH,
h emoglobinuria; hyperbilirubinemia or the Interstitial Nephritis
presence of schistocytes.
Acute ~d Chronic Glomerulonephritis
9. E levated liver enzymes are caused by Systemic Lupus Erythematosus
hepatocellular necrosi~.
.Diabetic Glomerulosclerosis
10. Low platelet count (thrombocytopenia), Sdert><;tenna
1QO,O&O{mm3 is proba.b ly du~ to micro-
. -- angiopathic hemolysis induced by spas.m. The Po'lyS,rtetitis Nodosa
triad ofltelilolysis, ~levated Liver Enzymes and Pol~c Kidtley Disease
Low Platelel Count is given . the pnemonic
H~LLP SYJ:Idrome. Rentwast::ular Sten9sis

. EchuJ1r.sta.i$ the ~te~en~e of convu~sions in a C~onic Renal Failure (Dialysis-dependent)

wo~an With undet.~rng pre.-eclampsta. If pre- Renal Transptant

eclamJ}~!a is n ot pre~ent, conv4lsions may .1.

rept-es~i'l,1 a nel,lrolQgic dis<>rder. . ... ~~ G-:~fi" !f'. ~:~:

. :-~~~};: Chronic Hypert~sion.du'!: Jn_Endocrine Oiseas~.t ~~---/' '
Chronic hiPerten&io~ is suggested by the Cu$ing's Dise~se ,a nd Sf11droi:l)e
presence ofa.blOOd p~ssure of 140/90 nunHg or
:greatetr1-p por t o.. pregnaney or is detected before f7imaryHyperaldoster.:>nism
Ql.e 2011> 1~ of pregnancy ~d persists long ~er . Thyroto;cico~
-deliv.etYi:~:}.fultipaf~ty ana .hypertension jn .
preVio'iis :t>re~cy help support the diagnosis. Pheocl):romocytoma
Es~n:tial tainilil'll hypert~nsidn is responsible for '~! ' : ~
Acromegaly
90 -percent o.f urtde'dy'ing vascula r disease in -.
pregnant-women. (?,ther"C<l:uses: are -listedin 'Table
39': 2-;--- . . .. - . . . . .

Sup~rhnposed pre-eclampsia on pre~existing

chronic hypertension is c haract erized by
increased diastolic or systolic l;llood pressure over
baselin~ hyper:ten.sive re adings .a nd i s
accompanied by profeinur.ia a.nd sigas and
symptoms of end-organ dysfunction.
an
trophoblastic hypoperfusion with endothelhil
dysfunction is the most consistent change in
pteeclarhpsia and is believed tq be the pivotal
insult in this disease.

Sup.e rhn.posed eclampsia on pre-existing Pseudo-vasculogenesis The.o ry

ch~onic . hypertensiori is convulsion occurring in
~ wq,Uan with chronic hypertension and
superimPosed pre-ecl~rripsia. The indicators of
severity in pregnancy aggravated hypertension are
. simiiar ta those of acute pr6-eclampsias. .
PATHOPHYSIOLOGY
Numerous theorie.s have been advanced
regar<;ling the cause(s) o( PIH and the reader is
referred to the book of .Chesley4 for a historical
review .of these. Current data indicate tQat
A pathophy::;ioiogical study 5 has examined the
hypothesis that placental ischemia occurs at an
early stage anct upr:egulates placental production
. of a soluble protein called soluble like tyrosine
kinase 1 (sFltl) that leads to maternal endothelial
dysfunction and its clinical sequelae of
hypertension, .p roteinuria, and edema SWftl acts
'as a potent antagonist to vascu la r et\)thelial
growth factor .(VEGF) and placental gro~ factor
(PlGF) which help to reduce vascuiar fone and
blood pressure.

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~
 {
588 ,~_,,SECTION V.l: COMPLICATIONS "IN PREGNANCY

The study further showed the foUowing (Figure 39.1). This proces~ can be. described as
fmdings: follows:

f.Total serum sFttl was nearly 5x higher in those A) The early stages of placental development
with severe preeclampsia. than in take place in a rd~tively hypoxic envirqnment that
normotensive women, and this .d ifference was favors cytotrophoblast p!'oliferation rather than
not explained by earlier gestati(lnal age. differentiation .along the invasive pathway.
2. Serum ELISA lev:els of free VEGF and P-lGF Accordingly, this cell piJpulation (green cells)
were significantly redt.1.ced in th~ p'l"~sence of rapidly increases in number as compar:ed with the
recombinant sFtt1. embryonic lineages.
.3. .Angiogenesis, i;l..S reflected by endothelial tu"be
fonmi.ti.on, wasi.ohihited byserurp:.fromwomen B) As developme-nt continues, cyto-
w.ith pi"eeclam.psia. a.").d a.n analogus effeet trophob1asts (dark green cells) invade the uterine
Wa.s noted in vitro when .sFftl was added. to wall and pl~~ the t!iatemal ve-Ssels, a process that
serum from normotensiv~ Wb~en. Adding helps maintain :a stale of physiolGgical hypoxia.
VEGF and PlGF to pree:ctam:ptic seru=m As bdkated by.the blunt arrows, cytotrophoblasts
migrate farther up arteries than veins.
restoted tube formation. M m .v itro CJ..ssay far
:m.icro:vas~ula.r =rea.ctiv.ity showed . that. . .sht:i C) By 10 to 12 weeks ot.human .pregnancy,
bleckeC. lhe ..dose::.depenq~nt :1n.crease in bl~: floy.r to _the interyill.Qus !;p~~e:~s. A.s"..the
vasod.ile:ticn produCed :by VE~F.- or .PIGi-~: endov:ascu~ar con:)<p;;>nent .of _ytoiro.phobla~t
4. ' M.ost importahtly). re<iompinap.t actenovirus inva~ion :P.fogre$ses, .UJ.e' cells n;ti,~t~ .aJcng .tlie
. enc.<?dirrg ~he. murine sFltl g~rre p _toduct lurnina ofspll:al a,rteiiql~s, replB..~g the.Iil~tbmal
proouttd''~igri.ifibi:D:t:,b:~rtenslomand.meaV;J.! .endotheliallining...Cytot;r.qphobi.asts,area lso-found ~'
albuminuria;;when.,il).ject:e~H~to pr~anh:ats:.' : in., ~e. sw;ooth musde waJls df these vessels. . In
llistopa.fu ~tiO.n in ilie pr~grr"i,mt-iats . no:p:ri;ll;pregnancy.th~ p~ess.whereby.,plicental
were . ~ells.. remodel u.te.tin~ arterioles involves th~ .
. treatd, with sF'lt1.:sh::>Wt?4r.enal-'glon:letU:JJ<
. erua,rgroti,Od~PJllW.loops:W:er~bc,c~uded. by .d~.d:a~ali.~-?-, inn~r. ~irq',of tP.C:."-1Y.9IIi~~rlal
.sw~Jllen; :hyperttophied . hd~pi1Hfry. c,e Us: por?o~~ Q.f;tlje~ y~ss.els~ As 3, r~sH+~> the.cU;:m;l~ter
.::These; fmqin~ sl;l.ggst a.,eaw:;e,laP.d~.eff~ct . of..'the :ai:terio.~e.s:.~xpanR:s: to . a:C:cot:Cpr~f.e..:tP.e:
.reiati"onsliip that . exces-sive pta.~:: ental dram~1:i.C:Pi~ea~ ln bl0$!i fl.<?.~ thatjs n:e~~e~ to
pr.odudic:;J. {):r .sE.In .cQatr.ibiif~,:; to s';~R91!.~E~~f~~..!?.f~~ ~~'i.;~. P.~:fP.-~pGi.: It
. .):ly~rt~nsion,. px:pteinur.Ht, .and,...globieritlar i~..IDc.sJY .tfi.J~;~.~~~,q .~gl?,.y~~~ .~_vasisiR.l~if~,.
. endo.th~liosis in -p,ree1at!:lptjc wom~n:. in some cass, to .abot:fion, wrrere9-s an ina9.illty
to inv.ade to :the appropriate 'depth is associated
Another protein fac.tor in pseudo- with of
px:.eedamps~ .<;md a subs.et :P~~it.s in
yascu~ogenesis 1s s.bh+'ble endoglin. It is whici'). the ;growth .cif the.Jefus is restri<;:te"a:
<
p.pr~~lat~d .in :syncy.tiotii:\phQ..bl~sts ~d its levels
,are.~gge~tea .-d #ga}id, .significant1y,,.:prior. to
ili.e jn~t .of p~p.~~ :syt:n,p.t9~s. u,!~!f.e.,. :il et
l:J.ave recentzy demOtl$trated ..'a 2-.3x. el)dq:gl{n
i-cc rea:se. 1n preJ;erm ahQ. term pregnart.cy,
res~ctively, co!llp:a{~d to . ~on-pr~griant states:.
$igriifka~tly, in.iid pr~ec:la~psi?., sev.ere
pr.e:~c1a~psi~; a~d H~LLP . syp.dr~rn:e a re
accoinpailled .by <t,rurther th:tee~ ,. five-, i;Uld.Jen-
fold increase in..eircP.lating. ep._d oglin, re.s pectively.
Tn:ese "elevated endoglin leveis Closely para:ll.el
i n,creases in s.E'lt~L~

: What cau~ee the upregul~tion. o"f..s}flt1.: and

other anti-angiogenesis proteins'?. F.lshe~, ..et au
<?ffe~ an. expla;11ation. that. p laceq.tal-.:hyp.oxia
(decreased oxygep:) serves as the driving force"for Figure 3 9 .1. P:;eudovasc~logenesis and 'placental hypoxia .
U~,e phen~nnenon. of "P.Se].ldovascuio genes is." (Fisher; et.al.') . . . . . . ..

Scanned 8y: ~
 .CHAPTER 39: HYPERTENSIVE DISEASES IN PREGNANCY
A summary diagram shows the current
thinking that preeclampsia may be considered a
2-stage disease (Figure 39.2).
. Chang~s in Various End~orga'ns
I>rC:eclampsia mus t be Viewed, therefore, .as a
IIiultieys~- -disease affecting alrn{)st:aU organs
of the'bOdy witli endothelial cell dan1.age being
central to .its .~ymptomatology.
He!tlodynam'ic changes ca..'l be sU1lllllarized as
follow~:
1. Myocardial contractilitY is rarely iplpaired prior
to therapy and ventricu!at function is within
nonnal 'to hyperdynamic. .
2. Afterload is elevated in the absence of therapy.
3. Cardiac.o-utput varies ihversely with afte.rload;
if BP and afterload .increase, then cardiac
output falls.
4~ Medications which decrease afterload
. (hyctra:laiine) inc;rease cardiac output.
5. Ventrlcular preload is normal or even low in
the abse1;1ce ofvolume 'exp~sion.
6. Hemoconcentration of blood volume :is . basic
to women with HDP; th~s, they are sensitive
Seanned lly:
' 589
to vigorous fluid therapy when l,lsedt(rcorrect
the contr.a cted blood .volume and even to
normal.blood loss at delivery~
HematolQgical System
Hematological abnormalities associated. with
these diseases are the following:
1. Thrombocytopenia may develop and at times
be life-threatening.
2. Some plasma clotting factors may decrease.
3. Erythyrocytes may be $o traumatized that they
undergo bizarre shapes {schistocytes) ~d may
even hemolyze.
4. A severe ~epc~ency of the soll.lble ci>~lation
fa,cto.r$ .may occur in .t:~,i pr.~sence of
con.s umptive coagUlopathy conditions like
abruptioplaee~ta~ . . ~.:;._:;.\.,;".
..~. :,.~.:~~f-:::-_7:;:... . .
5. Aritithtombin III 1$ decrea:s:ed!')~~w.hile
flbronettiils ~ increased in pre~ecl~p~ia.
EndoCrine Cha:n,ges
Wllile p.lasxna levels of renin, angiotensin .U and
ald.Q:St~l:Q.Ue.: ..~r.e. .in.Gt~A~-~~f iti riPrm_gJ
.pt:egilancy.., ...these.Jralu.e.s..decrease ..to .i:h.e
nor:m31 nonpregri.ant range in womefi with HD P
who still retain a lot of sodium.
A. potent mineralocorticoid, deoxy-
corticosterone (DOC), is increased during the
third trimester pre sumably coriverted fron:t
plasma progesterone in ricn-adrenal tissues.
'Increased levels of antidiuretic hormone lead
to oliguria.
. . Atrial natriuretic peptide (ANP) is released
upon atrial wall distention from blood volume
~pansion and this leads to increased cardiac
output and decreased peripheral resistance.
r.
The Kidney
While .n ormal .pregnancy is characterized by
increased renal blood flow and g~merular
filtration rate, these run ctions are d,ei~eased in
HDP. Plasma uric acid i~ typiqllly el~ated and
proteintlria is frequent in the third pregnancy.
Microscopically, there is the charac teristic
C
 590 . SECTION .VI: CQMPUCATIONS:IN PREGNA~CY

glomerula! ~pillacy endthelial swelling with Risk factors ~ss'Ociat~d with the pregnant
subendothclial:depo-,Sition .o f hornogenequs protein woman:
material called glomerular capillai;y endoth~osis. o First p~ancy (6-7-x, .r isk)
o A&e under 20 or over.3;5
T:he Liver o High blood pressure before pregnancy
o .?r~vious pre-eclai:Ilptic pregnancy
Lorig ccnsid~r~g as :a pathognomonic lesion o 'Short inter-pregnan,cy :interval
in eclampsia, per:i;pq~ h!iirn>rr.hag{c -~Sis in o Fam.i)y history (mother or sister had
the periphery 'of the liver lob~le most likely . pr~clrunpsia) .
~~lains the. elevatian ~yf liver en.zymes. The.$e o p besity rfhin is h"l / S tout is out!)
le.sions ip. turn may 1ea9; to 'l.i,ver m pture {)r me o Diabetes, ~ddney disease, rheumatoid
formation ofa ~ubcapsl;tl.-.u- herh.at~ma making the arthritisj .lupus or
s61eroderma.
p51-tiept col:QpJ~ o..i ~:pi~tric or R;UQ pain. o lOw socio-econcmic s tatus .
o Poor protein w Jpw ca:idum in the diet
~.J::rllfervous_ Sy..tem
Rjsk. f actors asscx:i:ated with the pr~~nant
The princ~pal cet:ebral .lesio~:s are ~etna, Wonmt\'3 Jms~d or part:her
hyp~remi'a, fucal .an:xni~ . thr<:>mb.Q sis an.~ o First .time father.
h.~+n.o=:rh~&,~ .~~~t Vf ;~s ()'. ~e p~ Ol o Pr~~~~ly ~thered. a pre-eclamp~)c
. ecialn,ptic ::woii:).ep<rev~ h~dep.$e 'c6rtial .a.teas P{'~g:F~..cy
~ept.~~~nti~g . p:~t:eiht~ .:li~m.a,t-i~g.e.'s -a~d
.infmtion: "Amf.;iit~$i~~$.!4idi1t;;Ss}'":~~d; retinal Ri*factorn ~ssq<.jated with the -fetus
deta<:;lui1:~ntt:m.~YJ'~\se.r.~~;;~tdQ!~m:siF-~inflJI , .o . -~.-il.iltll~tal;-pr.egn~cy . .. -.. "' .
. .us~ to~w.~.~setwies.;~a. b;~liev., ~u~d o Hydr~ l triploiciy .
py cetebi:at~;~it* tp the :pat:i,e~~,s ~tn$J P?fity to .o Hy.datidiforrO., mo-le.
autor~te .cer~b~f:blP.<>Q ''flow~ 'A. more ~mister
.ca:u$e.:
. ... (.}t-c0:niais
. . - : i-n~-m.e.m~~
.. : .. ..... ...: .. : .. .. . . : . -
:~

... ... . .. ,c~inidi :~~~~e~t: 'of~:the. -bi~~ -p~e~Sur-e

is the :key to the ia!!n:t.l.q.~tion .and: Iq.ilruig'ern.~nt
.. ~Ce>m:p:r1)IDJ;s:eQ; . phf;efiti:t1 :p.erltt~i<>li froin of p~e~.ecl~~ia. Q'~estions have' b~en a:s ked
Vt;;.~~~~s~~:,Y.-fi?.emajorcUl:P.rit-4;the reg2.tding..!he-acCur.a:c-.f of;f)~--~dmgs-haseci:-on
. genesis""P.f-perlnatal:-m:artalitJ-dmd-:nrorbidit;y 'seY~..f?,:ctor.s-{siZe-pf-arln-;;qidto_r-'BPcu:ff;:which .
!ts~qdi.e_t~:ci. Wit4 :~~?. Pi~inlsheit i'i:hrce;1h~l l{orpt1{Qlf t:ound to u~, t.\.qle of $P I'eadi:Q.g, etc)
_tn~r-ru~ion h'?:~ b'~e~ .$e?.;~tr:-;ed ~-it-h. ~irett but.' cimici:;(n.s u::~v.ally e:niploy 'Vf0:/90 n:irn.Hg as
. .l;n~~~i.eme~ts -u~ip.g ih:(< Iti.ck pFinci'pl~. with abso1ute Gut~off. values :for ..hyp.e rtension. The
'i ndJr.ect cleata:iic~ ;r ate:; 'o f s-q:bstati:C:es like ' ;lx:ha~or of bl~ pf:'e~ure ,using .prefP.'laill~y h as
'qep.~p~~~;~~FQ'ge.~a:te-~cj. ~~d:~~ntly - ~~ nse<t . by .c).i,nic4t,t:is ,~n pn!dicng future PIH
by. J)oP,}?lr. Y:r9cHj..~.s;v~f'o:r~ ';i~qJG~!! 9f the in the lvfean At:teiip.l. :P.tes sure (}41\'P) test.
Uin:Oili~.bihd :\ltePn:e art~:n:~~- .A .pa$~.gnpmqruc
lesiqn::ca:lleG.. a ii.te :iitherds'i~ w.fj.cs. 't?how n in The Mepn: .Arterictl Pressure (MAP) ..Test
. .
pl,acen:tiil: bed. bio;p:~ies . of .hypertel'lii've -women
.cl}ar~ctei'~ ~.bY . p~)~+.in/~nt ;H:p.i d-r,tch f parp cells J'4.e an a;r~erh~l pressu r-e . is ~-efin e.d as the .
in the :ut~r<lp'4l:c~~-~ ~essels. &stolic pressure + 1J3 tbe pU.l$e p ressure or, in
math.em.a tical form, lviAP=DBP+)/-3. (9BP-DBP) . .
DIAGNOSIS
.A.MAP ~~ue in. th~ .2nd trim~te'r (~-.7) ><!0
'
.C lil:Ucal ltlstory mm}!g or a MAP value in the $''\trimester (:MA.P-3 )
> lOS ~rilHg has resulted in. a n increased
Epi4~:~.ologi:c.a,l studies.-.a nd pr~vJ_ous. c:l~nical ind.dettce.of.pr!!-~clamps~a-and.perinata}deaths. 1?
:experience :have:ihown ~he-:fo\lo'y/iqg. t~ b~, risk The lower; critic.al cut-offs in the 2"d trimester-
"fa.ctol'~ ,ir)., ct.he fUture . dev.e.lopment of repr.esent the m.ld-trimester drop in BP which
pre~da:mpsia: .
. . the belief that ~ro'phoqlastic
. strengtP,en-s
. . .... . .. . . . J
.

Scanned 8y: C
 CHAPTER 39: HYPERTENSIVE DISEASES -1N PREGNANCY
proliferation at this time has resulted in dilatation
of the spiral arterioles. Expressed in another way,
the tbsenco of a mld~trhnester drop in BP
de~p.lte .!rtflP2 values < 90 mmHg may predict
futl:.re PIH based on: t~e absence of arteriolar
vasodJlatation ~O:d ahould alert the phys.ician
. for closer foUow-up. Some authors suggest that
the .MAP~2 va.Iue may be more predictive for
chronic hypertension. 11
Laboratcry Tests
.Although one ca-11 employ esoteric test's to
predict PIH, there are probabiy theSe simple ones
Whi6h :can be used as we!l without expending
.much needed resources:
1. HematopiL Pre-eclampsia repre.sents a state
. ,o f hemoconcentration .. and . increased
he~a,t:ccri.t levels, .A fall i,n repeat hematocrit
va.lri~s may denote cliniCal i.mprovem<!nt,
exeept'ip cases :Of hemolysis. . as~ssmcmt in high . risk.pregnan_:ies: (~~e
2 :- . :Piot~. xnay be' doeum.en1ed quantitatively
or qualitatively. .Amounts greater than 300 :rr.J:g/
24-'h oururine sampl<~ ot di?stick values of 1+
.o r ~ore )D.ay denote PQ<'r pi:ogn.6'sis, Studies
On IiiicioMburi:linuria and calcium / creatinine
ratios,as :predictive for PiH have been repc:)rted
but the$ehave t~:> be validated.
3. Sen.un uric acid. There are strong evidences
that uric acid:. values -correlate wtth the
development. of pre~edampsia,~ 2 .the severity
.. of~pre-eelampsial~. -and- inc:teased' perinatal
moiWit"J;H
4. H(W'.oglobinuria, hyperbilirubinemia, elevated
LDH and SGPT values and thrombocytopenia
diagnose the HELLl> syndrome.
Ult~sound
Dopplf r Studies
. The current th11.1St in pr(!na tal prediction of
PIH is Doppler Velocime try. The b a sic 1mding in
. PIH or pre-eclampsia is .hypertension which
causes an increase in the afterload and dhninished
. bloodflow: Diminished blood f iowmay be n~flected
as a .diastolic notch, an -increased Systolic I
Diastolic ratio (Stuart index), pulsatilit:y index or
the . more o:m inous absence or reVersed end
diastOlic (ARED) blood flow.
The following reports summarize the Doppler
flow velocity stud,ies on PIH pregnancies: Placental
Scanned 8y:
591
bed biopsies reveal unconverted uteroplacental
and pathological vessel alterations15 16 ; higher flow
velocity w~vefonn indices in the placental end of
the cord indicate an increased placental
impedance17; &. systolic or early diastolic .notchin:g
of the uterine arteries and ARED flows .are highly
predicthte of poor pregnancy outcome, . high .
pennatal mortalitY and neomi~ nior1:>idity _.tU9.20,2t
Recently, abnonini.l Doppler veloCity :indices
in hyt)ertensive women have been associa~ed with
abnortn:al neonatal and :!arly childhood neurologic
symptoms and_.neurcdevelopmental imp~ir
ment.22.23 Moreover, Doppler may yet prove to be
an elegant way of demonstrating the deleterious
effects of various drugs when used in pregnancy
based on studies on MgSO4 , methyldopa and nitric
oxide studies. 2,.
.Neilson and Alfirevic~ reviewedl t s~die~ with
. 7,QOO .W.otnen .us.ipg .Dqppler ultrasouru.i :tor fetal
.Lib~, 1. 2002)' and spowed the follo~.;rog;:.~,.,.,~~'\ilts:
. ~ ,
L COm~d .t n no Doppler ~rra~~~ur;;Pi:>)?.ir
ultraum,i in high riliik pregnan,cy.,.(e,~y
those.. complica.ted. by .l:lYPe~e.~~io.rt,.,or
presumed .impaired . fetal __.gio}v't'h);..:was
e.
as.s odated with trend to :~,..I.:e;i\\~tic:m" .in
P<!tinatal deaths (odds rafro 0. 'tt'/'9'5%
confidence interval Q.SO to 1.01).. . ..
2. .T he use of Doppler ultrasound .w~s also
a:s~ea With rewer:m:a'U(;uon:s~ofiabOr . . oaas
--..--..------ ..-..---"----..---""-'.~- --... __,., __....~.1~----..
ratio _0.83. 95% confidence interval 0.74 to
0 .:9$) and fewer a drp.iss ions to ho~pi~ .{ odds
ra?o 0 :56, 9!)% 0.43 to 0.72).
3. No differenpe wa~ found for fetal d.is.tress in
labOr (0R0.81 .95%.CI 0.59-1 ,13) or.cesarean
delivery (odds ratio 0.94, .95% 0.82 to 1.06)..
. They . concluded tha t the u s e of Doppler
ultr;a~ound in higb risk pregnancies .a ppears to
improve a :pumber of obstetric care outcome::s and
a ppears promising in h elping r educe .p eri'nata l
deaths.
~
 <592 SECTION VI: COMPLICATIONS
. -. . IN PREGNANCY

volume with.3D :UTZat 11-14 weeks<ietected .2 0% Several ~tudies have consistently confmned
of pre-eclampsia patients. Further evaluation of the effiei~t preventive action of low dose aspirin
this techplque is needed as it has a 5% fa1se against tbe devel.o pmentof.p re-eclampsia in high-
< positive rate. risk patients. 3 ~~ 39 The situatiott i~ .u rtclear,
however~ wh,el) .aspirin is .g iven to women at low
In sununary, current methods employed L~ the risk for the development of PIH. Four 14):recently-
. predic.t ion arid detecti(\n of .PIH include .f isk conduded trials show that low dose aspirin should
. factors, moJ;iltoting the be~aVior pf blood pressure not be given rol,ltinely to gravidas at low risk for
cll1Ji.ng pre~~y (MAP tests}, i.,lse of basic and PIH development.~ 3 "'
esoteric laboratory ~inations and curie.ritly the
.t).oppler ultraso)4-nd study of blood vessel flow end A recent systematic reView by Duley-.et a1 44
3IJ ,pla~~J,\tal vo1um:e. . . (59 trials with 37,560 womel)) Showed that
antiplatelet t.he.rtlpy is associated with:
. ~b~i.rtox
1. a 17% reduction in the risk of p~eclampsia
..'Bi.n ~d l>l~t . (RR 0 .83, 0 .77 - 0.89}. ~specially in high r isk
patients; .
Evid~~6~: .i~ overnhelmi~g t~at a BMI > 30 2. an8%redut;tion in threlative rlskpfpreterm
incr~~~;$ e .risk . qf preeclampsia. S~veral
. birth
. . \AA
mn.,..
v :9,... o.: . . o~~
n 88 r..7
);
. autbo~ . )?.~e ~hown th~ wpmen with B:Ml > 3. a 14% 1'~Uctiori in feW. or neonatal :deaths
.3 .o.,:l;lad.: ~n il}.crea sed risk .o f gestational .
hypcrt.ension~:P,~.c1aJnp"iaJ,~.s~tjonaL;dia~te~ (RRt't86, '0.7.~" 0,9'81; ~d .
andifctal~~<:~D).Pal~<l"ith~woriletr:With . 4 . ~ J9% .:tedt!ctlop i.n.~.all."'tor~gestati<>.nata.ge
-:a a:'M(.'<3o.. tbe-int11;1e,;ce..or.obesity:: on:.~ the:.. . ~e$ :(o~9o:.o~63 t:b o..9.a}. . .
-~ ~,ipci~~e'Qf:pr:eee~ps,ia 'may :bedue 5. . rio.,s~f;isij~:sjgtlifi~t.diff~rence~' bytween
to a.ented ptacentiit p:Tr04uctii>n of l~p.tin31 , .tr~~en:t :~d ilfr.Pl.twu.:ps . f~i' ~Y other
. adifloPtctiri~t)r.tr;;igiycerides -an:dtnilanuriation.33 .. o\ltebmes... -
.. .~1:':: . . . . ...: .. .
... .. ....
Lc)~:D9ie. ~P~: : ..
T;Q..e .. autbon . coJ}clU.tl~cl tl'lat tttitiplatelet
, once the pf;ttie,nt for PIH ha~ ..b~.en . ag~;!!.._.~: l~o.SJ!._aspitih, have .moderate
r~slc
identified, -ii"i~r':but-15ii~ 16 try .~a .P.~~~(it~ ];)J;n_ditJLW:h.en.._used- fp,~ . .pre:vontion ~f- pre
~c=e,: ree:eliif'ertt-:i\a.ge'h):..pre.veri~ve therapy .ecla,J:il}'>.$1~ .and its cons.e quer.ces . Further
'roT :Pill is iow .d'Ose ,~spirin . .' the p\.it-ative ,infqnnatl6n is requi:(:ed to as~ess which "women
m~~sm ,for 'its a'clion ~s blis:ed 6il: a furtcfipnal are mo~t ijkety to :behelit~ when.SJJ:ouldtres,tmeni:
i:a:Qbala.nc~ b.e~wcen v~sod.ilat(n and :~ best started, .and -at whatdose ..
va'Socon$ot(ictor :~ic.osanoids. In :p~a .PaUents,
:circul~ti.ng: levels of 'l'htolilho~ane A~ f.l'~A2:} From L"le for-egoing .r eports, low-dose aspirin
of
4et:iYed:trom platelets lite j.n.ereased while for the .prevention pre-eclampsia may be ~ven
P;i'Qst;acyclin (POl) levels defived from va$~.;lila.I provided:
ClldO.tliefiu'm ~re decte:~S~'d. ' LQW . dose aspirin
effectively inhibits TX ..A2 from the an:uclea~~d 1. Patients have been identified as high-risk
platelets w}1etea;d'~GI ~ be. resyntheskq from bas~ oa .previol.ls history of hypertension,
the nucl~ted endothelium. Moreo ver, .p latetets adveF~ .obstetric outcomes, W..P or rolL-over
(TX-A2 ptoducer.s) in the prehepatic circulation . t<;.s ts, ab.n.on:nal Dqppler waveforms or
a re exposed to the !'tCtive acetylate.d for.m .o f ap,gio~~,sin. ~nsitlvity testS:,
, salicyljc aciq while endothelial cells (.PGI 2. Patierits have no hlstary of.aspirin allergy-or
,producers) will. o~ly be -r-eached arter passage ..h,yper:~<m:sitivity (add peptic . disease - or
though the. .J>Ortal circu.Ia.tion resulting in .the coag\ll9pat:hy)
neutral d~eetylated $3.licylic acid71 Jt has been 3. :Treatment is sta..r:ted during the second .
re~ntly showt&. that low cdo.s e aspirin in pregnant trimester to prevent fetal malfdrmations in
:women a.t tis~ for . p~e:<rcla~psia. inhibits .:both theJirst trimester,
TX-A2 an~I llpid: peroxides although the plasma 4. noses are kept a:t .60-80 mgfday based on
level of.PGI r.mains: unc hanged. 3" , the majorjty of reports,

Scanned 8y: ~
 CHAPTER 39: HYPERTENSIVE DISEASES IN PREGNANCY
------------~----------------~------------~.~
~-.. ------------------------~...
5. Monitoring of platelet counts and
coagulation profiles are regularly performed;
6. Monitoring of the fetal ductus arteriosus and
urine production/amniotic fluid volume are
done.
High Dose CalcJlim
Oral intak.e of high-dose calcium (2 Gm/ day)
to
has been proposed prevent pr~-edampsia. The
roie of parathyroid hormone iri BP reduction has
been impli~ted as follows: High dose calcium
exerts a negative feedback effect on parathyroid
honrione + lowering intracellular calcium ion
levels 7 smooth muscle relaxation and .diminished
responsiveness to pressor stimuli. Furthermore,
calciUlll supplementation is associated with higher
levels of calcium excretion which is coqpled with
an ioti e;cch&nga With magnesium resulting in
increased ltvels of serum Mg -7 smbOth muscle
tela,ca tion in blood vessels -7 cont~ol of
hypertensi9n. 45
A ~duction in IUGR and BP levels among PIH
piti~nts ha:s been. reported with oral calcium
supplementa.t ion.9 46 In a..-lOther study, using
urinary calciutn excretion and urinaty calcium/ .
creatinine-ratio as tbeir criteria, the illcidence of
hypertension was lower in the treated group vs
placebo group (7.2% vs 10.7% for gestational
hypert~nsbn, 2~6% vs 3. 9% for pre-eclampsia).
The-hyp-erlension.preventive effect .was .evident as
eadyas the-28lh.week ofpregnaney.H
The most recent systematic review by Hofmeyr,
et al. 4J (12 trials With 14,946 women} showed the
followiilg results With calcium supplementation:
1) The.ri~k Of high blood pressure. was reduced
With calcium supplementation rather thim
.placebo (RR 0.70, 0.57 to 0 .86).
2) There Wa.s also a reduction in th~ risk of pre-
eclampsia associated wHh calcium
s upplementation (RR 0.48, 0.33 to 0.69). The
effe~t was .greatest for high -risk women and
th'ose with .lw baseline ealciutn.
3y t he cotnpti~tt~ oulco~~ -"~~t~tnal death or
serious morbidity" was reduced (RR 0.80, 0.65
to 0.97). Almost all the women in these trials
were low risk and had a low calcium diet.
4) Maternal deaths were reporte& in only one
trial. One death 09curred in the calclum: group
and 6 in the placebO group, a diffex:erice w~ich
Scanned By:
593
was not statistically significant (RR 0 ..1:7, 0.02
to 1.39).
5) There was no overall effect on the risk of
preterm birth (RR 0.81, 0.64 to 1.03), or
stillbirth or death before discharge from
hospital (RR 0.89, 0.7.3 to 1.09).
6) Childhood systolic blood pressure >95th
percentile was reduced (RR 0.59, 0.39 to 0.91).
The authors concluded that calcium
supplementation appears to almost halv.e the risk
o r pre-eclampsia, and to reduce the rare
occurrence of the composite otttcome 'death o,~;
serious roorbidity'. There were no other clear
benefits or }Umns.
Anti-oxidant Therapy
The initial s uccess reported by Chapell;. et al.49
with antioxidant thl::--::'apy {Vit C 1000 n:ig and Vit E
400 mg daily) has not been validated by
subsequent t:eports. 4H 1 In fact, in~ a;; systematic
reViewof antioxidant .treatment usiiig(Vrt:anilii c
and Vitamin E involving 10 trialsliwith' 6533
women, Rumbold, et al.52 re ported.the' folloWing
re~mlts: . . ..
' ,: I~ ' ' - 'J
1) There was no sigtlificant difference:])etween
antioxidant arid control groups for the relative
risk of pre-eclampsia {RR0.73, 0;51 :;. 1.06),
severe pre-eClampsia (RR 1.25, 0.89...;, 1.76;
pretern:t:~birth (before3~weeks). ttm. L 10,.0.9~9
- 1 ;22h SGA infants-{RR-0 ;8 3, 0 .62 - l ;ll) or
any baby death {RR 1.12, 0.81 - 1.53; four
trials); .
2j Women allotated antioxid.a nts were more likely
to . a) self-report abdominal pain late in
pre~ancy. (RR 1.61.. 1. fi - 2.34), b) require
antihypertensive therapy (RR 1.77, i .22- 2 .57)
and c) r equire an ai)tenatar admission for
hypertension (RR 1.54, 1.00 - 2.39). However ,
for the latter two outcomes, this was not clearly
reflected in a n inc re ase in any other
hypertens ive complicatiohs.
The authors concluded that evidence from t}:1is
r eview does not support roUtine a ntioxidant
supplementation during pregnancy toreduce the
risk of pre-eclampsia and other setio,us
complications in pregnancy. ~
.fjf;;,
In summary, rec ent reports have dq_~l:lm ented
the efficacy of lqw-dose aspirin (60-80 m g once
~
594 SECTION VI: 'C0MPUCA:T40NS tN PREGNANCY
daily) in preven.tin,g PIH in patients at risk but
reports also .express ca1,J.tion not to use it in low~
rislc pregnimt women. High~ose catclum(2 grams
daily) has also been reported to prevent PIH. The
woe of anti--oxidant is not l'ecominended.
TREATMENT
J4ANAGEMEN.T .OF. ECLAlciPSlA A.ND S~RE
Pjm.EcJ.4MPSlA
Three . car.dmal principles gov.erri the
m~n~gernent ~r f\lll~bloW}l eclampsia ~4 $eVere
.pre,.eclaill.:p $ia: :1) C:ontrvl c>f convulsit>~s.
2) Control ofhypertension, aild 3) Delivecy .!l-t an
opfunum .$ ie and mode. The.management ofmild
pre-ec1ampsia s4a}l be discussed separately.
Conttc>i ~t Cota~l()ns
the an:~nvulsant .o f chpice is ma,gne~i:um
~~te tM&s~J:. .AlthQugil Some .:p~er ~.pam.
. .the<bltes'flic.lthas:SbQ\vtl\the;superldtity-'Of~gSQ~
over _dia%epapl:Qr ph~nytofn;,_ .
. The su~riorlty . of m~esium s1,J.l!ate .as .an
an:u;consulvant :h as been . der-ived .. from the
Jo:ilb$g: ~~tts: . . ..
,.
: . . . . .. ,. _ :~ '. ~ , .. .. . .7.J. . . '
. Dl.llera.n4-M~nd,et$on:-;~l1J.~ :1A th~u- tuticle,
Magne$'1u.nl'iNU'ate~l.is-~~ !or te~p~ia
rr9f~W!~i.~~I4~PY !~-~~9rf~L~hiiw~<fiK~r;~
a.. M.~~esiUl'll. .s:ulfate was . associated With a
subs'tantial red.u ction in the recurrence of
.0nml.$ion$, when _con;lpat:d.-to. diaz~pa;m
~(re~Uve ;r,isk Q;45; 95% ~onfidence
0.35 to 0~58)
1). ' J&~f:tW;,;n:Q~ty w as also.reduced,.alt,.li;ot}gh
thl~ giff~rente wa~ borderline . fot statj~tlcal
signifi~ce {telati.V~!' risk 0.60, . .9'5<>(., CI: <0:'3e-
J~o0.). . be ab,artdoned.
c. There are no differehces in any .other ~e~sures
of Qutcome, except for fewer .1\pga~: scQ.r~,s <7
.at fi.v'e-tnblute,s.(relative .risk..(). 7"2 .9 5.% Cl0.55-
: _().~4) . and in length of ~t;ay in .s~SlJ >7d_ a ys
. :(relative risk 0.66, . 95% . CI 0.46-.0 . 9'5}
as.sociated with magnesium sulfate; ,
' rpey conclude9 - tha~ . magnesium sulfate
. appears :to ~ ~ubstarttially :mqre .effective than
diazepam for treatment of eclampsia. . pla cebo. b) 24 percentof. women. .given m agnesium
Duley and Henderson-Smart?~ in their article
on magnesium ..S.ulfate v ersus . phenytoin for
eclampsia (The Cochrane Library, 1, 2002) showed
that
a. Magnesium sulfate was associated 'with a
substantial r.eduction in the recurrence of
con'Vl.llsions, when comp~red to phenytoin
1re1ativ~ risk 0.30, .95% confidence interval
0.20 -to 0.46) ~nd the trend in maternal
rn.o~ty favored magnesium sulfate, .but this
di.f{rence was not statistiqilly significant .(RR
. 0 .51 ... 9'5% ct: 0.2:~5-.1.06). 'rbere was also a
reduction .i:l;l the risk Of pneumonia (RR .44,
95% CI 0.24~0.79)~ veQtllation 1 RR.66, 95%
CI 0.49-0:QO) ~d -adni.ission to an intens ive
..c~,r~ . unit (RR .Q67, :95% .CI 0~50-0 . 89)
. a~~~d W),_ththe ~se of ma,.gnesillpl.sulf'ate.
b. For tll~ bab,Y, ma@'l~siu.m sulf.at~ as .~ssoiated
mthiewer-admissions to NICU: (M 0.7:)., 95%
CI 0.58-0.91) and Jewet babies who died .or
were in NI.CtJ for >7 days (RR 0.77, 95% CI
..0~63;:(}',95}: .
. .
Tb,ey con~tufied . t.ha.t mag~esi\Jm su.l fate
ap~..:to -pe,s-q.pstantially ,;m9re .effeetive than
phe_n~in fc;>r.:.ti~Qfien~ :ofec4mlpsi~ . ,
. . .: .. . . .
.
Puley. ~d.Gulm:e7...oglu75 review.e d :iJla,gnesium
s~~t.e. v~rs.l,!S lytic .c.oc~ -for ecl;:u'Ilps~ .{The
9?.9h.~~..:!4~tiH'Y...1~.. _6.QQ~) ..~Jlel .bQ\Y.~J:l ~.th.;:;t
~$lwn. IDillat.e__ ;Wa.S.,..bd:ter.~I}.)ytie_.coclctail
at preventing Nrther .convulsions. [relative ;- ris k
(RR) 0.09, 9.511/o confidence mtent.al (Cl) 0.03"'0 :24}
and wa~ assoelated witb Je~s .-r.es p.ira.tory
depr~.s~~~n {RR 0 . 12, 9$% ci :o .o2-0.9l).
jritef\l'al Magnesium~ swrate was 1;\lso a$~iat~d with. fewer
. mate't~?cal deaths than lytic c0ckta il, but the
diil'~rcmce was-,notstapsijcally siWficant (RR 0.25,
95% 1 0 .04- 1.43). They then ,c~n1u"e.d -that .
magnesium su;lfa,.t e is the ap:.ticotwlil$Qllt:Of.choice
for women with ~lampsia .m d lytic co.clctiill should
.
the efficacy of .~p.agnes-iuzp sulfate in the.
treatm~n~ . of. -~~ver.e. _pe~eclampsia was further
enhanced by the re~ult's of .th-e MAGPIE trial53
consisting of 10,141 w.oJ:rien \Vithpreeclampsia
in 175 hospitals in 33 . countrie~ (half Qf whom
receivecJ.:m~gnesium- l>Uif~t~ artd.. the ot!:ler palf
received pla,cebo). Significant . 'fmdings were.:
a} W,om.e n allocated in the ,magnesiumsl.l:lfate h a d.
a 5 8% lower risk of eclamps ia than those allocated .
Scanned 8y: ~
 CHAPTER 39: HYPERTENSIVE DISEASES IN PREGNANCY ' 595

sulfate reported side~effects versus 5"% given 3. Urine output of at least 100 cc every'r
placebo. Most side -effects were respiratory in hours, and
nature and were higher iti women who received
anti-convulsant treatment before hospital 4. Serum magnesium for greater a ccuracy.
alli-nission. c) Maternal mortality was also lower.
e.in;ong . women allocated m.agn~sium sulfate Control of Hypertension
(relative :r isk 0 .55, &26-114) . d) The only notable
. d.i!Iert:nce L'l matemal or neonatal J11.orbidity was for SeYe.r at questions remain- unanswered
placental abr.!pti.on (relative riSk 0-67, 045-D89). rl!garding the use of anti~hypertensives in
pregnancy like the need for drug treatment for
The authors concluded that magnesium chronjc hypertension, the choice of the best anti-
s ulfate halves the risk o f eclampsia, and prob~bly hypertensive sgent and the fetal risks involved in
reduces the risk of roaternat death. There do not mate~__anti~hY:l)ertei).siv~ therapy.
appear to besubstantive hann.ful:effec.:ts to mother
-or baby in the short -term. . The use .otanti-.h yperlen$ives fQr BP reading~
of at iea$t 160/110 tnmHg to prevent ma:temal
t. .2.-year follow up of the women and children CVA-hemorrhage is no longer disputed and the
involved.in the MAGP.tE ttW $howed ho in.crea~d . drug of choice is Hydralazi.ne {Apresoline). The
:ttiorbid!ties . .c oro_pared to . the genera l js
initial dose given as a 5 mg lV bOll.l$ followed by
. popUlation.54 ~ 5 mg incremental increases half~ hourly if diastolic
.. ~
HP does not improve up to a totcil dose~ of20mg.
Reeently~reported diawbackS to the use of . -- ~:c ~.-- - .
MgS0.4. incluQ.e . neutropet}ia .and nosocomial As di:o,icians, however, we ~~s.t"-ii~'Vt;;:>an
.ihfectiop.s inJnfanl:$ of ~y:pert.ensive motbersS6 st, 2-dequate knowleag~ of alternate options;~:hould
-lowerfetal biophySical ptofile:S~:;:otes by decreasing Hyclralaiipe nqt work. Beta.;bJockers.l ike .L abetalol
let~b~tni.ng. :wcre.:ase<l-lncldence:cfnonr:eactiv.e bave .reccivro-wide attention in the UK for they
N5Ts and.decieased variability of the FHR:;a and have ~ proven effe~vein lowermg:.systolic 'a:nd
. cijsttitbed fetal artd :xruiter..ai calcium homeostasis diastollc -BP and pi:'event more severe fonns o{
and bo.n e density_S9 ' , PIH60 They prevent 'Ventrkular 'mhyJhrp:ia,
tqchycardia and pulmonary l!dema.~t' flowever,
advene err~~ts dn fetal gtQ.wtb . and fe'tal
.t.1gSO 4 can be ~dmini-stercd as-follows: he.mody&:Jalnjcs-have--been-repatte-dfollowi.fi g
therapywithAte:riott>l'1U'fd.PinO:o162 anaUl5ellio1.63
a) Give a loading do~ of 4 Gni IV bolus slowly
over 5 minutts foUowed -by a maititenance dose Nife.di:pme. a .calcium~channel blocker, has
of'l-2 Gms per hour IVdrlp. . been shown tti reduce the maternal 'BP in pre-
eclamptic women remote from-term64, diminish BP
b) Give. :a loaditl,~ dose cif 4. Gm tv bolp.s s lowly and protein~ and improve renal funttion65 and,
over 5 mli1.Utcs .a nd 10 Orii1M (5 Gm itito each if given sublitigually, can substitute for parenteral
bu~t.ock) followed by a zr..airiteriance dose of 5 ther'a:pyU . and . can prevent erythr-ocyte
Gms IM every &hours. aggregation. 67 Nicardipine, another calcium
antagonist, offers theoretic;al advantages over
Please be reminded that the vials of Mg$ 0 4 Nifed1pine in that itacts more selectiVely on the .
are not giv~n mgrams and the earegiver will have peripheral vasct).la.t ure with less botropic effect
given
to convert V'i;>lume .(~ Irils) of a strength (% of tachycardia and r ela ted symptoms of flushin g
s6lution)to give the final gram dosage (i.o. 20 cc and hot flushe s. It h as .atso lower rate of placental
df a !~too/o solution ?: 4 gmms)
. ~ ..
. . ttans~rt . with.'limited exposure of fetal tissues. 63

The safety of MgSO_. is monitored a t the Sodium nitropru.sside may be used fqr signs
l>edside using th~ following points: . of severe hypertensive encephalopathy. :::.

L The presence -of deep .tendon reflexes A~E in4ibitors are not recomp1ende4._duririg
pregnancy due to fetal side effec;ts like defective
2. Respiratory rate of> 12 per minute skull ossifications, oligohydramnios and neonatal

Scanned 8y:
r-..
~
 -596 SECTION Vt COMPLICATJONS tN PR!=GNANCY .

'ai.luria.9 Diuretics .are not to be used as therapy
uniess there are evidences of pulmonary edema
or t;:ongcstion. 8
Optimum 'rfme :an~ Mode of Dellv.e.ry
Five factors govern the decision to tennin~te
pre-eclampjic pregnanci~; these include age of
ge.stati9n., .se;verity of the diSea.sf'; ft!tq.l status,
matem{tl conditi(m an:d n.:u.rs~ry capabilities:
Genefai ~<lelines to foUQv...-intlu<ie tb:~ .following:
1), Hospital~e all pati~nt.~ once ~j.gn:~.:.
sym:P.tomsofp~e~lampsi~ are e\'l.dent 1~.may
.even be ~:ore pru,<;lent to..aqmit a :ca~e of mild
.....pre.-,e~.l"a:lll'f>'~i?- ~o baseline ilS:ta. aan be
b:Ot.aln.. . . pro~ply ~(j.r:e ti..~
aspirin and hjgh dose calcium. Non-
. improvemenLof either matemalor fetal.s tatus
while being monito r.e d in the hospital may
.mandate delivery.
4) Labor and delivery options .may 'inClude
.cervical . .ripening with ci;xyt~.cin or
prost~glandins an1. ;a~iotomy followed by
va,ginal deliv~ or ct:sarean section in'sekct.ed
cases. Once. tb~ eelamptic patient is oriented
to time, :p1&.9.e .and ,per.so.n , jmmediate :;ter)s are
~en. to effect delivery by U~>il;lg a dilute.dose
or of.oiqtocin {5 units ~t l;iterof fluid).
Our treatm:ent pro~toCQl is :s~milar t9 the
Parkland Hospital .Protoeols- e~cept that we are
Wi th.e U..$0 ~J ~e<ul

'2) CUrtqitqffinlon:sta:tes i.h:atit:Qmediate d~live.ry Secti:o:aesJ>C2Y. .u: thi! m.~t ~etu:s i3 gx:~
~j.~i:k\l~'tqr'fhe :IoTiowiD,.g; restriete<I~ the B.i~hop~ sre .. 'is uru!;l,v6rab}e (<S)
. ' . . fO'r .induction. fhe fetal J?p$ score Is 'kiw {<6/10)
t!'Jal ,All:~.Of< epl.ajnp:slaregarillezs of.age bt or . if tl:t.e 'C'fG tra.cbg shows perSistent late or
:. :g~tati:on. - .severe :variable d.ece!era;t iDhs. We lui~e . used
M1s~p~o~tbi . an:<i~p~o~t~gl~diiJ.;.gels. ior :labor
b), -~er~.p~la.tnpti~ whQt~.at ~t-~:. .!riduction. l;>u.t w.e; 1n:ust ~ .Wary' of.t he in~
we~ks 'preg"j:r~t in th:e ..pt'ese~c,e~ 9:f: a lrrltAb:i~icy< c.f the :: u:t:ru:s ; ind . hyp2rtonic
...,.. _ :tna~ fe~lU~ e.nd.: ~ d~"U~t-e p.~ .,t:Opit.aq!O:ru;.:.ita'stl.YrneonatiUsU.r.viva!itor $>ve
-r fa,W~.- ~The::~p~ce:<:>f::qimpiic:ai~oris:~ . :.. ~i:w~ks :AO~:is$)s%: and"{qr 28::32.-Y.reeki AOG
...: : : Uk~;;prci.In\,ure..~ptiir~ .o:f...m~:O:i!n:Ut.:Ss :is -75o/o-~..n,(Fthis ~makes us::J::XiidiftO O:elivednfaats
(BR.PMJ;. IlJG:l~. abruptio placenta ..and of pffi ~6thers at thl$tiine.
m~!er=n~t .Qr.-.f.~Jal .de:terlq~a..tion :tay
.mttndate
...~~k;-;--t.e-~t.-1"-- oeven earUer---;c~:'7--;
deiiveg--;:;;--:-----. t han 34 '
MANAGEMEN.T..:OF:..i.!ILD...P.~EeLXMPSL\.oo
. . .. - .. . .
. wae~~_tp~s ~:~VJ....e.d;m-:l:&-gt:r:,~p._m. GESPA110I'rALl iPERT:ENSIO.tf . ' . 4
th~:se ins.t anceS.. HE.J;L:P $yndr:ome is 1

consid.e:re1i a varlant of s.evere pte:..
ecl'aPl:P,$ia 1 in.d. is t~us mana:ged
aC.~:rdmgly..
<?.) :Eviden~e .of. severe ;m atm.al :disease .as
ev.id.~ .i:;y.\l.ilPntrilUabl~ 4J-~~~sion
of' '}6Q/J 10 .'h1Hg, cllgU:fj.a. .-<:400 :h~~rs,
Gcrnttove:rsy . exh~ts on.. ti-.:e i:?.top.~r fl!.ooe cf
JD!l.~ement of tl1ild pr~-eplampsia' {~~ if
rem.ote.fr.om tenn).'?erusaiof'tlie tit'eraiiire Shows
r..o ~0ular ~g01d standa,r'd,. of .fu,era,py for this
eohiliti9.~. A:m'I;>'!Jiafui:y nl:~ageri).eiit is .an option
.ftYr .c~tnp~t wome*-
. .~

t;hroffi.bocytopen1~ <tbb;dOO'/' c-q .s.ct'rt). . .

pU~):'ri'Onaty ede'l:ifa acp.q lmpe,~~ililg A su,ggested protoeo1 . for t.~e managerpent of
edru:iipsia. mU.d f):t.e~lamp~ia consists pf:

d) EVid!!n~ of fetql co.Dlc,promi~e . base~ o n 1) Wtia.J ho~iwG:a~qn to ~ptain ..ba~fu~ d~ta

~bporin~'J.:eW reovep1ent cout1tjllg, Q't.Gs,
BiQphysi~ ~ofile :SGQre mo11rtor:ing .B.!ld
AREP pa,ttems o,h boppkr. velocilp.et.cy.
~.) ln the.pre~nce.~fUnichl.:Use~e:at ~31.we~ks
,of age of gestation , conservative~ nran:agemerit
,shotild.focu~.on ,ne ~~uatiq~ :bf.matem~ an9-:
fetal status pl.us. ' therapy w ith .an
antj~.onvulsa.pt, anWiypert~fl:sivc, lo~'-.do se
and :QJ.ordt.or .f:eto-m~temal status. Baseline
maternal Weigh.t . B.P, hexp:atocri~ .SGP.T, uric
a cidJ platelet ~ount, fetal Bp~ and Doppler
vel6.mehystudies ;;re .perfoqned. The:mother
'is also instructed to :perform':fetal mov..e ment
co tints da:]Jy. and "st ick to a low: salt, high
calci~J!l di<rt . . Ip.variably, our .Pa:t!e.n ts seek
discharge .after .3 days but they are advised
follow-up 2x.fweek .

Scanned 8y: ~
 CHAPTER .39: HYPERTENSIVE-DIS:EASES IN PREGNANCY
2) OPD follow-ups. basi~y consist of review of
fetal movement count. chart, BP reading,
weight and a non-stress test (NST).
3) Any deterioration of OPD monitoring will
mandate re-hospitalization. Non-reactive NSTs
merit immdiate fetal BPS (with special focus
on amniotic (luid volume) and/ or D.o ppler flow
studies for ARED flows.".
4) We prefer to give bra! methyldopa~ low dose
aspirin and high dose celcium even on an 0 Pb
basis.
. 5) We tend to push the mild pre-eclamptic patient and hea.--t !allure. There is an increased risk of
to as near term as possible :p rovided fe te-
maternal status is not impaired.
In sutnmary, actual treatment of severe pte-
eclampsia and eclampsia i s anchored on .controi alter' the ~ourse of renal disease although
and ure:v.:ention of convuJsi:on s, control of
hype~ri.sion ~"ld tenninatlbn of pregnancy using
the 'best:roode and timing p,f delivery. Clinicians
shol,lld be cognizant of various . pha:rtitacologic
option~ iJ1 the c ontrol of eClain;ptic"convulsion and . and ofbeing .SGA(s maU for gestational age). The re
hyperte.~~on. The timing ;~'"ld manner of -delivery may be a higher. risk 9f stillbirths or intrapartum .
are dic"..atet;J.by the _gestatio.n ala ge, :q1aternal ~d fetald-istress due to a brupti() plaa;nta:o~thronic
fetal .. si.a~s; s everity of the dis eas e and the
capability-of the nursery. {Figures 39.3 & 39.4).
MANAGEMENT OF CHRONIC HYFER'l'ENSION
The incidence of chro.n ic hypertension varies
and the etiology is :qsually e ssentiat or idiopathic
(80%) or due to rena1, v ascula r or e.ndocrine
dis~ase (~0%).
Signs and Symptoms
Patients with chronic hypert ension tend to be
older, obese, multipa rous with as:sociated m edical
diseases like dia betes and re n a l disea s e a nd a
family history of hypertension. The typical p atient
b as hyperten s ion alone without o.thersigns of pre-
e c la mpsia . The diag no s is is m a de on th e
documented pres ence of hyperten s ion before
Conception or before 20 weeks gestation or the
persistence of hypertens ion 12 weeks after the
puerperium . Renal biopsy will confirm the
diagnosis but is not usually n e<:essary s ince the
d ecis ion to delivery c a n be b ased on .clinical
grounds.
Scanned By:
""': .
Labo[litory Findings
Most laboratory work-ups will show normal
results. The chest x~ray and ECG are usually
normal but may show left-sided cardiomegaly in
~-10 percent of cases. 70 Eleva.t~ serum creatinine,
decreased creatinine clearance and pr0teinuria are
also present in 5 - i 0 percent of ca~s.
' . .
Compllca.tio.n s
The main maternal complication is
. ~uperim.posed
pre-eclampsia in l:'i,b out a third of
cases .and de?-ths are u sually due to strokes (CVA)
abruptio placenta with its attendant ris k of
disseminated intrav.a scular coa gula tion (D!Gi,
q.cute tubulat rtecrosis or renal cortical necrosis.
There is limited e--.;idence that pregnancy does not
d etenoration of r enal function occurs with pre-
pregnancy r enal insu_fficiency_
The fetus ha.san increased rate:of"pfertl.~b:irity
intrauterlrie . aspbyXi_a . . ' :.!ii ' :.:- . . , '
. . ;- .:- : ..
~
-~
Genew Ob.stetric l\1anagem~nt
_ _ I_~ _9\c:. Jl1e(fi~~~ ~i~~9.!Y . :P.f . th~ pr~gnant
hype'tten s ive p a tient, attention is -paid t o the
duration .o f hyperten sion, u se Of antihyperten s ive
m e dica tion s, history of ren al or heart disease and .
.the ol,ltcome of previous p regnancies. Phys ical
e xamination mu st include a fundoscopi~
ex:..q.mi.na tion, listening fer a renal artery bruit, and
ch eeking the dorsalis -pedis artery for coarctation
of the a9rta-.
Baseline labor a tory examination s s hould be
obta ined for organ s like ly t o be a ffect ed by
hypert en s ive c h a n ges or to d eteriorate duri ng
pregn a n cy; thes e include CBC, urina lysis , BUN ,
creatinine, serum electrolytes, uric a cid , calcium
.p hos phorus , ECG, liver function tes t s and 2 4 -
hour urine collec tion for c reatinine cleara n ce.
A ches t x-ray is taken for su sp e~"f~d h e art
di sease, a 3-hom OG1'T for pos sibi~'di ab e tes
m ellitu s, u~naiy vanillylma ndeHc adct(YMA) f<>r-
wild s wings in b lood pressure in ca~e s of
~
~98 SECT~QN VI: COMP.UCATIONS IN PREGNANCY

J; P-REDICTION AND DETECTION OF PRECLlNtCAL

. .
DISEASE

RRfo:seooJNG FACT?R J .1 EM':x ~NfCAL ;w~m> 11L_ _:e:::ru:::~?::ter==p~Rs=o=F=P=IH~---_jl ..

flRST~ -~'MEIGITG.I>JN .MAP> go !MI Hg
.Gehe'~POSmON \.K'WAAD TRa-0 IN Ill' ~$TS(SPT~~
. .. O(Ef1m F.Ac'f . .' ECMJ. Ul!C!-00
ll~Wi~~l.EYB. loi$AFp

: .~ F.lliROti:CT!NASSAY
C'.lOI.JM~
~J>Sd,A. Ai:U::IISEfSE ~VELOOMETRY
~HY~TENSION

..: ' .. t -~

. .
II. PREVENTION STRATEGIES
1. BMI
2. ~:~.~-
. 3.. lil:Qht!~~

I
. IIL'MA:NA"GEMENTtOF CtiNfCA~ .DISEASE$

. . .
1.. ~GENERA!.... MANA-GEMENT PRINCIPLES

1da....f~bi.~~~~-M.i~N.
.. .:: ::
~~ ~:~
.:l
. .. ... .. .

. oRuG:bfrilONS . DRtJ\10?.TioNS WJERNING FACTORS

. :.M?sq4._. .. ~tazine .. -AOO . .
~!Tl . . ~~--~ . .. . ~ve;:ily Qi the: ~as.e
~rl$- :calaW~eh~ .,~- c. ~=~~ -
Barbiturates " D\!Uome Maternal Status
. Mv1eth)1dopa Nurser.y: Capa'city

2. .CONSERVATIVE MANAGEMENT -VS.. IMMEDIATE:fJ.EUVERY

(See Man;;Jgement Algorithm, PartIf)

.._\ . : . ... .
-~~ .
3. DEUVERY OPTfONS

PR.OS.TAGLAOIN
AIANJOTOMY
OxYToCIN
CESAREAN SECTION

. .Figure3 9.3. Management algorithm (Part i):

Seanned lly: C
 CHAPTER 39: HYPEHTENSfVE DISEASES IN PREGNANCY 599

r----------~------,~:;- .
vs. I IMMEDIATE DELIVERY I

I'AOiol
lJGIIS!I
STEROIDS
ABJll'I'TIOI'VC(HTA

V,;ololOo\J FM -sillo
I 0 Mo<l!Wring
Wolght .
llsT/CST
BPP
~AI.
,..
Sl $)( rN
Ut>EJcoms ~ ITlOfliWMo
Atmiootn\eltJ

* .MA.TERNA;l ANO'fE]'AL COMPROMISE

I fETAl.~ .1

Flgure';39.4 . Ma.t).~ement algorlth!:l [Plut-ll)_.

pheochromocytom~ . Ges tational age c~n be are nt .high risk for p!'e mat-urity.;_-.-gr-_o wth
doc.lmerited and lUGR <:an be picked up by re~dation ~d death. I'. .
serial t.lltras:ound
. .. .
exa,n1inatipm~
. .
~
while ~e.tal
.
well-
.
-being may be ass essed by the NST+ AFl t>r the .- CONCLUSIONS
b~~physic~ prcftle scoring. . .. -:"'"' .. . . ~

This chapter 'h as attempted to ' ~~ve~ ':re~-e ~t

Frequent indications for early .delivery contributions to the va st su bject of .h~ensive
include .s uperimposed pre-eclamp$.ia. dbo.t deHl ~n pre.gnancy. The -inflttence of
undei-lying-medieru problems like dia beMs m-t'd pr{)te't)tromres"nast~~ ~-,~ - th~. 4!~~:V~!Y::2r @,ti-
:renal--insu-fficiency, a bnorma l artterpartarFfiR . angi.ogenesi.S-Jactor s {sFltl / endoglin) ~d the
and an SGA fetus. A pa tie'n t with worsening phenomenon of p seudo-vasculogenesis .a nd
hypertension between 24-34 weeks may oe given placental h ypoxia as the explanation f9r the
betame thasone or dexamethasone to acce!erate development of _pre~eclampsia.
pulmonary maturity if delivery .ca,n be delayed
fer 48-72 hours. . The c linical approach is mainly through
prediction using cUii:ical risk factors, physical
Prognosla examina tion, l a b o r a tory examinations a nd
ultrasound (Dopp ler in particular). The next step
Pregnancy outcome is usually favor~ble in . is preve!ltioxi -through diet and BMI control, anti-
patients with m ild chro'nic hypertens ion and platelet thera py (lo'W dose aspirin}, calcium .
petrniltAI ~4tviva>l fate is hi-g-h. Prognosis is supplementation {at least 1000 mg 1 day). Finally,
guarded when any of the foUbwing -is .-p-r.es~:t'lt: tr~at;~e.nt consist s of anti-convulsant therapy
severe hyperten s ion in the first tr.~me s ter, (pr efera,biy With magn esium sulfate), control of
superimp9sed pre-eclampsia before 28 wee~s .hypertension {hydralazine I calchim blockers I
gesta.t ion, antepartal . rena l in s ufficiency, . methyldopa) and delivery a t the appropriate time
hype rtensive cardiovascular disease, o r governed .~Y 5 mai.n f~ctors: l~ gesta~.,2..n.a1 age,
congestive cardiomyopathy: 'These patients 2) seventy of' the dtsease , 3) fetal~'Status,
usua lly requfre l on g hospitalizati'on a nd are 4) _m aternal COndition, and finally 5('~Ursery
likely to ..require cesarean delivery, Their fetus.e s c apabilities .'

Seanned By: ~
 60.0 S~CTlQN VI: CO~PLICATlONS 'IN PREGNANCY

POINTS TO .REMEMBER

Hypertensive diseases In pregnancy continue to be a !e~dlng cause of maternal and perinatal mortality
and morbldittworidwide. Local data show that they cause.roUghly 1 out of 4 maternal obstetric deaths
. {POGS, 2006). .: . .. .. . .
Basic understanding starts with benchmark kno'Nledgeof definition of terms:
o Hypectei!Sior.
o Prp.teinuria
o Gestatiohal Hypertension
o Pre-ec'lampshi~{including criteria for severe type)
o. HE~LP Syndrome
o EctamP$Ja
o . Chr~ic Hyperten~ion . , .
o.. ChronicHypectet~sion \\tjt~ superimposed Pre-eclampsia I Eclampsia
Further ~:mderstandlng the pr~IZ!ampsia..puzzl~-necessarily involv&s knowing the pathophysiology of
this "'dis~se~of.theories . GehetiC.metabolic, lmmunologlc:a.id :other possibilities have been proffered
.:-..... buttne strongest finkage h ?s so far.been the pseudq-va$cu.l<;>9enesis -theory centered around !he prc-
cmd an!Pan9iegene'tic 'factors {pla~ntal gmwth fact6r:and vaseular endothelial grO\Wrfactor varsus
solubl:-:ftt-1) .
. ."
l;)iagno~s:is.:r:nad~:ttRough~the\Jsual'sieps: ... . .
o Clini<n HistorY(to.incllle id~_ritmcation .drisKf~ors in~the mother,.fat'1.erand fet).Js):and .syrnp~om
. re\ii~w:6.f':oltiet 'Of9an~systeitJ~:- . . .... . . . . ..
o . Ph)>siciiL.f=Xamin~tici1 mainly centered-on b16ad . pre,ssure ilieasurement .
o ~qryT~~ (he~t~~;p:~t~i-~~se~m :~irt:acid;, platere.tc6unt: bi.lir.ubin:arict liver enzym.e$,
. LDI-l:~:signs;of hamolys'is. in U:ie:peripn~r.al smear) .
. .~~. .9::: rUI~c;mQd:(QJo.~;-:.9~~w.tll~nd;P9ppler).:..
P:re.v.entiOn',~f.~Pt~~!amps!a 'dev~loprn~(:}t :h_as beenC9nsidered based on sever:qt.evidence-ba~d
"trla1srbn~(>MiaJnc-:06se:aspifih~andJilgtcd.e:{a.t!.9..~,pQQQ:ffi9}~!~~'!' : The .origir'!aJgood-resuttwnn.
:th~se$t~antf:e~ants-GVi.tamins.0aM:E).hci.s.notbee,tv.al\9.ate.g.P.y ~~.eq.u enHnafsahd'is :uierefore
n9icutren~. ree6mmended. .. .. ..... ....... - -- - ..... --

Three main general ai.ms of definitive .treaJrnenr are:

0 'GonttOI ,o'fConvulslons:(drug of ctK>ice'.is rnagn'esium .sulfate)
o C6ntrol'.6fHyp.erten'si6n
.o Optimum Time and -M0de cf Deliv~ry
. .. . / . . . .. . . . .
The;qitj.<i.!.iime of d~liyety l~ . main~ygpv~rn.ed by 5 factors: . .
.o Age of.-,gestatibn. ln.genera!, oricethe;34th week.ofgestation is reached, delivery is recommende;d
)
tor ~tem~l safety. .
o ~.e.v:~f.iW <;Jft.he di~ease. Ec!amp~ia .ii:li'!ndate'?. clel_ivery reg~rdl ess of gestational age. Severe
.P.reecl:ampsi~, p.atlents ar.e usually :de_llvered on~e }4 weeks.ot . pre gnancy is :achieved but
.CQnserv-?Uve :mea_slires .at .< 3.4 weeks.can~ trieo in higiHisk ~nters. Properly-'in~ormed pati~l)ts
wii:h mih~ .:preedamp~ia can h~ managed.as outpatiriss._ . . ..
0 - "t~:fatemai.evai]Jalion, Regular.. ch~ks of the mother's multiple-orga n symptQmS; vital signs, body
weight, lnpU:tand bUtput inonitorin'g and.regu!ar:review. of.meaningfullab.oratory examinations are
~~~~ . . .
o Fetal ~tatus .is reg~larly monitored W\th daily fetal movement taunts, N$T or CST;_~iophysi~l
prefite; _growth m on ito ring.~ .O~ppler uttras.oun<:L Ster:9ids .. {24 mg .of betame.tha sone or
de~amelhasone) have. proven lnvall.iable in enhanc!ng neonatal survival especially against RDS.
o Nur-Sery capabllltY. Most P.hflippine nu_ (serles j~port a hiGh sur.-.:r!valrate .<1t 3~ wee~s.

. -
Scanned 8y: C
 CHAPTER -39: HYPtRTENSIVE DISEASES IN PREGNANCY
1. WHO/UNICEF/UNFPA Maternal Mortality. Estimates
from2000.
2. Lewis 0 (e<l): The Confidential EnquirY. into Maternal
and Child Hea.l th Sl!-Ving mother's live$: revieWing
maternal deaths to m~ motherh<>od safer .,. .2003-
2005. The..Seventh RepOrt on Confidential Eqquiries
.into Matc:rrWJ .peaths in the Unite<l Kingdom: CEMACH
L..-is. 2007.
3. Philippine Obstetrical and Gynecological Society.
Annual Reports of the Committee on Nationwide
:' StatisQCS, 2006. ~~ . 80: .277 282.
4 .Chesley~. Hyp~rtep~;ive.Di90t4enin Pn;~cy. New
Yor-k. USA: Appleton-Centu:y-Cr.ofts, 1978.
~- Mayna.r<l SE, Min JY, Merchan, et al. J Clih Invest
2003;"1.11: 649-658.
6, ~e R J, eta!. Solubl~end~gtinandot}ier~ul~ting
''lin~giogenic (ac~crs in pre.:eclampsia. N En~ J Med
2006;355:992. . Ultrasound Obstet d:Ynecoll99!; i: 192-196.
,:;r" ~ed"Horse K, Ya.Q Zhou., Oent>&cev 0, Prlikobphol A,
:Fo\llk R. McMaeter M, and Fiscller SJ. T'!::l>phoblast
diffr;rentiation during embryo iinpla.'iltation and
. ..,,, ~ fOiliuilion.o f the :rnatertuiHctSI interface. JCl2004; 114
. < !6): 744-754.
8.. CUnningham FG;-et at". William!/ ObStetrics (2l"'). New
. York, USA: Appleton~Centucy-Croftll, pp~ 763-818.
9. Rep~ JT, Villar J. PT~~cy-induce~ hyperten sion
andtow-birthweight nte r6Je <>f"'calciuf:d. Am J Clin
NUtr-1991~:-5.4:-23'75; ....:. . . . .. . .
10. Pa,ge EW; Christiansen R. The:Un.pact of mean arterial
pressure in the second trimester upon the -outcome of
ptegnancy._AmJ Obstet.Gynecoll976; 125:740.
1 ~ Chesley LC, Siba.i i3}11. linical significance or"elevate~
m~ arterial pressure in the seeond t:riliiester. Am J
.Obstet Gynecoll974; 159: 27~-~79.
12. Redman CWG, et al. Plasma urate measurements in
predictlng fetll deaths in. hyp~rtensive pregnancies.
Lan_~e~ 1976; .1: 137b-1373.
13. P"llak VE, Nettles JB. The kidney ,in to~emia of
. p~egn3J1cy: A dinico-'patl"\ologic s tudy based Qn renal
biopsies. t-4ed.icine 1960; 39 469-475.
14, pavidso~ JM. The urinary system. In: Hytten F,
Chamberlain 0 (eds): Clinic.iU Physiology in"Obstetrics.
Oxford: Blackwell SdenUflc Publica:tiQns. 1980; 289.
15. Voigt l{J, J3ecker V. Doppler flow meast?-r~ments and
histomorpho\ogy of the pl<~.centa:l bed in uteroplacental
insufficiency.J Perinat 1992; 20: 139-147.
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16. O!Qffson P, ~tal. A high uterine arterypulsatilityin.d ex
refleets~~ defective developmen~ of place~ tal bed spiral
arteries in pregnancies complicated by hypertension
and fetal growth retardation. Eut J Obstet Gynecol
ReprodBioll~93;49: 161-168.
. ' . .
17. Kucllelk~I. e.tal. Umbilicale stromungsva-haltnisse bei
g~stos~:patient - innen ..._ gestosecharacteristisches
Doppler phanQmen. Geburt$hilfe Frauenbcikld 1992;
52: 589"591. . . .
18. Thaler~ et at Systolic or diastolicnotcll ilnrterine artery
blood flow vclocltY wavefonns in hypertensive p~egnant
patients: rclationship to outcon::e. Obstet Gynecol1992;
.
19~ Brar HS; Platt LD . .Revcn;e end diastolic"riow velocity
O!'\lll'n bilical aneryvelocimet;ry in high risk pregnancies:
an Otn-inous"fu\ding with ad\:erse perinatal outccme.
Am. J .o bstet 0yneeoll985; 1~9: ss9-Sti.
) 0. "Mand~to 9P. Significance or" ab~t or rever-S~d
ertd"dia$tol.it flow in the fetal aorta and. ~bilicai a.<tery.
. . _ -. .. . ..1 ...cr::~~-;-_ ~
21. R<><:h.~$0n )3, ~tal. The .significance:Of< a~t',tnd~
diastoliC 'telocity i.-l utnbi;liq!] artei)'v~i:Y.:~~ciOiros.
A!1l j Obstet Gynecoll"989: 156: 1213-1218...
22. WeissE, ~t al. Blood flow velocicy wa,vefoml;s::~~ the
middle cerebral .artery &.."ld abnon:naFneuroiOgical
evaii,lations in liveborn fetuses with'ab~~:)f.mer'sed
end--diastolic flow velocities of the w:n.QUicW.--llrterie.s
Eur J ObstetOynecol R,eprod Bioll992;"45: 93-1 ()9.
23. Marsarx~t.eyn : ~rtt.raui~~
- -~ -- riow ~d stnatal
blOod
-~-- -- --- - 1>.9- .. M
niUro1oi!e development in groWtl:t reta...--ded fetuses. Biol
Neonaie 199,2; 62: 258264.
24. MatsalK. Role ofi)oppler -sOnography in feto--matemal
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44. . . .'
25. Hafnet", et al. Vltras6und Ot?stetGynec<Jl2006; 27: 652-
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Comstock CH, et al. Am J Obstct Gynecol 2004; 190:
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27. Belo.golovkin v. Eddleman KA, Malone FD, et al. J
Mat Fet Neonatal Med 2007; 20: 509-513.
28. YoungTK, WQ9dmansee B. AmJ Obstet Gynecol2002;
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29. Cedergren MI. Obstet Gynecol2004; 103: 219-24.
~0. Callaway [,.K, Prins JB, Ch ang AM, Mclq,tyre HD. Med
J Aus t 2006; 184 : 51.
C
 . ..
602 SECtiON VI: COMPUCATJONS 1N PREG~CY

31. Mis.e H, Sat:awaN, Matsumot.o T, et ..aL ~~gm.ented 46. Lopez-Jaramillq )=', et aL Dietary calc.ium supple
placenW production of~~ p~p$: Possible mentation and prevention of p[H.' La n cet 1.990; 375:
involvement of .placental hypoxia. JC~M 1998; S3 (9); 293. .
~225-32~. .
4 7. Ec1i.zan JM, et al. Calcium supplementationto prcven t
32. R~say JE, Js,ill;ie~n N, 'Greet JA. !llld Sattar N. -h :;pertensive disprders in pregnancy. N .Engl J Med
Parado:icica1 elevation in aQipnectin.concenttations in 1991;3~5 : 1399.
. . :~en with l)'reeclainp&ia..Hypertcision,~003; 'l-2: 1391-
~94: 48. lloJmeyr GJ, Atallah AN, Duley L~ Calci.1m
sU:ppleili~ntation - dur.ri_g pre~ari.cy for preventing
33~ Bod,il.az: U4. Ntss Harger ar ail -'~o~s ~
REi hyPertcir$ive'4isordert and related problems. COChrane
!nfla+nmation ~d trlg1y$trldes partihlly m~dia~ the ~t3JSystem.cc.Reviews2006,Is~e3.Att.No.;
. dfect.pi"e"p~cy Ii!MI.onthe:~Of-P~Psia. CDOD1G59. DO.i! 1,0.1002/14651858.CD001059 .
}..Jn .JE:Pidl#niot~(X?S; 1'62: 1198:-lMli. . :pu1i2. . '

. ~. Walsh$W~et!U.~~~~~lipid:~de 49. Chappell LC, Se~ ~.

Briley A(.:, ei aL -Effect cf
and th.iom.bo~ l>ut not p.rostacyclin m: pt'egllant ;ntioxid.ants on -the
occurrence of -pr~clampsia in
.. .. :~~I;Den, ~ ?9bstct Gynec:ol1'99~,; .~-61-:, 9.W.- women li.t ~- tis k: a-rand6miied t:iial.- b eet
1999; 3$4.:'8 10.:::816; .
~s: 'Bea.J.Jlil~ !l,.et.ru.: Ptey~ntion.ofp;~~p~la. :by.early
:antiJ>)atbJ.et ~-:P:Y. t.an'cet;.t9as;.1:~~'
. ... - . 5 0. Beaiiey:D; Ah:ola;\3 '1~. -J;..i$gston J, Orlggs M, Sl:BM.
Vit!m:Un 'C an:d~ supplep:len~tion in wo~in at high
36 'Mill.c:.b~g;H~, ,et &4.-Low~l)~ ~_p~J>reven~ PIH ris~ for pt~_edamp-sia: a do}l.bl e-bli;ld, p1,<i~ebo
:.,: and,; . pte.:::edJirili>~~a _in -&,~g).c't~!}s{n"-~;Cnsi.tive contr-olled 'tri3l. A:m.J b'bstet Gynecol 200S; .192:520--
:21.
. ::;~~gia~ .~ce:t:~?86;-+~ J.:--3. .
, -5L .~O:stob. .CD.L:,Briley: :AL... Seed.-N;+-Keliy: FJ:; Shennan
- . ~7:'-=;~~-~==~~;ot!~~:
: . rdii. anclcit: }{ thO.-:
~t. .'l<rwi.."::rli$k'~gn
: :
198'9 :j'~ed''
. :Mi. ~.for( !Ae'.V::It~'i'ili'" ::J i,n .P.rc~Jiim:psia (VIPf!riel
CQn~. Ni~riilp.~ and ~ -~ in p~t
... .U-~HT~
321: 351...,356.
. ~""- '""'. .
.
~-
. .
, :t
. wo~~ ~furpte~psia {1Pif.,al)~ rai'l.tlOmii:ed
.. .... . . :P~P9-~@Ueatrful.;."U.n~t~
. . .. ~
~;.367: 114!>-1_
. . 154.
,\>8. ::M~~li,~~t~:D9PPle,r:~~d.~d:~~lWii:J.;_in ;. si. RumPQld ~ f<;>r ~~e 'ACTS StUdy.Group (Au~n
.ltbe.d<:O&nttiQ.n;e,tid ~-DiCventi<in: Of Pik.
:335;~1Ss'~~isss. - \tiui~
9
l9. 0; . Co. ""'P._.P...k. _men_ts). ~tamin.s
. ra._tivc.Trial.... oi.,..
llal,;o . .. - . e.and E
-~a. th.c . :ii~ks Q.( .' pr-ec;.el:an.p~ia: and p~rinatal
.... comp1ieationS.. tt En,~~fJ t{~e~f2~_; ~54: H9tH~.V6 .
.:.. .. ~ .. . .... . ..,.. ! ~ .

$ ...Rumi;l,old.A. .p.uley..~, ..ete>wther--~A,H-asl~RR.

.Antioiidari.ts {or J>Teventin_g p.re-ttlaiA.p~ Cochrane
D~J,t;l.bil:seofS~~ Revl(:W3i00'8, bsue l .Art.No.:
40. paraziinl. -F~ to;.~oS li.s..P~- irl]l.t~ventiop. and o04227. pOl: lO.lOO~iH6srasa.:~ilo04221_pub3.
tteatment ..of (UGR -.and, PiH -~~ stu_dy pi Aspirin I ' < ' , ,, 1,' o

_ . :and:P,r,egnan~.:~~t.-.}~3_; ~1:' 3?6-400. 54. .th<ff..GPJ;E.irial Gci.natwni:?tig;~~u:p. D<> womp1:With

pre.-e.Clamp si:a, and t h eti- :h~bies, bene.f it" 'fr.o m
4.1. 'Ha\1-th -Ii, et.al. Low-:c;iose ~pirjn th~py. t;o _pteve11:t magnes~Ulll SW[-a:te? ' Th~ )4.AGPIE tricl, J:l .P,l aceqo
. pre~edamp'$ia. Am J O~tct O)'necol t9.92f u>~: lQ83'- cbntro'ile9, "t!illl.. 'Lancet i0o2; ~$,9: _137-7-1.8 90.
ib93. . . ..

55. The 1fAGPIE t~ru-C'qllaborative Grbup: Th e MAGPiE

-42. SfuaiiiM; et -aL Preyentio~ ofpF.e,eclamp$ia With low.- Trial.: a r;uldo~d ~ ~om.p~g ~gnes.iUD;l sWfa_te
. do~ -~spqm ln.).1e$.hy.h\Wip~'q3 pttgnapt :WO!llen. wi~r_i:i4tcep.o for;p~e-eclaplpsia., o'utco.q~~ fo r wom.en a t
N~n~j'.~~ed:':i:9~3;. 329: 1;.-2.1'3~1~1;6. . 2.j~. 'BJOG-2007; 111' (3):' 300-30:9 .'

43. Cqllabor{lti.ve U,w:..d.ose. Aspirin Study in Pregnancy.
Lancet 1994;'a43: .!519..{)29.
. :' . .
44. Du1ey -L, Heride.rson-Smart D J, Meher s, 'King JF.
Antiplatelet -~gcnt.s _for pr:eyenqng pre~pSia IUld
its complicat'i.ims. -coclu'ati.e pa.ta.ba.se.of S'yst~matic
Reviews''20.07, ~~sue. 2. Art. No.: CD0046S9. DOl:
10. 1~2/14651858.. :CD00.4 659.p-ub2
56. The MAGPIE Trial Colhiborative Group. The .MAGPI E
trial: a r-andomized-trial comparingmagn_esiuo;J.,~ulfate
:with placebo. fon>re-ec~~.Psia. Outcm'; for Children
at 18 months. ~tiC 20{i7i 114(3): 289-299. '
57. Motlz.inho A, e~ al. Effect of maternal hypertension on
rieoniital .neutrp~_n1a..'a nd n osocomial infeCtions.
Pediatt 199:2; 90: 430-435 .

45. -~ ,JM, Ct ill. The relationship ~tween calcium 58. r a$h PL, et.~ EITect of early-ons.:t'bactenal sepSis br
intake and pre,gnancy~induceq;. hypertension . Am J 'PIH on neonatal WB:C and platelet .coun.ts in irifants
Obstet 0ynccoll988; 15~: 898: . .< 1200 ~s. J Matern Fetal Med 1992; 2: 1-4.

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 CHAPTER 39: HYPERTENSIVE DISEASES IN PREGNANCY
59. Schneider H. Drug treatment in pregnancy. Curr Opin
Obstet Gynecol 1994; 6 fl): 50-57.
6.0. Smith LG, et al. Calcium homeostasis in pregnant
women receiv".ng long-t.:rtn Mg$04 therapy for preterm
labor.AmJ ObstetGyneeoll992; 167 : 45-51.
6 L Pickles CJ, et al. A nmdomiu:d placebo-"Ccntrolled trial
oflabetalol in the treatment <>f mild to moderate PIH.
BrJ ()bstet Gynecol1992; 99: 96.4-968.
62. Bhorat 1~, et al. Malignant ventricular a.ahythmias in
~psia: A coQrpari.son oflabetalol with _
i lihydralazine.
Am J Obstet Gynecol1993; 168: 1292-1296.
~: 72. ti~kker GA . Sibai BM. L.owdose a~ in the
63. MonU!n S, et al. Randomized COQtrolled trial ofatenolol
and pindolol in h~an pregnancy: effects on fetal
he-"l)o.d ynamics. Br M;;:d J 304: 946-949-
64. Crt.licks.~ankDJ, et al. IUGR and maternallabetalol
trea~ent ii1 a ra,ndom .a llocation controlll:d study. J .
Obstet Gynecol 1992; 12~ 223-227.
fS. -~sibai BM, et al. A r:ai:ldom.iz.ed pros pective -compllrlson
of nifedipiD.e and bed rest vs_ bed re.s t alone in the
. man~gement of pre..:Cclampsia remote from term_ Am
.; Obstet Gynecoll9~2; 167:-879-884.
66...]smfill:.,AA, ~t ai, Eval"!lation of nifed~pine in the
. treatment ofpre~.clsmpsia... Int J Obstet Gynecoll993;
40;.3.Q1.-4 3. . . .
-~ ~: . ' ... ~.
fJ7. Chenoy R, et al. Nif~pine sublingually: an effective
treatm.e nt .o f severe hypertension in pregnancy. J
Obstet Gynecoll993; 12: 167-168.
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... 603
68. Tranquilli AL, et al. Nifedipine treatm~l in pre-
eclampsia reverts the increased erythro.cyteaggregation
to normal. Am J Obst~t Cynecoi 1993; 167: 942-945.
69. Catbonne B- Nicardipine treatment ofhy.ptrtension in
-pregna."lr.y_ Obstet Gyne"Col1993; .8 1:908-914-
70. PiperJM, et ~. Prcgnimcy outcome following exposure
to ACE inltibitors. Obstet Gynecoll992; 80: 429-432.
71. Mabie WC, Sihai B. Hypertensive statesoCpregnancy
In Alan DeCher!ley, M Per.noll. (eds}: Current
Obstetrical audGyr.ecological Diagnosis and Treatment.
Connecticut: Appleton and Lange, pp 380-397.
preventlon of preeclampsia and fetal grov.rth
retardation: rationale, mechar.isms anddinical tiia.ls.
Am .J Obstet :G ynecoll993; 168: 214-227.
73. Neilson JP, Airltevic z. Opppler ultrasomld for fetal
assessmenti."l high risk pregua.'l(:ies.[Coc:brane Review).
In:. J'he Coc!"...rane Library, l.; Z00;2. QldOrd: Update
Software.
74 . .Pu!ey L, Hende~onSmart D. MagnesiUm '$ulphate
ve:r~us ~azepam for ecl-ampsia{C~R~~) . L,:
The Cochrane Library, 1, 2002: ~~~era~;. ")Jpdate
Software. !':>-<if.. .
;. . ..... ' .! .-.,~:!.'
75. Duley L, Hendert>on-Sm:art D. Magn~ sulphate
versus phenYtoinfor eclampsia :(~ Review). In:
The Cochrane Libra,ty., 1; 2002ti0Xfoni:-:-'U p-da,te
So.ftwa.-e. .~ : . "'' -~ '
-. .
76_ Duley L, G~glu AM. Magp.esi.um Sul_pbate v:::rsus
.l ytic cocktail for eclampsia (Cochrane Rewicw). In: The
Cochrane ~Libra--y, ~ ; 2002. Oxford; U~ Softw~e.
r

.,

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 MTJLTIFETAL PREGNANCY

VALERIE TIEMPO GUINTO, MD

Epidemiology of Multifetal Pr~gnancy

Classification

Diagnosis

Maternal Phys,iological Changes

Complications

Antenata! Management

Labor and Delivery

Unique Problems
Twin to Twin Transfusion
Acardiac Twin
Conjoined Twin
Single Intrauterine Fetal Demise
Fetal Reduction or Selective Termination
Other Rare Cases

.:;:,...
;'t'"

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 SECTION VI: COMPUCATJONp IN PREGNANCY

;Er.IDEMIOLOGY OF MUJ.TIFETAL PREGNANCY retained, the dead fetus may become mai~edly
shrunk~n and ~omptessed between the. uterine
. . The frequency of roonoiygotic twinning. is wall and
'I~embrancs of the living twin giving rise
.3~5%, and is relatively constant in the :Whole to 'what i.s called a fetus papyrace.u s o~
world. Dizygotic twinning, on the other hand can compressus. Combined .intra- and extra-uterine
..be influenced by mce, and thus variis in incidence pregnancies may also happen and is c~!lea a
;iO..differ<!nt parts of.:the world. Multifetal pregnancy heterotopic pregna.J;lcy. s.6
.>. ra_tes, in gen~tal. have incre?,.sed significantly in
-th~]ast 10 ye.ars. Jnthe US, there has beena~S% Risk facto.rs
)IJ~ in twin :births, 115% i:n:crep.:se in-triplets,
:..' i-4'9% .increase in qu~d~_p,tets and ?- .250% 1. ~ered~ty o: I ' '

~ . mcreasein;q\ti:ntgple~ts ,or ~~I:,oraer:l>irlh:~ ~~ .

..inGrease ~as I?e:e.n attribute<! latgeiy to the ~~ m~tetnal and patemal.farnfur bist~ries
-~~t:~'if.E;vai]~i#:~'oX: 'a~s.;-~t~;re:pro<!utiv.e , 'fot twinning .ar~ as~a~<l :with -tWin o*'$pn.-ijs.
tehn:o~ogi~ ifn;d d.e*-~g child'biith to a -~ter .:::rhe,matex::tililfa.t;riily' ~e; 1loweyer, ha~f~n fcund .
' : :~ge.1 ol . tb have a stronger mfluence than the patern~
fa.:m,ily .line. A d.i.zygptic twin :mother has 1 i.Tl 58
. , . :.fu.~. the Philipp:.ipe:S, the rate -of twinning and chances of.g ivihg birth to t:Wiiis; .but, a ~gotlt
. 'mmt.iple pref};rumcy has .slightlY mcreased from twin: father With a singleton :wife has only i hi:.h 6
o;.:~~r= to 1.94 in 16 years. 3 'the jricrease~ however~ ~~:ces. Maternal role in .monozygotic as :WJ!llas
. wa;'attn'b"ltzd to.a pr.cb?.ble better reporting:(Table diZygotic twinning is demonstrated. In contrast,
. . :.. )4
:4R.} paternal role is . only seen in d~gotic twi.ntringJ
. ... . '

. : :. : .. .'Tlie mcioeneeis .cpi:.o baply ev~n: mU.Gh hjgh~r. . '2. Race

There are instances that. ohe of the twins may- be
... .. !~lighted and :pever. de:Velpps. S~C$1.~Y .e no:ugh :Twins are. ~ore <:ammon arno:ng black:woint:n ...
: : io ';h~:nio~:. If. feW q:einl~ h~ppetrs. }:)efore m:eo
(1. to
pr~ci~s) Compared- w4ite W.Qnien.' ;
. : :\tht:_,~end :offuef'ii'St trimeste-r, the fe.t us D;l.ay be {l.in Too p~gnancies). In A~~. twinnin,(ris 'less
.-.~~pipletety resOr.~ without a trace-atd~livery.'If corn.monat lin 155 pitths.7

Figru:.e 40. 1. Rates of:multiple pregr.ancics -inth-: POGS-.ac<;.redited hospitrus.

Yea.r Singlet~n . All Twin Triplet Other Percent

' . Multi pi~
.. ..

19&4 91848 44& 426 22 0.49

.. ., 19:>5 9l61~ 808 0.88
'19&6 1037{)7 994 9.82 11 o,96
1987 101'06 992 974 17 0.98
19&8 104668 1040 101~ '22 . 0.99
1989 146$09 1933 1849 6 132
l99Q 129906 2352 2595 26 4 1.81
1991 170687 1749 171-9 30 I 1.02
1992 170~3 3302 2746 52 6 1.94
1993 16&4-13 2889 2842 47 97 1.76
'1994 192517- 249.4 2185 33 4 136
1999 151-0 ll 1048 989 '57 2 0.69
2000 294484 4008 2059 43 136
. .
Repar:U of the Committee on NationWide Statistics, PPilippin~ O;bstetrical and Gynecological Society .
. '(POGSJ. T*en from Fest:in MR: E pidemiology .of m.ultifetal pregnancy. In: Clinical Practiye Guidelines
on.Multifetal Pregnancy.2002; 1-10.

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 '607

3. Maternal Age and Parity fertil~tion of 2 ova by .2 sperms. Tll~y have

the.r efore different genetic makeup, much like
Maternal -age and parity likewise affect ~iblings from diff~rent pregnancies. Depending on
dizygotic twinning. ln general, the higher the age the timing of the initiation of cell division,
and ~ty. the higher the chances of twinriing. monozygotic twln.~ result' in one of the folloWing
The peak in twinning is obsented at maternal age (Figure 40.1):
of 37 years when JllWdma1 hormonal stimulation
enhances the rate of double ovulation.
Grandmultiparous women. in Nigeria have 3x the
risk of having a twin offspring compared to
prifuigtavids. 7

4.. Pencori..,--eption JntB,k:e of Vitanlins

lnWc' .0~ vitailllu. befote. durliig coneeption

and in early pregnancy com,pared to controls has
been $ll6wn in 4 Cochrane ~ystematic teview to
~..,..
,.lti....... . erl:Jk. :or multip
..__ 'th . . . . te. .,""'""
-tation :'RR
1 1.38 ,
9S%er). ~~ to t.70;2Q.~$.6 wemen);4
. s_ ;,~:!i1~~~ty4'~~ent .
\ ,

~Ultiple . QVUlatfop.s are . iMreased in

prCgnimcl~$ wl:iete ov-..Uation induction agents are
us ed. Multi:p le pregnancies in pt:egnancies
induce~~th (;lotniphe.I1e happ~n 1.83 j>erce~t.to
53;5 .p,a~t. ot the time. While in pr:egnanc1es
where>~Wrul menop.auw gonadotropin ~d/ or
choriOnic ionadot;ropin are used, th~ incidenCe of
multiple p~gnancies even increased at 18 percent
t<> 53.5 ~rtt.7
In a&dition; assisredreproductiveTeciu'lotogies
{ART) have been blamed for increasing the rate of
twinning in some countries to epidemic
proportions through the practice of transferring
mote than one e mbryo. ART .has been associated
with a 30.:fold increase ~n muitiple pregnancies. 9
Tvw-ins resulting from ART can-y a .more adverse
outcome compared to the singletons. The surviVing
co-twin in conditions termed as vanishing twins
were also being linked to poor outcomes. 10
Fi~~ 4().1. Variations in ch<\rionicity and amruonicity in
i:non~gQt;.C~griM<;ies. . ... . > ;:~ ..
- . .. ~)~~-. ?~~-~y ; .
~l:! ' -
1. Dithononic; diamniotic twins, when diVision
r;)Qt:Y!t~4 (lijrjng Hie jirst 72 hoU.rs- afte't
-re~ti:Qtt~' They'ba\1e: 2 ptacentas~than Can.
-~th:r~tJe~at~ti:tictfr<lrir~~cn--o~r-or-ru:sed'.
2~ Monochotionlc. dianmiQtic twins, when
divb*>n occurred d\ll'h:lg the 4"' to the 8th day.
MonoC}):ori()nic. pre,g nancies have only 1
p~centa; . .
3 .. f.top.oehpnonic . monoamniotic twins, when
. divi$i()n occurr~d .after t;he 8th but before the
i2tn day.
4. C'..onjoined twins, when division occurred a fter
the 12th day (Figure 40;2).

In contrastto earlier beliefs, both monozygotic Diag1;1osls .

a nd db:ygotic twinning are in c rea sed in
pregnanCies resulting from infertility treatment. 7 1. Ultr;;t~Oi.ltid' .

Cla.sslfi~ation Ultrasound is invaluable in the evalu a tiorr and

Monozygotic (or identical) twins are gene.tically
the same, having come from fertilization resulting
. from 1 sperm and l e gg. On the other hand,
di:iygotic (or fraternal) twins result -fr.om ti:te
management ofmultiple gestations. First trimester
ultrasound is very helpful in identifj'fn g. the
number ..and location of gestational sac~ (figure
40.3), .the number and viability of f~tuses or
embryos, zygocity, chorionicity and anuiionicit)r.

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~
 608 .SECTION VI: COMPLICATIONS lN PREGNANCY

Monochorionic, monoamnionic twins are

monozigotit. Dichorionic, diamnionic twins,
however can be monbzygotic or dizygotic~ one
third of. munozygotic .twins are <;lichorionic,
diamnk>nic. A thin, inte rvening me~brane {<2 mm.
tbickl is -a sign of monochorionicity~ the "'tWin
~identifies the 'pcintwheretwo nlacentas in
a dich9rionic twin .pre~ancy have fused (FigUre
40.4.) . Th,e Q_~mpristration of 9-iiferent genders is a
mark~ of dizygotic twi.ri:s.7 ~

-Fi-g.u"t:e~4'o:'4.-rne -"'t:Win 'P.ea:K- sfgn Tq-e:fi-Ch<>rionic

.Pregn:$c~es . .lFrom: ~;,...i~ e. co:m/lean:)ing/ twin/
fig\u:~~jpg) . .
(; .

First, second and. t.p;ird trimester ultrasound

ma.~:~ers of :chorfonicity ah:d a~niop.i<;:ity a r e
Jurtb;er d:i siusse9. in Taole 40.2. 11

2. aistory and .Physi~ru Examination Findings

Multifetal pregnancy is suspected whe1:vthe

uterine size is larger than wh at is expect~d bas ed
in a given ge.stational age. Differential diagno~es.
are inaccurate date .o f last r;nep.st~ai p.e.r .iod,
uterine myoma, excessive amniotic fluid
(polyhydramnibs}, and hydati difqtm mole.
Identification of. excess in fetai p'arts (tvio .beads,
ri.g'u~ 40.3~ Dichori~nicp~an~ seenasi gcitat:lonal
;sa{:S ill firSt trimest,erultiasoUn.d..Wrom.:.~.-iame.cq'm/ for in~tap.~e) usua.J)y in.th third tri.ID.esteris also
l~g/twin}figuie7"jpt) . ... . . .
. .. .. . ,
: .
. ru1. examination fmdirr~ seen in nVins: More thw

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 CHAPTER 40: MULTIFETAL PREGNANCY 609 .
--------~--------------

one fetal heart tone is also seen. The presence of
. risk factors (ovulation induction techniques ,
elderly gravida, maternal family history of twins,
previous pregnancy with twins, ~d higher parity)
ni.ise:; the P<>ssibility of multifetal" gestation.
seen in twins, tp~~e findings alon'e- are not
diagnostic. There is still no reliable biochemical
marker in identifying multiple gestation. 7
fdater.nal Physiological Changes

3. L3.borator; FindiJ1gs Geneta]ly, there is an exaggeration of the

physiological changes seen in multifetal
Altho~gh elevation in the maternsd serum pregnancies: Maternal bloop volume normally
alpha-fetoprotein and chorionic gonadotropin are increases by 40 to .SO% in .the third trimester or

Table 402. idru-kers of cltoriooicity and .ainnicnici i.y:

First Trim~ter Markers .ofMrionicity ~d Amnionicity

----~--~----~--~--~----------
Done at the 6h to the "1 Qlh .g estational week.
Each gestational sac (GS) forms iu own placenta and ch~rion.
thu~. two GS irr..ply a diclwrionic-diam."1im:.ic pregnfthcy.

Seen at the 7U. to gu. week .of gestation.

The amnionic membrane surrounding each embryo is.better seen .,
..; through transvaginal ~traSQ"\lPJ.. '
If there is on!y one amniork membrane s utrounding two . .. . ;.
embryos (or surrounding :two .embty(micheartbeats), then,.i t is.'
. monoamnion:ic, monoc.horlonic.
lf there are tWo ammonic _m embrane$ insi~ one OS, the~ ;tis
d iatnnlo.nic, monochor.io!iic.

. .. "' '- :
If the twins have different genders, ~ pregnancy is n~~~~ii~:d.~;; :.:.
~iamnionic-dichorionk. . . . . .

Number ofp!acentas If ther: ~two ~~~~ pl<lcenU!._~._ -~ i.~. r~:>$:i!Y ~icll9tiomc- .

afaniiiionii:. . . .
lflhef'e"fs on:ty"omnmiceftfa ~n;if.can either ""&e"monochOCionic
{cnly one place_nta) or dichorionic {the twO plaeentas ~re fused) .

"'l'win-peak" sign This 4; a triangular proj~_g zo1,1e -9f tissue, wider at the
Cho"Q.onfc peak sign chorionic surface of the placenta, extending and tapet~g to the
intertwin membrane.
This js seen in dichorionic pregnancies. Its abs.ence however.does
aot eiclude the possibility()fa dichorionic prtgnancy.

Presence of intertwin membrane The presence of th,e inter twin membrane poin~s to a diamnioh.ic
pregnancy. The umbilical cotd of each.twin is i>llowed .and their
. .. sites of inser:tion on the placenta are identi~ed. Theintertwin
. membrane is .searched for bet'fCen the two sites of iusertion. Its
noll-visualization however may_ mean any.o ithe following:
a. monoamnionic twinning; J;l. diamnionic twinning withqne
twin .v .ith severe oligohydran'lnios r esulting in stuck" twin;
c . normal diamnionic pregnancy v.'here tbc membr.ane.is not seen.
due to its thinness and orientation.

Thickness of the intertwin The intertwin mem branc in a dichorionic pregnancy consists (i2
membranes layef1? of amnion and 2 tayersof chorion IUld is therefore thi&er
(> 2 mm) than the monochoriooic,diamnionic membrane, whlh
i~ only com posed of 2 layers {)( anioicn. :.

Modified from Lagman:-Py P. Multifetal Pregnancy: Diagnosis. In Clinicai Practice Guidelines on Multlf~tal
Pregnancy 2002.pp.l521.

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 610 . SECTION Vt COMPL1CATH)NS IN PREGNANCY

singleton pregnancies. . in twins, the increase is 2. Vascular . in ter.chan ge be.tween the

S0.-600/o, or.an extra 500 nil.more of blood .is seen.
Physiologic_:anemia is more pronounced, with 10
gfL average h~maglobin concetitration :after 20
'weeks in twins. Likew).se. th.e increase-in car.dlac
ou tput, resulting from increased heart rate and
stroke volume, is als o more tnarked.
monozygotic twins may result in ~erse flow
v.rith acatdiac -fetus in one twin (Figure 40.5 )
or i..."L vascular disruptions in a .deci:ased' twin
cati.sing e!ects such as mkrocephal y,
por.encephalic cysts, hydranen:eephaly, aplasia
cutis, or- J,imb amputation in the surviVing twin.

Because of the l~r.ger 'Ut~rine si.ze, the

- ab.d~mi.Iial o:x:.gans .a re .more '-compressed and
-displaced, the diaphra-gm is
more elevated, and
.pressure symptoms and dlfficu1ty in ambulating
and perfonn1ng tasks are more copun.on. 7 Due also
tp "4terine o:v.erdiS:~"J.ticn, postpartum hemorrl;l~ge
is also -r;nore conU:r..ori in multifetal gestatioh~
rr~bl~ 40.3J.

C9 tn:::>ll~tlon~

1. Co~g~nit.al Anomalies
... .;...:.

Conge~~~ "anotn.?lle;> . are ::9:ne .corlllP9:n-..ip,

. . m~tit'~t~LP.~~cie~;..:~ili~s,...p_r-~n:at:iil;-~di~gn~:st:ic ( ,.
.tests are olten ;~t:fo.ri:o.e~L . Malfqrma:ti,op;s . a:re... ~-40.;5..A~c twin"~.-
,app~te~y do_:u.bl~d. in ,t;wi~s {t.OS~ i,t;La:~?! : -Fioxn:wW-w:centru:!!.ciim:ol>r/ ..:ftn.p-:Ol~jpg
Plhlform.a:tiori:i>;in sil{gletdn$: coi;npareq~Wi~-2.J:2%
intwins., 2,4$% Jl?.inor mtirlforola.tW~~ iir- ~et"qJ+~ . .. . . . . . . ,. .
eoro.~-~~~-1~% iJ1~s):. M~onnat:j,cnS:3I'e~ - : 3,..__ . 1n~u~oot;.:~qv(.dihg...m::;tn.:thkd -t:rllnester.,
ceven: ~~ei- :ip:.:"m9P.9ZY:e;9tic: tw~s.;C~P1pared~:.~o,.,. ~sultin~ in aberrantpt>~it;i<)liing:1 .
diey.goti.c .twins (3~ !% eompar ed -t o 1-..9%,
:respect:IVely};-r.Q.e prepensity of :st:ni~tural defeits "In Philip~piu e .Gen e ra'! Jlospit<~;l fPG.H ) .
'j.:n: .~9P.o#g.~ti~- twifls;.cqfup~ed-~~1$ dyzygotic -co.tigenitat art'()m}qres w.~f.e :no"J.~.~1j~~-lli~gp,~~Y
~s..arui:sj.ngletons..,can 'Pe.~+a~ifiedas.defects m-~ase:ct m #furmetal~ge-sf;a:ti~n C<>~pued t_o
resulting froni any
<>fthe f.Ollo"Wl.ng: s_inglf!tons, probably-because of .l:P.e l:iigh rat~ o~
adri:l!ssions -with-co~getiital.~Q'~es in PGH~
1. M"o~oz;yz?4c .twinr:ijhg. s uch as.iz;t -~oP.-Joln. being a 'tertiary hl':>spit:al ~d- :P.r1ill~ :referral
twins {Figure 4.0.32): center mthe Philippine~ (T~ble 40.l).
. ' . .

Table 40..3. Ma~mata.nd f~ .~bmplicat.j.on3 Ofmultif~tal gestation c;:Omparcd with singletons in Philippine Gener nl HospitaL

Maternal CO~pli~tion~ Stngletons Mtilti.ie.tal.Pregnancies RR 9S%ti p

.. . . - .
n (freq\l_enc:y) n ,(freq_'l;lency)

Postpatturi:l Hemorrhage 56 (0.0,02) .2~2 (0.202) 102.1 J6.9-135.2 o.o

Hypertension 4473 {0.158) . 3.26 (0.239) .. L48 1.3+1;63 0.0
. Fetalf-N~naW.~mplications
-Gestational ~e at 0.0
delivery<34 weeks 2011 (0~071) 318 (0.228) 3.2 2.88-3.56
Congenital anomaly . 458 (0.01.6) 32-:(0;023). 1:92 0.92 ~2. 02 0.54

Totat 28,239 1394

Data taken from the UP-:PGH Perinatal Statistics 20.0 3 to 2006. RR, 9;5% CI and p wer~ coputed using Epi Info.
Legend:. RR-Rdative Risk, CI-Con:fidertce Interva,l

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 CHAPTER. 40: MULTIFETAL PREGNANCY ' 611

2. Abortion Chronic twin~twin transfusion is ttle maj or

contributor to the poor outcome in discordant
Spontaneous abortion is mor.e common in twins. 7
multifetal ges tations. Twin pregnancies are
identified in 1 in 35 to 1 in 44 of pregnancies
endirig in. spontaneous abortion. H is also more
in
common monozygotic than dizygotic twins (with
a ratio of 17.5 to 1 chance):7 . .

3. Low Birthweight

Lew bitthweight is more common in mul~ifetal

pregnancies due.to intrauterine growth restriction
a.ndjot preterm delivery. The growth of twins is
similar with sing1etons up to 28to 30 weeks. After
'wruch, there is a lag in fetal growth, such that at
36 weeks, the ~venige wei&ht is . 2.8 kg in
singletons and 2.5 kg in t wins. Up to 50 percent
of .t wms have low birthwei!Shts compared ~ .only
.a'Qouf 5 percent in singletons. The growth ar twins
. ,,starts ,to .decline at 38 weeks, comparable to 40
weeks:in singleton pregn~cies. This led others
:to . .conClude th:at 38 weeks may already be
,}postterm for: twins.7 The long he~d notion that low
.prr:..hweig.ht LTlfants from a Iil:U:ltiple gestation fare
l:!~tter .than a .low . bitthweight infant from a
.~ -smgletc11 }'rregoancy. is l1ot <i:prtect. Infants from
..;..:.:~tiple .p regnancies are actually not only loW in
'l>irthwcight but are 3lso preterni, making th em
even fare worse than singleton infants . 12 :-::
. -~ --- ~ ~l~.

. The ,r ate.of ,sm alLfor:.gestationa l age newborns
w,ere .:not .s~grt.ifiGantly ,diifel'e rt t -in -higher -order
. gestatip~s compa red with twin pregnancies in
FG.H. This is probably due. to the high ra te of
referrals of pregn.ancies with. su$pected feta l
growth restriction admitted in this tertiary hospital
{Table 40.2). . As the n umber of fetuses increase,' the length
4. b iscordant Growth
Perinatal morbidity and mortality in twin
. pregnancies are related to .d'iscordant growth
between the twins {Figure 40.6). Birthweight
discordance is computed by dividing the difference
of the weights by "the weight of the la r ger twin.
The higher the'discordance in weight, the higher
the chance of s tillbirth. Compared with less than
5% birthweight discordance, the adjusted odds
ratio for a stillborn fetus a t 10 to 19% birthweight
discordance is 1.4.1 and 4.29 for a 40% weight
discordance. Moreover, the discordant pretetm
tWin is more likely to h aye grade 3. or 4 intracranial
h emorrhage a nd persistent ductus arteriosu s.
Figu~-~..4.0-.6 . . P.er.inatal.deatil.. in-twins ~i~h growth
di~QfQM!;y, .
5. Preterm Birth
of gestation decreases. The average gestational age
at delivery is 35.3 weeks for twins. For triplets,
the average age at delivery is 32.2 weeks, while
for quadf4plets, it is only 29,9 weeks. 11 Prematu re
deliveries are u sually caused by a ny of the
following: .1) spontaneous labor which accounts
for 54% of twin preterm b irths ; 2) preterm
p remah.i.re rupture of membranes in 22%; and
3) indicated pt.eterm births for maternal and fetal
c oncerns in 23 %. Desp ite the ea rlier birth
h owever, respiratory distress sytid ro rrie,
intraventricular h e morrh age d r. ri~~o ti z in g
entero~olitis,' which are complications:.:tglated to
prematurity, a re not more common in tw i ns
compared to siQg\etons with the same gestational
age.7 Neonatal intensive care admission is required

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 612 S'ECTION VI: COMPUC~TIONS .JN PREGNANCY

in 25% .of twjns, 75% of triplets and 100% of 9. 'Vanishing Twin'

quadruplets. 12
Multifetal pregnanCies comprise more than 12
Consistent with these d::~.ta, in PGH, there is a percent of natural conceptions, 12 percent of
~ignificantly higher rate of pretenn deliveries in which result in single births. In 21 percent to 70
multifetal pregnancies compared with singletons, percent of sp<>ntaneous twins s een on u~~r:ci.~p~nd
and in rngher orde:r pregnancies, COiilpared with in the first trimester, l tWin is,'lost or' varlishes in
twins (fables 40.1 and 40.2). the .s econd trimester. The prognosis of the
remaining twin is often good.6 ln contrast, poorer
6. Cerebra:t ~sy neonatal outcome was observed in twin
prc;gnancies resulting in a vanishing twiil. ~orig
M~oi' :l )andlap i$ ~J;ruHipproximately a flfth those resl,!lting C:rom assisted reproductive
of triple~ pr..Cgnancies .:a.hd half .of .q uadruplet tehniqu~s. 11 ' ., ~-
pr.::gruuicle!i,.-'QO~pare4"t.o>cbildren who were born
singletons.. eembral palsy is Iound 4 times more 10. Perinata1 MorWity
often in ~.,a.na rt:t:imes more dfte:n in triplets. 12 .
. : .-~ '; .. .

. Stillblrth and neon-atal deaths are .more

7. ~ - ~ : _. ;;~$tid~.~ a.~rtens::on . ' .. . . '. . .. . . .
. .. .. . . . . common :ii:t. multifetal gest,ations, atid art mostly
......2 ~ . :. . h" 4 f, id .. . : . k f seen in mon~horionic pregrlan~ies. In PGH; the "'
... '~~. ;p~cy : .a~ ~ ;. 0 mc.r~~se ns 0 occurrence o( st,illbirths and neon3;ta1 deaths were
. pree~l~pna; C9tn]>~te.(,i . to . ~tngleto.ns, t ~tati' . ti. all 'gnifi . t .,.Atw . . 4o..,:.... .. d
d . Aio.~t - - .. ,. . d .. <.... . . . ~tv' u.rth" - . . . no_ ~ ~ . _s c. y .. sJ 1cap. -~ e!'n .......uAS an
.~.n ej>ei;):.,.~ 'Otnn::e :_ at>. 1:.;;tn,.,,. .."': ~ ermore, high .: d . . : . .. .. . .. ...., w... ... . , .. .
~$&fd'~'earl\'~l"'a.ild'lri()re severe . . . .~r-Qr er.gestatio~s,. m :co:t1,tra:st:.to w.o~Atts seen
,P
m ._: ~-Attb"'
.. w"..nS ~
~.,.., tb _;, ~.. .;..;,:n.w!t'e..... f : -~ . , _ -'-:!'. .. ' . .in the
vUE.AA' e uV"'4~'~.,. .0 p.....~Cl<:llllrSta
general p<lp_Ulation an _. d h:l :f oreign

ll~etatui'e.
.
~ .,. .....~;;~11-~. eo.inp
lllLw!D
atitbU~: .~ith
"
tripl~-tS severe .ThiS;is.pt<;>ba:bly beca\lse .of<the:4isp[()pt>rtionately
"' h'"'1,. t f f . .. .. . .,d . ttil
:' - ~;:..~d. .i stnore .e.bttilii.on.:-in triplets 1
l' .,.,.
. tt>A.: r-a es..o re1errc;is :o cQ~puca ..e J;nU p e
pr ' . .. : ~ : . . . . ' . g~stations referred from Other institu~~PS (Te.._b le
8 a: ... tatit>~,:Dia~tC!s. ; . 40.4). .
. . ,e$ . ,. :..~ .. :-~:: .::.,. .:...... :. . ' . ... . .. -

G~statl~n~ ~att\~t~s is :mot~. ~'dm~on in 11. Other less common. complications

mUlt:U'etat,P~~Wide$: cQmpa:re.d.. to - ~i~gleton$.
~enty_:,tw(,..:t6~39--pereent of triplet prgrianCies Fatty. .liv;er 7 p~h:non~tY- -eml:>oli~.m ~d other
.are compliqated by gesta;tional djabetes, e~mpared t}lro.mboembolic phenomena and pruritic
to .3,.:6 pe~ntin twin pte'gn,Q.ndes. The higher the urti~ papules artd p~sttj.Ies of.pregnaricy were
or<Ier of.m\l.itifetal ge~~tion, t he Ji,igheds -t he risk also .found to be disprop<:>rtio.n ately Di0.1'1:! c()mmon
ofgestatiortal diabetes, with eaGh trdditional:fetus, . in multife tal p regn ancies; compa red to
iner~sing the ri$k by .a factor. of 1.8. 12 singletons. 12

'Table .40.4.Fetal :o utcome ih :twin 3 compared with higher-order pregnancies in Phj.lipp\ne General Hospital.
' '

Fe~ OUteomts Twfus n Triplets aild -Qu~fuuplets RR 95%.Cl p

(frequen cy) (frequency)

Small for gestational age . 590 (0.443} 26 (0.413) 0 .9 3 . O;q91.26 0:63

~w 5-min\lte APGAR (<7) 9 9 (0.074) 9 (0.143) 1.92 1.02-3,62 .0.05
Stillbirth . 45J0.034) 3 (0.041) 1.41 0.45-4,4l 0.56
N eonaWdeath 82 (0.06 1) 7 (O:ill) 1.8 0. 87~3.74 0.116
Gestational age ~t delivery .
-< 28weeks 66 {0.05) -7'(0.111) 2.24 1.07~h68 .0.03
~ 32 o
wcekil ' 192.{0. 144) 29 (0.46) 3.19 2.37-4.30 o.'o
Total 1331 63

. D ata taken from the UP-f>GH Perinatal Statis tics 2003 to 2006 .. RR, 9 5% Cl ;md p were ~omputed u sing Epi l nfo . . .
_Legend: RR-Relative Risk, Cl-Confidence Interva l '

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 CHAPTER 40: MULTIFETAL PREGNANCY
Antepartum Management
the ultimate goals of antepartum management
of a . twin _pregnancy are to prevent v ery preterm
delivery, identify and manage intrauterin.e growth .
restriction, deliver the fetuses with the tninitiluro
trauma; -apd have expert anesthesia and neonatal
care available.
1. Nutrition and Weight -Gain
Multifetal pregnancies have higher
r~uirements for calories. protein, minerals and
vitamins. Weight gain of 35 to 40 lb for twins and
50 lps for triplets is recommended. BecauSe of the
...more pronounced physiologic anemia. daily
supplementation with _30 mg o! iron and 300 ug
of fo.late is likewi.s e recommended. 7
2. <Prenatal Diagnosis
- .. , Prenatal diagnostic techniqu~ a:re difficultto
"'~i*rfor:pt .and
interpret in multifetal pregnancies.
The reliabilitY of setum screening for Down's
";.~yndnmie is unknown because of the s cant
.. in!oonation .a.vallable . .Conipared to singletons;
..~nl811 studies have:d ernonstrated t4a,t m~ al.pha-
fetoprotein in twins is .2 .04 times higher, meap
.. human . chorlon.ic gonadotropin is L93 times
. h,igh~.r and mean unconjugated estriol is L64
ti.~~ .bi.W~r., . ' -
The invasive t~sts (midtriinesteramniocentesis
and first-trlme~tet chorionic Villus sanipling) are
the .J)laip prenatal tests used in multifetal
gestation. Both tests are comparable in safety and
effectiveness, in the hands of experienced
cperators, Careis taken in making sure that same
amniotic sac ..is ~pt Sat:Q.pled lvviCe by infus1ng
indigo Gaimine or evan~s blue dye after sampling
the firs~ sa.c . Use of methylene blue dye was
associated With s.m aU intestinal ~tresia, fetal"
hemolytic anemja and fetal demise.7 Aside from
the difficulty in ascertaining which sac is being
sampled, other technical probJems in invasive
tests when done in multiple pregnancies include
the need to traverse t.~e sac of one fetus to reach
another fetus sac for sampling, cross
contan;lination from other sacs, diffic1,1lty in
accur;ately mapping the fetuses, difficulty in
deterznin~ng .whether any of the fetuses a re
monochorionic twins, and difficulty in fetal
reduction (in cases of one fetus with a,n euploidy). 12
~
Scanned 8y: "\:_:_:J
' 613
~
3. Fetal Surveillance
Serial biometry to monitor the fetal growth
is done at 2- to 4-week intervals in the third
trimester. The presence :of discordant growth or
intrauterine growth restriction warrants further
evaluations to monitor fetal status.. Discordant
fetal" growth (birthweight discrepancy of 20-25%)
is suspected when there is a difference in the
sonographic estimated fetal weight of at least
20% (~ensitivity. of 80"%, ~pecifidty of-93%, PPV
of 80% ana NPV of:93%). Other prediCtors of
discordancy are differences in biparietal
diameter (at least 6 .aim), abdominal
circumference (at least 20 nun)~ and fem:oral
lepgth (at le"ast 5 mm-)1 3 Amniotic il~id volume
is m~asured to cl>.e~~l9r:p(>ssi;l,>le uteroR~cental
insuJfi;~ie.~~Y . Jf d~A;e~s~.._:;flJ~er an(! . Iil_ore
rr:c.4\i*iii :~ailiatUiia : .au ,llkl!Wi$~ ;i:t:Pne .In
'.~itt~~W ':S"Ci~ti.otl~ th~ ~elti~;~tJ;t~~~en"t
of:the deepest: p<H~~t .of. -atnnibdri- tltiid,:iii. ach
sa<: is th~o~~ more~t'r.eCJUen~y u~~?.~~4.i&an
the. .at~UU,otic fluid .~dex rneasurJllet.,.'l&.:c:.~,.
: ' . .- . . . . - . .....:
._ :~...,. ~- .
.. .. . . . .,,,. ,iJ:H,~ ~~~;,:.
. In .. additic'n. fetal sutveillan~e ~ttsijig;,fhe
b~opl_lysica(prOrue .and: n~!;tteSS te5ts: is .dO'ne.
In.prego;.mties Whete :diseo~t.~,:ij}(ljor .
intr~t~rin:e -gro:\.vi'~ are.susp.ec~d~,:l).p:{;,pt~r .
. ultra.Soundof1:he ~'Qilicafarteri~s ,ot-.l>oth'.nvms
is vezy useful,.in cotifil":t:rU:ng'the <li.3gn()SiS!.and in
~!:=~t::r~~~..
ou~~ '1 :Com.~-tO..noJ)oppler-seaiini,ng,:..the
U$e of.J}opp~et: t.Utrasoti.t;ld hi high fisk pregnancy
(e~pecially 'th:>se ::co~p!ica_t~ .by . ~~rtensipn ~or
pi'eslimed Un:paj:ted feW gn)wth) Wa.s as$0clated
with a trend to a ruction in perinatal deaths
(odds ratio 0.11. 95% confidence interval 0.50 to
1.0 1). 14
4 . Pr<:vention and Treatinent of Preterm Labor
and Delivery
a~ Rou~e I-iospitalization with Bed rest .
Routine hospitalization for bedrest to delay
delivery was found to have no benefit in multifetal
gestation . Among unc-omplicated twin
pregnancies, bedrest was even associated with an
inQr.e ase in."very.pr:etenn birth of< 34 weeks a ge
of gestation -(Oft 1 .84; 95% CI l.Ol;~t34}. No
benefit in prolonging pregnancy was al~~bserved
in routine hospitaliza tion or bedres,t in t w in
pregnancies complicated with cervi"cal effacement
ru:td dilatation. 15
 SECTtON.V\: COMPUCATIQNS 1N 'PREGNANCY
b. Cervical Length Measurements
Cervical length is :measured in the sagittal
view by transvaginal ultraSDund .with an emptJ
. maternal bl2.cide:r {Fig-ure 40.7} . A measurement
of 25 mm represent~:? the lOth percentile for
s~letoris.Wilen useD. for prediction Of preterm
birth: in: twin~, the fuidin.g. of <.25 mm cemcal
~ength a,t 24 weeks was tite he:st predictor of
p.retenn d-elivery.l2 H<;>wever, the lack 1:>f .studies
i.n:vestig~t}ng improvement m outcome With its
u~e 'Pr~ctudes its routine. use .in multip~c
ge:Station. 7
....... .~
. ... 1:"'
. ;. .
- ; :
;~ l;enf#l.t~l'easUretneii.t. .
l':,ri>p1:
. . . . . f ../wl(j. /corer.{) 1 Jpg
wWvi;ce~.~9AAlbr
. .
Serial'djgita,Jevaluations Of eerv~callength an4
dilatati.o n by eX:pe.r ienced examiners have p6sitive
pre.d~ctiv:e '{a).1,1e~. .of90 .to;. TO%. Howevr, it is
examiner de.p eiident and less 'objective than
..ultrasoUp.d meas.~~men tY
c. ; Home Uterine Activity Monitoring
Home uterine .activity monitoring did not result
in improv~ent:in ou.tcom:e,.and is tlier-efore not
cwT.ently 'recommended.
----- -
d. Prophylactic TocolytiCs
In a Cochrane reView of 5 studies comparing
pro phylactic betamimetics with placebo,
proph,ylactic oral betai:nimetics reduced preterm
labor'(F.R 0:40, 95% CI '0. 19 to 0,82) but pretenn
birth<.J7 weeks \vas not reduced (RR 0.85, 95%
Cl 0.65 to 1.10). 11 Du~ . to the greater increase in
plasma volume and cardiac output in multifetal
gestations. maternal cardiovascular complications
with the \lsc of betamirnctic tocolytics are more
.often seen. 7
e. CerVicai Cerclage
. Placement of cervicai cerclage in the
midtrimester in patients With twi~ pregnancies
and with. short cen:iccl length did not prolong
gestation or improve .p erinatal outcomes.
f. Corticosteroids for Erihanci!;J.g ~o~
Matuiity :
. ~. . . ." '""
';. . . .'
Th~ :-Natipnalinstitu~es-:ofHealt.lired>mmends.
; the use . -coriico~t~roiC!lLtt>' ep:h'anee ieta! h:.ng ..
rrdtuta'tio.'n:...iti.s~gleron .ar.=m,uJtipk :ge:sfa~on:s in.
:pr.et~~:rin/l~.~:en,d:.im.pen<Wzg deJ:h,ei}r.(<34.~s .
: geifta~oii) ~ In.-: a: ::eothra.P:~r. ~y'etem~tii: .teview
.. sub~oup .~a).ysis' .~f 'studies'wbl~h.>dealt =-Wi.ih
m:ql~plt; .ge,statio~ ~m.:P.ruiJig: ~dmirllstratioa of
(;_o..:r.tiP-P-~te..mtd~ :and :pl.acehc,: no_._sla.~tical
.di.ffer.ence.... .hi .the....iollo.w.in g. .:..wer~ .seen;
1}chorio~onitis (RR OA8. 95% CI 0.044A9 ,
7.4 p~.ies}; 2)t~W. d~th ~ o:S3,.95% CI
0.2Q-L40: c252'irifan.tsH ~}neonatil!leaJh~ojg,
. 95% .CI o.39-1A;51, 2'39 Wants); 4Jrespiritory
qistre~s .syndrome :(RR p;8Z;,. 95% Cf 0:60~L20,'
. 3'20-infa~tii; S.)cere~roventrl<;~~heroorr~(RR
(}.59 1 g:p% '1 O;O't-"2.06,. i $7 . itlfants); or
6)bijthw~i@t (FWMb $2.. 3.!5 g, 95% CI 146~23-
310,95, 'iSO infa,ntsJ. AlthougJ.l there -was .<'!. trerid
tow:a r4s h~nefits m. t;Jle treatment .g roups, :the
srtiail ~ple, size i:~nilted:iA Wide ranges of '9S%
confidence m ter.vals which <;ros.sed Ul. 17
Twit) .g.estations have higher L::s r atios as
measuted in :the amniotic fluid compared :with
singlet.{!us of the same a.ge Of gestation from 31 to
36 weeks-. Howeve r, when 112 twins were.
comparecl.>w ith .m:atched 224 s ingl.etdns, the
.incidence of r-espiratory distress !)yndf?me (38%
....
Scanned 8y: ~
 .. CHAPTER 40: MULTIFETAL.PREGNANCY 615

versus 35%, respectively) and use o( mechanical 4. Group B Streptococcus prophylaxis if

ventilation (41% versus 39%, respectively) were indicated;
similar.7 5. Readily available facilities for immediate
emergency cesarean section;
g. Prete.n n premature rupture or the membranes 6. Ultrasound for determination of the fetal lie of
. . the second twin;
Twin . :gest~t~pns. compl.icated. with pre term 7. An experienced ~-.esthesiologist/ anesthetist
pretnatUre.mpture {)f the membranes ar~ managed
who can deliver l;lppropriate 3-liesthesia for
expectantly like singleton pre.gnanc1es. Small
urgent cesarean section or .breech extractiop.;
studies done comparing twins w.ith singletons
8. A trained pediatrician or neonatologi~t skilled
m~aged eXpectantly showed no difference in . in neonatal resuscitation for each fetus during
latency (ruptu~ to delivery time) with patients.7
delivery; and,
9. An obs~etricia:n w~~Us skilled !n evaluathlg
5. Timing of Delivery
th~ presentat:ton ~d posjtion of the ~nd
twin sb(>uld attend the deliyery. 1 ~
Since the growth of fetuses in. twins start to
dee1ine at 38 weeks and th,e .r isk of intrauteJ;ine
LabOr Stimuiation a:r1d/ or induction
gro~ restricti~n ~d .perinatal -d.:.ath inFreases
s!gn\ficaJldy after 38 weeka, decUve dehvery at . j:~t ....... . . ofla'""-trin
. rm..
.& ....e.I:U"' s~ge . s..N. . ~.ns
. . is. sht>rterthan
. .
t erm .ha$ .be:en suggested to . avoid these in .
singletons: Thil;;- is tb'6Ught:to ~s1.1,lt fronrtnot:e
.complication~. . liowever, .a Cochrane systematic
effici~nt u-terine c ontractions in twiris, -~d srilhller
re\!le'W id~tified only 1 small stUdy involving 36
. women ~whieh tried to answer .w hether fflective size of .t he n.-st . ~- compared .to .singletri~~{~flt
. since ;uterine -cOtltract]ons .in m\l].tiple:g~!~~?qii
deii:;,ery: ~at 3T.wee ks is bette.r than e~~ctan.t
can alsobe dy!>functiorial., labor stimu;tatidrl:n~ii:i'g
management. There we~e no stattstu::ally
dilute intravenous :i,ri!usion of oxytoein ciUt Be
. siJmifi~t differences se.en in cesa:ean. births, .safely carriedO Ut)9 :."' ' .
. ce~ births for fetal-dlStr_!:!SS, pennatal death,
. h~ll1Q;t:d~a,~e : ~ recruiring blood :- transfl:!.~ion, . .Fetal H~ Ra:te- Monitoring . .,__... :::::~:;:11;;;:.:. /~. _
'm ~Iiliim :stamtd
. ' ' := . . . ;. . ts ...
. amniotic
f
. luid and -low.APGAR :._~- ~~:'-~.~ .t,~..~- :-
: ' . . . . : . ~ o '' .. .
~re.~ S::m mutes. .
Both twin:s have to be monitored .uihng
. ' . ~
f : ' .. . . . - .- . . . .
t:oc0momt9r3 de~gn~ Jot' .twJns. An ui~t<>und
i.abo{~~~~~
-- ,,._
--~~~ ......
ry
_, ...;...,-:__-!.:' ..._ ... . -- -::
_.._. - ~
.. > .. . . ... .~ . ..
-:..~- .. ..maCuu
-L.:!;.;...~.e--sh. 0 u:l:.:a...:k-
. u uo; .....1i'.<~
"'~~r6r'irc-c:tlftlt:e
. "laceiiient
*' .
~~si~s-t,l-~ttirfCllilg . i~bQ/.~~ . delivery oftransdu~rs~()-"av~i<tmoniroffiigom:{ on:e-tWiii
or lliistakfng the mother's he3f! rate for fetal
o!'the n1Ultiple .gestation.. .
br~dycardia. The mother's heart rate shoUld also
The posSibl coinplicatio'i~s i'!!lated to labor artd
be' cheeked t~ :make: sure it is fetal .lle:art rate the
. that is being monitored. {}pan delivery ofthe ~nrst
dellvery. 9f a patient. with Jnl,ll~iple gestation are
twin, monitoring should continue for the second
numerous, .a nd mcllJde preterin labor with or tWin :until d~livety. 19
without pre:terni, ; prem:1;lJ:ure rupture of
membrane~.. abr;upt,io placenta, umbilical cord
Anesthesia
prolapse, malpr~sentaHon, dysfunctional _labor,
and noi:l-reassuringfetal sta-t us. Th'! follcwmgare Epidural anesthesia is recommended to
the r~ommepded prerc:~quisites for the labor and
provide adequate pain relief during labor . and
delivecy. of a patient with multiple gestation:
delivery. It has al~o the flexibility of providing
.appropriate anesthesia for spontaneous vaginal
1. Continuous fetal heart rate monitoring-during delivery, internal podalic version for the second
labor with a trained obstetric attendant of twin, and cesarean section. In cases however of
present throughout labor; . fetal distte's s where epidural anesthesia is deemed
2. Readily available blood and blood component inadequate, generill .anesthesia al!iO ~.done. .can
product~; . .. The patient with multiple :g estation is mor~trisk
~. lntravenous access with a large-'bore .catheter for supine hypoten;>iori syndrome, thu_s, adequate
throughout labo.r.; intravenous pydration has to be given prior .to

Seanned By: ~
. 616 SECTlON VI: COM.fl>liCATIONS 1NPREGNANCY

indu~tion and the pati~nt has to be kept in, la:teral morbidity and use of general anesthesia without
decubitus position. 19 a benefit in neonatal outci:>me.:u

Mode of Delivery Time Interval Between. Deliveries

The decision regarding the mode of delivery
of twins i.s determined by several factors;
namely, l) fetal presentation or lie; 2") estimated
f~tal wejght, parti.~ularly of-~ B; 3) .es tllnate.d
fetal weigpt of twin B relative. to twin A; ,4) skill
or the obs~txician in intrauterin-e .manipulation
.a nd vaginal -b reech delivery; and, '5) fetal $tat';ls.
As lo:Qgas there is c::ontinuous fetal and uter..ne
monitoring, it is not n~cessary to have time
restriction Qc:tween the deliverie~ of the twins.
T):lere :"is no e1tcess in 1()\v APGAR sco.-es ~r in
trauma L fetuses deiivertd beyond 15 Jilinutes.
There is however .h igher rates oi c esarean section
hi the seeond nvin delivered b~yond .1 5 minutes. l9

. Themost important iactor thatdet~rmines the Triplets

modeo!de}hrecy i$:the fetal presenta~on. The most
con;tmon comb ina-tion is . ~e.phalie-cephalic. Most . of triplets ~d higher~order mwtiretal
followed by <;epha,lic:-bre~ch and ephaJic- pr.e gn.a ncies aie delivered a~ot:ninally because
ttarisverse and the lea;st common is br.e ecb- . the rlslt Of cOtnplicatlO:n$ sUcl\ :as cord proby>se,
breeb. Tbe ~Pli~e-~ephtillc twi.n;.:ai-e best fetal .o b$t."1lc.t ion and abruptio placetita are
4elivtted y~g~a!J:Y . Ipi<*tl9ti.$ f~r- ces<U"e.an increased {Figure 40.8). The~ i~.:al$0 ~ difiicwty
section of ibe ~cond . tw.in are -ilie ~e .as .t hat Qf of s.ultarieQ.us monitorjng of -the fetuSes. The
. $ih~,~J~ri;}p'{~~~:9;d.e.~ .~-~eiy .ilvn~~a$s~ng re~g fotUses m ay :entail dilnct:llt.intrilutenne
..!eb.tll)~.,~~'~titl~or.-;:p1-Ql~p*r.CPi:4:Forrthe. -:J;na:rn~uve~;1:l'h-chmtyev~ntU~Je$:ult'jn cesatea.h:
~hilie ~t ~~- ~(! ~.Prt~ted ..~.n~:~ .. sect:inn';J 9
:yQg)pa! e-e~~ecy -~n . bC. ,ely __earned: o~t~_ w:ith :
t:O~rilete -~ extraction -of. the-$CCOnd tw'Lfl if .
the ~~f~s ~t-~e.a.s~ .1S.QO,~s. F.C5~. the ~nd .
twin -witli::.a )~we.r.:,:w.:eght.),cori$~der,,..e.iter;naL..
cepmw .".\r~on . followed by - v~~ de1iv~cy. .lf
~- ~P.h.~Ic v~jQtt ~ ll.P.su~$.$~ :1! tht;:te
i 's :u~bAlclq. cQ.t4 p'T6ll:fp5e, ir:~e're i's. .~~k~<:t
.dl$
__1t.iP~"':~5A.m-uie-w-a~i3qrme:'"'"tati~
~----'--------@, _____ ~~--~~------- ~-;o.nrl
twirls where th~ s econd ,fWil:l, -~ m~ch bi.gge_l\ .odu
~ell o"f"fe~ distress. <resarean ~ctio~ .is .be$t
don6. mgetierat. w~~Ti the1ir&ttwirf1s Q.otcepbalic
-(breeCP . pf.-.mm~erse}. c;e~- sectlon .i3 .the
recomtpenaed .m ode of'"dellv.ecy .b eca\lse the
. Saf.~ty :Of vaginal .deJiver:y-- has. not .been
:d ocumented yet ~d there il:i the potential of
lot~g ~tween twins when the second twin is
cephalit. 19

Th~ Qptj.mal rol.lt~ of deliV:e.r:Y for monoamQ.iotic

tw.lns r~mains unclear. ;Cesarean secti.oo is . . . . ..
generallY peffo.n ned for this i,pdication . In ~- ~~udy . Figure 40.8. Triplet pregnancy with ~ant growths and
o( 20 mono~mniotic twins, 15 underwent . intrauterine fetal demise.
sue$snil vaginal delivery. Since .monoainniotic
pr~gna..Q.~i;s are v.er_y rare, performing a
proS.pective randomized controlled .. trial Vaginal Birth Mter Cesarean Section
{nve~dgatiilg the route . of delivery m-a;y not be
fe~sible.20 There is scant data,on vaginal birth of twins
.in patients with prior low segment transverse.
A cOChta.ne reView found that-ce~axean seGtion uterine scars. In a retrospective study involving .
for the second twin resulted in more febrile 210 women with low segment transverse uterine

Scanned 8y: ~
 CHAPTER 40: MULTIFET,A.L PREGNANCY
scars where 118 women underwent elective
cesarean seGtion and 92 women undexwent trial
-of labor, no uterine rupture wa a observed. 7
Unique Problems
1'win to TWiE Trans.f usicn Syndrome (TTI'S)
Vascular communications with .placental
vessels may occur between two fused placentas.
It occurs in almost 2S percent of monochorionic
pregnancies. It may also v ery rarely occur in
dichorionic placentas. The most common fonn of
. anastomoses is between arteries. Most of these
vascular connections are balanced an:d thus do
.riot pose a risk to 'the fetus. In twin to twin
tran~fusjon syndrome, the don(>r twin is usually
:growth restricted, anemic and has
oligohyd~mnios. Wheteas, the recipient twin
whi(:h .Js discordantly bigg:e r. may have
palj:hy.diamnios, polycythemia and even, hydrops
fet.a.l~s~' 17'rhe syl).drome is tisuaily seen in the
secOnd~trunester and rapidly progresses to pre term
labor. ~ ,pret-erm premature rupture . of the
.mem.br~es and fetal_ mortality iri. either of .t he
fetu$s.. due to heart failure. In some cases, the
~~ ~li~ohydramniqs in the donor twin caus es
it:tc{1<>9il.1$tuckjn:cne siaeoffne uterus. The stuck
twi.Il'is-at'a.dditional risk of-pulmonary hypoplasl.a
and ma1fonnations. 12
Several theories were-prop<lsed-explainmg this
syntlrome: vessel anastomose~nn-placenta:s are
often bidirectional and may be seen in superficial
and deep vessels. It is theorized that net flow in
between the placentas is usually balanced.
Imbalance in the net flow may be due to the
asymmetric bidirectional blood flow. Or, acute
imbalance may occur in the sudden death or
compromise of one twin. Cerebral necrosi$. in one
twin may result from the repeated episodes of
. transient imbalance in n et placental blood flow.
Another th~ry is the syndrome res ults to a lesser
degree .frow. asymmetric biqirectional ~lood flow .
but" to a --gre~ter ueg ree , fto.in the pr.e sence of
unidir.e ctional blood flow~ Velamentous cord
insertion of one tWin may also ~esult in" twin to
twill transfusion syndrome. 20
Central nervous system (CNS) injury is
common in twin pregnancies with twin to twin
transfusion syndrome. T:he CNS inJur~es. se(!n
include .m icrocephaly. porencephaly . cer:ebral
palsy, and multicystic . encepha lomalacia. In a
Scanned 8y:
' 617
. .....,.i~..: .
study with 17 monochorionic twin pregnan cies
with TTTS severe enough t.o requtre
amnioreduction, cranial ultrasou~d of the 31
neonates a live at birth showed 1 ~th a major
cet'ebral infarct, and 10 with more minor cerebral
lesions such as subependymal pseudocysts, white
matter cysts, basal ganglia echogenicity 9Jld mild .
lateral ventricular dilatation. These lesions were
observed in both the donor and recipient twins.
In a nother study, white matter lesions were seen
more often in _pregnancies with monochorionic
compared to dichorionic pregnancies. In cases
where there is 'tiTS and one twfu dies. in utero,
acute CNS lesions may o ccur due to the massive
blood transfusion through the anastomoses in the
placental vessels. ln ohe study, 20% of the
surviving twins were with CNS abnormalitie.s. 20
The criteriafor the antenatal di~gnosis ofTTTs
include the following: monochorionic twin
gestation With ..p1acental va:scu1ar ;anastbhloses,
same-sex fetu$es, intertwin birth wetghf.ilifl'eteiice
.ot at 1~asf20 petcent,. polyhydram.-iio:S of tl:lk~er
twin, oligohydramnios ~f the . smhll.e"f't:Wi:fi.~ 1=!~d
hemoglobin differ~nce of at least ~ .gpdt~ the
ultrasoul)d criteria, are at best, orJy 44% ~ecutate
in the diagnosis, that cordocentesi:in:s-~strongly
advocated by some to document tlte::~~~~gti:>_i:)i:rl
difference. 20 ' '.' ~ :"f .q,;,.-~-;
Serial therape'Utic amniocenteses a te most
oftenu:se<nn-th:etteatm.exit ofTtTK Amruo'ticnu.ra
ieauC11o-ii - iit Tne reclpTerit fv/in 'whh
polyhydramnios is b elieved to result iil favorably
changing the intr=aamniotic pressure and placental
L...-travascular. pressure allowing redistribution of
placental blood flow and
nor't:mJization bfamrrlotic
fluid volume in each sac. Other more aggressive
treatment mod~ities used in very early, severe
cases are laser coagulation of the placental
anastomoses or selective fetocide by umbilical cor d
occlu.s i<;>n. 11 Septostomy, or ob.literaticin o f the
intervening membrane,. has been successfully .
carried out and res ulted in equaliza tion of
intraamniotic pressure.~ 0 Be.cau s.e of the increased
risk of sudden death, immediate d elivery s]:wuld
be considered in a viable fetus with T'ITS. 12
One case of an aggressively manag~case of
TTTS was described in the Philippine J .cwrria l of
Obstetrics and.Oynecology (PJOG). A ~3:t'fear-old
G2Pl (1001) with a previous cesarean section due
to cephalopelvic disproportion, was first diagnosed
~
 918 SECTION VI::COMPLICATIONS IN 'PREGNANCY ' '

with 111'S at 18-19 we.e ks, wh:en the ~hrasound .With acardiac tw in on admission, She w~s closely
.-$~wed .twins with the same sex, a single placenta, followed up. At 31-3.2 weeks, s he was readmitted
'and s evere poly:hydra:mnios of twin A and due to fetal cardiomegaly.and ~uspicion o f fetal
cligohydl'amnio,s ("stuclC') oftWin i3. There was no hydrops. She underwent cesarean section at
wd.ght discorg.ance. ln a e0urse of 1 week, the 32-33 weeks. Twin A wa s aca rdiac and twin B
pa~ent underwent 3 episodes of amnioreduc"Jon was 1.6 ~g. with a good 5 minute APGAR score
for a tot~ of 2,900 :rp.l of amniotic froid. _A.ft~r of 9. :u the second case was in a 34 year-old G2P 1
amni~ent~s.is, the intervening memb rane was. (1001) who was firs t seen at 2-2 weeks bec~use
i4entifie4. .AmiJ.ioti~ fluid. :Qf the sec;ond twin of . spotting. Like the fitst case, ~S:he was .firs t
~mproved, hpwever, the d~mor twin developed diagnosed with single fetal demise. However, the
. p.ydrop?a~Z2-.23: weeks. Digitalis was given to the . diagnosis was .revised .at 24 weeks to acardiac
mother lY'~used)f the feW l:itadyc~dta in tpe twinnin-g .upon :a repeat ultraso.und b y a
.4Y~Pi<;: baby.. .At 24-25 weeks, .wi.fu t?.-in. A ~till . _perin a:tolqgis.t. ~t~9 we~ks, .polyhy~amn:ios was
hytiropic,. fP.r().sei:'Q.ide was given . in .an n0ted. Amniored~ ction was advjsed 'l;m.t the
.iJlh:a.m~scular injection, to t.-.,rre d0nor twin, With patientrefused,'The p atient un<ierw~nt..ces.arean
. s.ubseqti:en~ :dis~ppe~ance tJf hyarops 2 weeks s eetion 6 .days after. Twin A w as a.c~d.iac and
~t~r .. GQr.l;i~e.nte~~~. wa.-s .d one on the 291h-.$(jth a.cephal\ls {no he<;~.d), a..~.d. w eighed 19S.O.~gr;,uns.
w eek whigh showe:d anert1~a (hel!loglobin of Twin B .was 1260. grams, ~mall for gestational
loi/t) on t!le '(iop:or . ~:i? Four di;tys ?Iter the. age, 30 Weeks by pedia:trlc aging. an~f with gcod
.pt~d'!lte:.'t~tal bra.dy~;axd:~a and 'blo'od.,.tinged APGAR.a t 9. In both cases; ~ucce~sfl,ll butcoroes
:~<:>.tic,nuid were :nqted. F~g exsanguiriapqn, Tes14lted from -fPTI.ely delivery.~
:an ~ci~ency,~esar~an. set.tiO.n: .~as~ done... -Th e .. .
.Jiniblliia.b\~rds'ov:o;o.'th;,:tv$'s'"Were-'~e~n';ihtat:~ O:>'nJof:ned.':TW;i:ris; .- :: :
u' nrortunate

.
lJ,.;
:twirr~,B
. '.clled::of.-cardiac;;fail:ure.'
~~o ; . : :. li . .. a ..: .- ..d:i d
o .n . .11 ce . .uswn occurs .a:r.fte.r th e ..1....:G.th '-~:
- ~ : o u .di~";.; :. ;. uaJ .-, . r
.o
a
~~ . 24 ~our: ~ter_d~ v:ery( :T,P,e '.....q~~~ tw:iP.: . e . . : fe~tidh: ino.p.pehoii~ni~. tnonoainiiloti~ twin . .
?n~~4 ,.da!~ue 4J .ne~ma.W.~s~ps~s.. gestation is seen .. h:rc9mple.te d'ivi:ston of the
~~R.. . .rsed .. . ~ ~- :al
.. .~. r f.u .10.' . :&.r-:".bl.~A .. .;.: . ... e~l?ryonic. ~~i~.c. ~e.s ui.t~ ii:; .c.Q~Jqi:il_e:4 iw~ns.
.1\J.jn~ :
: :=
;A ~~-: e-.,_e . .

0
. :r.e

~ Il t... ~"= .. ~C?-;rtiiac ' C9J\jow~d ~s ar-e clas's!fiecL atccil"a#ig t~ . ~e
' .. ... . ' shared body sit~; :namely,

.. :~ :: ... 'f~I~..!..l!~~. frgw...ll:W~ili~al..ar.tery.Xo.arlery ..--

ana:stQJAQsis_ :..b..e:tw.e.en ...tw.lns, . .mostly . in 1. . Caudal (isehiop.~gus);
.r:non~gotic p.r~gz;1andes with a . sin:gl~ placenta..
The . pump twin usu~Uy :dt:ve~qp~, . ,he;rrt failtp:e 2. cephalic (craniopagus ); .
{l:~e .t() . cardiac. pv:er.loi:td. Since biood flow is
. pfef~i~~~y. st,tppiied 'to theil'i~t.ve~$.els df the 3. .Anterior :(thoracopagtt's); or
p en*secft:Win, iricomplete .morphoge;nesis f~vors
dey~lopmerit :o( th~ lowe~ .p~rt ofthe ~lx.J:dy ,aq:<i 4. Po$teriqr (pyqpa g<ls). .
dereri~~t;ionOf th.e tis~ues of the -qppet p~t of
tlie .oody. rl:lls results. in missing parts (h~art.
Themo~t t6inm:ori is the t:horac<ipagus. Ai-eview
l~ng$, J1.ead an.:d upper extremitjes ) ~11 the
of 40~;4''3-t deliveries in S'irtgapore r~vea;led only 7
p erlt,i.s.ed tvi:in: P'ercutanequs. umti1lica1 cqtd
c6'nj9med twins, 4 .t;~,fw~eh:aie ot'the thor:acopagus
ligitidrl:-iii the.'Pe;rfuse'd twin res ulted in 7 we.eks group. Accura.tt; detenhina:tion Cf organ~ shared,
. .gahi;eq. in ~ st\iqy. 17 Since the pump-twin is ~t
U:s,i.I).g ultrasouna.'or i:'nagnetit resbnapce iffi~ging
risk d_f h 'e art fa ilure, close rrionifciring -is done
(MR:I), l.s 'done fo't progr1ostita14on and planning of
l;l.n~ the emergency delivery. is done. once heart
surger:y.2 1 A P.diatric surgeo:n sht?uid:' be"part of
fa,i:lure is suspected 'in a v iable .fetus .
the .team. A shareci heart or liver u sually carries a
grave prognosis.
TWo cases are described in the PJOG. The
first c ase was in a 27 year-old G2PT (100 1') who
Single Intrauterine Fetal Dein.ise . .
was fU'st ~drtiitted itt :2 2 weeks ands d~ys age
o.f gestation.' .due to S\t spicion o( sin gl e :Qeit:h oJone twin may occur rerriot~ from.
in:tr.aiiter~ne fetal dem:is~. b u t was.. diagnqsed t erm, a nd niore frequently in monochorio~iC

Scanned 8y: C
 CHAPTER 40: MULTif:ElALPREGNANCY
pregnancies {8.4'% versus 4.1% inCidence). The
relative risk of demise of one twin is 2.3 in like-
St>...xed twin pairs compared to unlike-sexed pairs.
The pregnancy loss was strongly correlated to the
weight discordance in like-sexed pairs.
FurtheMore, the risk of death in the surviving
twli'its 5 .to--6--tirees higher in like-sexed :pairs. In
monochotioriic pregpanc.ies, the surviving twin
~sult.s in neonatal death in 30% ()f the time and
cerebral p alsy in 10%, in contrast to the benign
course of the surviving twin in the dichorionic
pregnancy .. The proposed mechanism .t hat
eXplains _the CNS. damage in the ~ur.ri-v.ing twin is
the massive blood t:r-"cillsfusion from the surviving
twin through vasc\llar anastomo.s es in the
placenta which hap~ns aft~r the Qardiovascular
collapse .o f the dying twin. "The CNS damage is
thought to result more froPI Ulis mechmiam rath~
than dissenune.tedi.'ltravasct~.lliJ" ~ation(DIC)
:ira tPe sum"'lip.g twin from ~e thtom:bopla$tins
uwised:.ftom the dead twin.t'. The risk of DIC in
the mother rare\y occurs, but remains to be a
theoretisal risk,. Fibrinogen and fibrin degradation
px;odUcj;$ tnay be se.nally monitored. l2
lf on~ C)f the twins died due to congenital
.anomalies. the .remaining t win ina,y pe c;xpe~ta,n.tly
ma..""'la:gea:If. thedeath" was in :a monochorionic
pregnancy. m anageinent is more. ~otllplicated
because of the high propensity -o"f vascular
commUI)ieations betwee!} the fetuse~, TI)~s. -CNS
da:mag e -is-:-more-Ii'k ely --in morrocho rinni"c
pregnancies~ and may-havealready ~en-p-r~sent
at the time the death of one fe-t us is noted.
Immediate de)ivery J,ilay therefore not accorQ. any
additional benefit.u
Fetal Reduction and Selective Tetoiination
Selective termination of the anom~ous fetus
is done in some countries in the second trimester
. through intracardiac injection of KCl (for
dichorionic pregnancies) or umbilical cord ligation
(for monochorionic pregnanc;:ies). Selective
tetminati0h:1s 'done to decrea se preterm delivery
and to decrease the chance qf fetal morbidity in
the surviving twin in cases where the anomalous
fetus dies in utero.2o
Scanned 8y: ~
' 619
Fetal reduction is also done in other c&tries
in higher order multiple gestation to reduce the
chances of perinatal morbidity and mortality. Clear
benefit was demonstrated in the reduction of
quadruplets, lmt nut that clear in triplets. Fetal
reduction i s also dune by intracatdiac injecti.on of
KCl.
Other Rare Cases
Tw.o cases .of twins with a complete
hydatidlronn mole and liv~ fetus ,w~re d~bed
in PJOG. TheTtrst one is in a 25 year-old G3P2
(2002) with vaginal $potting at 13 weeks and 4
days. Ultrasound revealed dichorionic; diaronioqic
placentation with twin A as a hydatidiform inole.
The .$erum beta."l'ICG -<vas elvat~d at 198,08Q
mR.J f"rrtJ. "On the .l8th hospital day, the pregnap.cy
spcntruleously arted :and .suction c;urettage ~as
do!le. Biopsy rev~akd complete H m9le.cop_firm.ed
.by .inununostaining. J>rophy~ctis;~~~~O"ti~xate
-was given 2 Weeks after the cur-et~g~~.:!lie ~nd
. case was in.a"32 year-old G3P2 {2002) with . vagfual
spotting at :18-19 weeks; Sh.e Q.eveloped
preeellPl;lpsia. Her beta HCG. was elevated . at
. 164~866 .nirtJfmLEritergericy -:hyste~toruy?y.rith
mole and fetus in situ was done lO :days:nflei due
to. hnpendins ectampsia. Due to the persistently
.incr.eas.e.d .beta HCG at 12 weeks aft;;r the
pr<:x:-e.aur~ Metlio"t':ieXate was'giveri: BOlli - tieiits
- -- - .. - :r -"----- - -- -- - -- --pa
were Iollowea up closely po~t-curettage.25
A v ery rare ca.se of heterotopic pregnancy was
also described in Philippine literature. A 28year-
old primigravid conceived after ,o vulation induction
With Clomiphene. She also received br0 mocriptine,
FSH injections and Profasi prior to conception. At
7-.8 weeks age of gestation, she had spotting,
dysuria and hypogastric pain. On ultrasound, a
live intrauterine pr-egnancy was seen togetl1er with
a C!)mplex adnexal mass. The patient was explored
because of a suspicion ofperiappendiceal abscess.
On exploration, right tubal pregnancy was
identified. Salpingectomy and appendectomy were
done. 26
 SECTiON VI: COMPLICATJON.S IN PREGNANCY .

POINTS TO REMEMBER

The Increase In mtJiti.fetal pregnancies has been attributed -largely to the widespread availability of
to
assisted -reproducfure technol~ies and delaying ch11dbh1h a later age.
Maternal role in monozygotic -as wen as d~otic- twinning is demonstrated. ln contrast, paternal role
is only seen in dizygotic twlnnln_g.
The following factcrs are associated with multifetalgestation: parental history-ofW!inning, black racs,
elderly maternal age, l'ligher -parity, periconception intake ,of multivitamins, and us.e of assisted
reproductive techniques.
Choriorifcity and amniocit,y :ill mon~~otic twins depend -on the liming of cell <fivision, the cartier.ins,
tne hig~r.IS:!l~ choriooleity and arpnionicity.lftell divisJonhapS>ens late,-lhat is, after the 12th day
after-~ftiatiOn, conjoine-d twins -resull
UJ~soond is lnvatu~ble ttl the diagnosis and ev~tuatiOn .of multiple gestation. There are uitrasound
manters -fOr the id_entifi~tiori of chorionicity an~ atnnioniCity.

.Ctm.lw.r~ 10 -~lng.letcns. ther.e !s.an _exaggeratloi'l-of the.matemat physiOJQgical (;hpnges in ;pregnancy

. su~,lh~t;bkd VOlume~- Ci$r-dia~ output and strcl<e VOIUmt;t arS'blgfter, heart r~~ is ~ster. ai'ld anemia
is nwre pronoufid. T-here_-is rtmre uterine overdistentioil; pr'es$ute Symptoms and -higher iisk of
:-!':,_;~1partum itemon'h!:lS~
::~:~Uire'Ni$.tt~~~-tb:~!rtgt~\9ns~~'jn':hl9her:'(t!rder!ge~tkm~:there: is-~an::ihcr~as~i:is~:of'cOrigenita1
.. 'ancinalies~:(trtot.e-;;prono:uf:lce.d{'.ln?.mono~yg:otic;twjnsthan di:Zygotic: ;twin$);: m~ternat- .medieat
@mptili$n$(dia~fes-.tn:ehi~s,:hy~rtenSibrt); .pteterm tabot''ai:id .preterm birth, -felal growth restriction
;-- and
.
~~ttt:!nt-gtbwth,
. .abG.rli9n
.. . and
. pennatala~thS.-
.- ;;~t~)lltir'flaf.;Qo~l$::ol~an~'~J1Ym ~:tri;a~ge.ment ~ :j -~n pr.eg~ancy .a~ to.prevent :Yery .pretetm .
. ., .:~~ :~e~~;c)~:,ig~n~~~;ffl~~~~:i.~tra~~:~;te~.clion~.to;~efJVer:the:~tUs~ .with,the.min.imurn. .
. . . :tirJti.fua', an(I]~f:h'ave. -expert an-esUl~ia and neo~ ~ :availqble. ' . . .
.. -~~~t~~-~~~~n~~m~lb:QI:!~Jil$~~!19Mtr.~~t.- blh~lcaLprniue..hJOmetry- andJ)opP.Ier .ultras~tind
. ?(~~~Elct,tru~.~P-att.Ym.Jnojjitoring :e>.f.m.ultifelatge$tions..
.Rotitine:h6spitaliZaaon for bedrestto d1ay .delivecy.Was found to h~~e no.benefit:in multifetal:gestaoon.
Wll~n-. used .f()t-.predictionof,pretetm birth:in twin$, the .fin~ing of < 25 mm tetvi~ltehgth at 2~ week.s
wa$..tilebestpredietor ct pretaritl delivery.
Jiom~rut.nn~.;~ctiVity rnPnitor-jng.did .not-i.esult:ln improvement:In outcome <and istherefore not current.)'
re~en~ed.'
.. . f>r9phylattic:oral betamiM,eti~s reduced preterm Jabot b!Jtpretenn b'irth<3'7 weeks was not significantly
redueed.
~> Placem~nt of ~C;ervicat :cerclage in the ri'lid.trime$ter in pa~ent.S .with twin pregnancies_and with short
cerVical length .did net J:'i(otong gestation or improve perinatal outcomes.
There is .a trend towards benefitwith the use of corticosteroids for prornoting lung maturity in twins,
but-statistical significance was .not demonstrated, probably due to the stnaU sample sizes In' studies
done.
Prete.rm premature.rupture of membranes in twins are mana9ed the same way.assingletons.
Compared to expectant' management. elective delivery of twins at term res,ulted in rio .statistically
signif~Cantdifferences In cesarean births, cesarean births 'forJetal distress. perinatal death,.hemorrtiage
requiring blood transfusion, meconium stained amniotic fluid and .low APGAR score at 5 minutes.

Scanned 8y: ~
 CHAPTER 40: MULTl~ETAL PREGNANCY -621-

Some intrapartal cprnplications .are more common in multif.etal gestation, thus, the presence of a
competent team and prepared delivery room is a prerequisite. .
0

The most Important !~ctcr that !;ic=termi:":es the mode of deliverf is the presentation of the first t.vin.
The mode of delivery for mono.amnionic twins remain uncleat.
A Cochraiie' review found ~at, cesarean section for the second twin resulted in more febrile morbidity
and use of general -anesthesia without a benefit in neonatal outcome. . .
As long as .there is continuous feli>l and uterinemonitoring, itis not necessary to h~ve time restriction
between the deliveries of the twins. There !s however higher rates of cesarean section in the second
twin delivered :beyond 15 minutes.
Triplets and h~her order gestations are best delivered abdominally.

10. Pinborg A. JVF /IC$1 twin oref!nancies: risks and

prevention. Hwu .~eprod Updat~ 200~; ll{6): sts-
5~. .
1. Martin.JA, HanillU)n 'B E, V\!IltumSJ, ttal. Births: Final
Data for :2000. Natioi}.al. Vital Statistics Reports, vcl.50,
no.5YHiaitsville, Md. National Center for Health 11. Lagm2.n-Dy _I>. M\lltifetal:. pregnancy: Diagn<l~is in
. Statistics 20C2. Clli)icai Practice Guidelines on MultifetahPI:e~cy
2002; 15-.2 1. .
2 . M(Uone..:FP, D'Altoh ME. .'M ultiple ge<;tation: clinical
characteristics and management. In: Maternal-Fetal 12. American College of Obstetricians and Gynecologi~ts
.: .~e4ic:irt.~_..5* ed;(Crea!>y and Resnik). 2004; 5!3-536. Com~ittee llQ .;P.r.actice . .Bulle.ti~ll, .._. ~:~~~~ple
.....;. , . gestation:cornpiicated twin. tPplet; .and mgn:X)ro.er .
3. Philippiite General Hospital Perinatal Statistics 2003- multifetal ptegnancy. Obstet GyneoT2oo4;'lOit 9-
8S3. . .
2006.

4. Festin MR, Epidemiology Multifetal Pregnancy. In 13 .. Gonzales RM. Antenatal monitoring in 'M~ituetal
Clinical Practice G'\lidelir.es on. Multifetal Pregnar.cy Px:egnancy. InClirUcal PracPceGuidelines on Multifetal
2002; 1-10. Pregnancy 2002; 27-32.

5. Robinson HP, Caines JS. Sonar evidence of early
pregn~cy failure in patients with twin conceptions.
Br J Obstet Gynaeco11977; 84:22.
6. Baens JS. Multifetal pregnancy. In: Textbook of
obs~trics physiolcgic and pathologic conditions, 2nd ed.
(Sumpaico Wand )Baja-Panlilio H). 2002; 410-416.
7. Ayres A, Timothy JRR . Management of multiple
pregnancy; prenatal care-part I. Obs tet Gynecol Surv
2005; 60(8): 527-537.
8. Rumbold A, Middleton P, Crowther CA. Vitamin
supplementation for preventing miscarriage. Cochrane
DatabaseofSystematicReviews2005,lssue 2. Art. No.:
CD004073. DOI: 10.1002/l46Sl858.CD004073.pub2.
9. American College of Obstetricians and Gynecqlogists
Committee on Gynecologic Practice and Committees
on Obstetric Practice and Genetics. Perinatal risks
associated with assisted reproductive 't ecbnology.
Obstet Gynecol2005; 106: 1143-1146.
14. NeUs6n JP. Alfirc:v.ic Z. Doppler ultrasound for fetai
asses$ment in high risk preguancies. Ccchrane
~ase ofSystematicReviewsl996, Issue 4. Art. No.:
C0000073. J;>OI: 10.1002(l4651858.CD000073.
15. Crowther CA. Hospitalisation and bed res t for multiple
pregnancy. Cochrane Database of Systematic RevieWs
2001, I ssue 1. Art. No.: CD(J00110. DOI: 10.1002/
14651858.CD000110.
16. Yamasmit W. Chaithongwongwatthana S, Tolosa JE,
Limpon.g sanurak S, Pereira L, Lum biganon P.
Prophylactic oral beta 1 mimetics for reducing preterm
birth in women with twin pregnancy. Cochrane
Database ofSystematic Reviews 2005, Iss~e 3. Art. No.:
CD004733, DOl: 10.1002/14651858.CDo04733.pub2.
I
17. Roberts P. Dalziel S. Antenatal corticostel;oids for
acceleratirtg feW lung maturation for women at risk I
for pretenn birth. Cochrane l)atabase of Systematic I I
Reviews 2006, Jsslie 3. Art. No.: CD0044S4. DOl:
10.1002/14651858.cpo04454. pub2.

Scanned 8y: ~
- -- - - - -
'622 . SECTiON VI: OoMPUCATiON:S 1N f>RtGNANCY

..
1'8. Dodd JM, Cn:>wther CA. Elective delivery ofwornenwitb.
a twin pregruirlcy from 37 weeks' gestatiOJ\. .CJu"~
23. Ramo.s -Costa CJS and Tansehgco L. "When heartbeats
are. $h:ared.. !Aq~;se ofacardiac twinning.Ph.il.J Obstet -
Databa.Se ofSfJstematic Review~ .2 003, Issue 1.'Art. No.: Oyn~1.2064; is(:wao-ss. .--
CD003582. 001: 10.1002/14651858.CD003Sa:L f'
24. ~alGG, TanFLand~yRL.Anangclu1ilisgttise:
1~9. Ayres A, Timothy JR3. Management of multiple Twin t.evet~d artenal perfusion sequence-a case
pregi1ancy: labor e.nd delivery. Obst:==t Gynecul S.urv repo~ P.hiL) ObstetGyp~col2006;.30{4): 2U- 213.
2005: 60{8): 550-554_
;25. 'Dy~egul:w DQ.. CpJ:!lp~ete fl. .mole v.rith live fetus: a
20. CroWthe< CA;. Caesareail dcllvery (Qr.the seqmd, .tv-in. re. rl o! two 6;1$es. 'P.hil' j O~stet Gynccpl 2000;
Cochtrme ~a:se ofSystelTlQ..IiCR.elAews 1996, l&'~e 2~(3)! 10'5-lld ..
.2 . A!'t. rio.: CP000047 . .DOl: . 10.1002/
14651'858.CDooo047 . 26 .. Dl;lePaS ~. 4~ Qca.rn7-l P;t-, Cm,z DC,, Santos RR,
Patawann'DM. Ee~rotOpic pregnancy ilfth 9-vulatior.
21. Ajres A, Timo~y JRB. Manag:emcnt of multiple .-~ ihduction cotl'lplicate'd 'by acute appel)dicitis'. PJOG
pr.e~cy: prenat.ai ~e-part n. Obs.t~f<;7yne~ol~l..!:IV . - 19:~; 23{~):).171~;3.
2005; 50{8): 538--~9. ' .

22 . Polintan-Dur.i:ng:MSH, Mendoza MAP, VB Castro. The

perils of twin-to-~ transfusion .s yndrome. Phil J
ObstetGynecol~OOO; ;24:{4): .1~-14{$.

' !

. .. .. .

Scanned By: C
 .41
PRETERM LABOR

MARIO A. BERNAR)>JNO, MD

Definition
Preterm Labor

Incidence of Premature Delivery, i.v1ortality and Morbidities

Premature Delivery Review .
Neonatal Mortality Incidence of Prematurity
Morbidities as a Consequence of Prematurity

Considerations for Preterm Birth

Estimating Survival
Lower Limits of Survival: Counseling Consideration ..
Upi>er Limit for Adverse Outcomes from Preterm Delivery
Economic Impact of Preterm Birth

Etiology
CategcYries .as to Cause
Preterm Labor
Preterm Premature Rupture of Membranes (PPROM)
Maternal Medical or Obstetrical Complications
Fetal Distress or Demise

Risk Factors Assodated with Preterm Birth

Demographic
Behavioral
Health Care
Medical Risk Predating Pregnancy
Current Pregnancy Complications

Pathogenesis

. Diagnosis of Preterm Labor

Criteria for the Diagnosis ofPreterm Labor
Differential Diagnosis for Preterm Labor

Scanned 8y: ~
Management
Predictors
Fetal Fibronectin
Salivary Estriol
Transvaginal Ultrasound of the Cervix

Preventive Care
Identification and Management Df Risk Factors
:Management of the "Pa.thb!l}enesis
Eouc:ation of the P~tient .
Hes:f(iction. of Activity

..
.~-
M;;tt1agetn.e nt .o l infeCtion
Surgi~l Management
Risk Scoring System
Ambulatory Monitoring .System
Progesterone

...,Pharmacologic Treatment of Preterm Labor

Principles,in:Wse;of-:Labor;:jnhibiting Agents
U~bor.:.inhibitihg 'Agents~
A} ~adrerierg ic -ReceptorStimlil.a nts
B) Calcium'Channel Blockers
C) Other :DPJgs .
Magnesium $Uifate
~. .. Pro~t~9(G!nd\n..tnhl.biton>:.
oy Other Newer Drugs
Clinical Mandgement of Preterm Qefivery

Maternal Transfer to a Tertiary Perinatal Cent~r

Estimation of Fetal Ae and Weight

Communicatio:n with a 'Neonatologist

Intrapartum Pharmacologic Adjuvant to Improve Neonatal Outcome

Intrapartum Monitoring

Management of Pa in

Method of Delivery

Resuscitation of the Neonate

.. Summary and Progn.osis

Scanned 8y: C
 CHAPTER 41: PRETERM
DEFINITION
Preterm Labor
- Tenn used to define neonates who are born too
eariy 1
refers to a fetus or a pregnancyor neonate that
is less than 37 weeks gestation (based on
WHO definition} but more than 20 weeks
gestation 1
With rel!ipectto.gttstatic;mal age, a 1\eWbom may
be pretenn, tetm, or. po.s ttenn
. . Witll respect to ~ize.:
o Normal size . ,. Appropriate for gestational
age (AGA}, newborn whose . weight is
betweenthe lOth and the 90th percentile-of
gestational ~e.
o . Stnall in ..size - Small for gestatio~al age
{SGA)- the weigllt is less than Jhe lOth
wcentile,
o Overgrown - Large for gestational age
:(iGA). Newborn whose weight is above the
. 90~: .perce~tile of gest.ational age.
JrematUAe refers to a oe0:1ate that has the
function exp:ect~rl of a n~wborn with age of
.gestation that bas .the f~ction ,ex.pecte~ o'f a
.n~wlxm;nvilli e.ge Qf gestation ~ess than 37 weeks. 1
Fetal gJ:"Owth restriction or ip'trauterine growth
restii.CA9n - ~ used -cor retus who~ weight
~s belowth:e 1 Otb percentile ofgestaticnm:l-~age
.. ' '" . -'
_i.A;w BirUl.W.e.i ght Infants 1
Iri.fan~ that are boQl. to9 small
a) Low Birl:h Weight infants - Infants less than
2,soo:grams . neona~ deat..~ ~-as 7 :6%."3
bl Very Low Birth Wei-ght. Infants - Infants
weighing 1,500 grams or less
c) Extremely Low Birth Weight Infants - !I!fants
weighing less than 1,000 grarp.s.
IN'CID~NCE
The true inCidence .o f preterm birth o.r pre term
labor is difficult to determine because of the
variations in-details of reporting. 2 .3 In the VSA in
200 i, almost 28,000 died.in their first year of life.
Pretenn blrlh which was d,efmed as
less than 37
weekS comprises 2/3 of these deatps. overall
infant mortality has continued to decline from
Scanned 8y:
LABOR 1)25
~ I' '
1990 - 2000 at a slower rate than earlier decade.
The declineis not much on pretenn birth. Preterm
.birth is increased OJ:'Jy in white non-..-Iispanic and
remains highest in black women. 1
T-able 41.1. Ir,cidence of preterm birth.
Philippine Obstetrical-ana Gynecologic:U
SocietY 1989 - 19982 10 ~93%
U..S.A. 20003 11.0%
In the f>bilippines, the incidence is refleetlve
of hospital deliveries and not the whole country
beeause. a. great~r perceritage of births .e.te. hQme
deliven~s.
. Piematurity has been a significimt . fact~ iri
th~ sunr:ivl;l.l of neonates. The leSs p~a:tttte-::ihe
in.fa.rit, the :g reater i$ the chance Qf sUtViv.aL~1t:.li,;s
always been the objective o f m~agemen'~~to '
.prolon~ - pregnancy ~ much as possible tOnear
terin. Survival will depend also on the Ca.patilit:y
of care. after .delivesy of premature. nepnat~.W
expertise:and advanced teeh;nology will romC'iflt:O;~
play. The mortality Tates declined' ' througij~ the
years from a high of18.5% in 1948 ti>30.36% in
. . .fJ1L..
.19$6 rh 14 0{;
r~ .n 1.'6 3 ..8"o
". .e nd
... 6.4 Yo.. m .19:6.5.~.
>. o 2
Ttre~r.f!tt~S"--6r- :n:-&teaitecf-1io-sp1fats-in:~rn~
Pnilippilie-obstan---cru1inifG""foecolejgrcal-sQcief.Y
showed t~at the perinatal mortality ni.te of
premature births was a.bout2l% in 1987.2 lnth.e
review':or the Task Force of"Prei:erm LabOr .o f the .
Philippine Society of Maternal and Fetal Medicille
in 2000, the stillbirth rate was 6.7o/o and the
Co.nslderatlon:; for Preterm Birth
There are cqnsiderations for preterrn birth. The
survival rates of :b abies are based on birth weight
at least between .2 4- 26 weeks or approximately
to
435 g 1540 g. Neonatill morbidity and mortality
depend on gestational age and matuntY with long
terni outooille for 24 -213 weeks, only 20 percent
will have no .impairment for 5 years or more. 1 Vohr
and co~workerS {2000) ass~ssed .o\ltCQ~ at 18
to 22 months in 1151 survivors from tb~IGHD
Neonatal Research Netwo:rk bOrn 1993 :atid 1994
with .birth:weightof4oO to 1000 g. Only perce'nt. 5o
had normal neurodeveloprnerital and sensory
~
: 6.2f> SECTION
. _. i
~
VI: COMPUCAT10NS IN PREGNANCY
~'

.-
functions. Those with low birthweight have status are also factors for preterm de1iv~.~.ll This
mark-edly worse outcome: chronic lung di:;;ease, is further supported by Hickey and colleagu~s in
grades 3 and 4 1ntraV;entricular hemorrhage .~d 1995 study that preter:n birth is du~ to restricted
periventricular perim.a):acia.~ This was similar in fetal growth. They have linked.prenatal weight gain
Wood and associates (2000) report. in EPI CUre with. pre term birth.18
Study Group of t.'le United .K ffigdom.6
Other factors m'(:!ntioned ar-e beha'Yioral 'in
ACOG in 2002 .rec.Ommended that for pur;poses nature such as cigarette smoking, illicit drug
ofrounseting, sur:Vival.~fore ,24 ;wedcs iS .n~t 1Uc~ly use and excessive physical activity 'and
pnd if they survive there are disabilities 1n the f.:>rin prolonged standing.l~.t,ts Alth:ough ti:).e study
.of mental and psychoJ71otor deve1o.ptne.n t, .of .S antiago and .cdlle~gues in 2005, found no
dysfunction ~m nearomotor or sensory an:d
communicaticn in haif of the sur-vivors. Transport
increased incidence ei =ecur:rent pr:eterm birth
in women WiUl a hi'Stocy of 'preterm: b.i rth and
..
:-
1:0 ~J~r:tiaiy tei+,ter.an.d.:clt>Se comguinica.tion with. whose workduring their current pregnancies
the fam.ily is .in order r.~gar.d;ing as~ess.ment, wa-s .outside the hom-e and r.e quired physical
pr.~gnosis and management.' Perform.anc~ : of exer:ti'on..'20 Lack of prena~al cate and
ces~t:~::;p. s~ction fot . preterm' aii(i . neon.a t.U, psycholo;gicaf stres~ plays a t.ple in preterm
resi!Scl~tion . v411 .litlSo depend en ili;e s~ypJ. ~9 lalic:rr. . 6 .t 7 $tudies have cori.Hat~d :::tress,
Aggres$iv~ attem~ 'ta})revcnt -delivety willdetx:J1d deptessi.o n, p:hysit<:ll -~btise anq. high levels of
oli .further benefit in 'u tero. De Pin:n.a and co- cortisol With pre term bi.rth. 21.z:<;'l3
workers;t~onclude<f that pr:evenfin.g delivery after
i-950 ..:~i;arnf.dl:xt ..~s ..~o~ .~~:fit.,'\:A.n:ot~~i' . SoiP.e medi~condJ.tion~ :may:,p,ut.a .gia:vida.at.
~1:\sid~ijori:-,~~~<ilie:.~ge:.~~~r.:m~~g',. ;greatet. rfsk ;\?f pret~::m' iabor: Tiiesecih1ditions
fQr l1J.:<r:-P~~~,m.,ne~n-at~~~,ap,:dv,:th.e,:~dd~tj.o:r!fil~~' include di.abctes. nepnr.opathy; :collageil. :v:asctllar
~ditur.~ J?r: .developxn:~~:.bandica_P?.. dUri;q.g .. disease. . ~:a..deter{oraqng..hlane:y.~di:Sease. :
th~rem~dei:pf cblldlioOd.. . .. . ,

. .. Curr~nt ,pregn~cycompliea~on~ t:hat .may ~

pretl.i$0-seto'preterm 1a~'i-<are ~..IoUQVis1 :
~

... ~~.~~~~~;.~~~~ ~f;~~~~~ .:,~ $,:~ 1} I.t!StotJNjf.previOtlspretermibfrtkot.aliqf:tion.

:~e~'~nd~.f9_gr~t~gpri~;~JJ ;~~J~:..1a~J:~ TJie Pi:et~~-F.r.e'qi~'fio.ri -St'fdy'io~<{ii.'&'ecf'~by
.71 J~.r.t.t.eon _p.ce.ma.tu~ ....r.u,}?J:UJ:e_,oJ_membr~e...
{:P:P:ROM:l, 3) Matemat 'J;D:eP,>:cal;.pr ;O.o.~~etr.{<>;al
:cc.tri:Puci~hns~Uh a:s,pr~"'CG.~Ps!- ;>r :Bl.3.:tehta
p~e,tia, .ap.d 4) ~e.tai. ,distress o:r 'd~rili~e as .in
qop:1ptoP,iiseE;I :fe:tl1s ba,s.e d .on thit .~urvei,ll.&tl:e
<;lone.~
There are. ~isk . Iactor:.s ;.tha--t :have h.ee;n
assci~~~t~d with. p~~t~r~ b.irth. T~i~ qa~ :b.e
cl<i:ssifie'(_! .~s
to: 1} Pemqgraphic, .~}:Be~vioral.,
Men:ex=; ei1icrr999rs~9Wooliiafl:hti~VK"llia:Prior
spontab:eou$ ptetenn d'iv~ry ~ed a ~-~fold.
increase !n th~ ris.k o f ieeum~de m the ctuTent
gest:;:!.tion ove,r th.o.se with no prior ~P?ntaneQUS
preterm deliVecy.ia'Th.e' nsk"Jor:tec'urrent preterpi
.
detivty. Jor :w.c;qneri whose firs.t 'deliv:err w.as
ptetetm \vas ,ifl:~ t>y three .fold ct>mpard:t. tO
women. with temn first bpcm in 1:6000 woln.eh at
Parhland M~mon:al :a'Ospital. 26

3) Health care,. 4) Medical ris k .pred-ating

preg.n~.ncy, and '5} Ct):r :tent pregnancy.
cpmpli~tion:
Preterm birth has been found to be m ore in
. deplO~~phic sit:\l~tions '~u'ch as:. Gravidas 19
y~ .eryounger.or ;of 40 years or,old~r..P.api~m~
et .ai..(I97.a}rep6~eda, 6.~ro..tis~ ofmate~al:age
<21 or- >36 years. an4 a..7.1% ri~k.;.for: a~mll..
statUre :<1.52. )ll_ 1119 Piimip,ara anti .p;:uit}r. 4 a ,nd
abcw.~ . iower . socio-econoni.~c st:at~s in:.t he
Philippines and .P.o or nutrition. p articularly
chiidhood.hut rition (:orrelates with socioeconqmic
2) Spontaheous nlp tufe ofin.'eTTJ..b.tqn.e. and
Ch.vrioamn.i onitis or ~mniotic fluid i nfection,
Infectipn M 'the .membranes and amniotic fluid
caus.e d by a variety of microorgan'i~in.s h as
enierg~d as exp~anation 'for ruptured ~embranes,
pr.e~em). .labor or ~th~ Bacteria are recovered by
tran~-.abdominal amniocentesis fror;n as many as
20: P.r.cent ~r. w9.men in p_ret.enn lab:o'r without:
ov~rt. c~cal: ~fectipn:. .az:d. in~ct membranes. 1 ~ .
.R ecovery of orgall;isrns fr.OIJ.l the chqrio~on was
s~gnifi~tly 'i.Itcre9-sed with spont?-neous preterm
labor.25

Scanned 8y: C
 CHAPTER 41: P~ETERM LABOR ' 627

3) btcompetent cervix or dilated cervix. Cervical decidual prostanoid production and re1ease of
'incompetence .is a clinical diagnosis characterized endotheHn by amnion-causing uterine
by recurrent, painless cerviCal dilatation and contractions. It ]>Otentiates the enhancing effect
spontaneOUs mid trimester .b irth in the absence of lL-l a nd THF. The inflainm(l.tory cytokines also
oi sponta.neous niembrene rupture, bleeding, or enhan-ce th~ expression _of amnior.horionic,
infection (ACOG, 2001). Approximately 25 percent decidua! arid extracellular matrix {ECM) -
.of women whose cervices were. dilated 2 - 3 em. degradi11g protec~.ses such as collagenase. It also
delivered prior to 34 weeks. Many have promote~ a mniochorionic, decidual -a nd cervical
complieations earlier in: pregnancyY This is inte.rleukin-8 .(lL--8) .production~ The cytokines
further supported by ultrasonographic findings. promote re-cruitment and activation. of
lams and co-..workers (1996j measured cervical granulocytes tha:t release .]?otent EcM-degra4ing
leng+-..h at ~pproXimately 24 weeks and 28 weeks elastase, lead{ng t~ further cervical chan,ges,
:i n 2915 women~Jlot at risk for preterm bitth. The separation of t11e chcrion f."Um the tiecidUM.> and/
tnean cerVical length at 24 weeks is about 35 mm .. or PPROM. Cervid\1. granulocytes .elastase activity
~d for women With shorter cervices experlened corielat~$ with the Bishop's .s core..during tertr~ and
increased ra:-te of pre term bir:th. 2~ Owen and preterm labor. Elevated c1:rvical levels of
ass6ciates (20011 teporteda sig~illi:cat)tcorrelation granulocytes elastase-ci-1-antipro.tease complex
of cerviealleilgthat 16- 24. weeks and suQ.sequent precedepretetm IabQ:t and PROM;33
29
preterm b.ir.th before ,35 weeks . Yost and
colleagues fu 2004 found \:i1at dilatation of 2~ 4
em dutiitg the second trimester, cervical DIAGNOSIS . .. .
~~-:. : :

.ulttasonogra_phit $a.'l predicted incr~ase birth

,.priot:;:tQ -3:5 Week.- The diagnosi& of pretenn la"QO~;,;js,dl:fit&it' if
there is no r::ervical dilatation anti>.:effac~ent.
Othet cau~s of preterm labor are: 4} Anoma.Ues ProgresSiVe dilatation is the true indicator of'...abcir.
,()f:eonceptiDh; S) Overdistended uterusJ :s uch as A frequently "I.J~~d critetion is Qne . ute,r ine
mUltiple .pregn.3ncy ~d . polyhydram:ios; 6) -Fetal . conttaction :m 10 inin,utes with a,dut-afu>n:.o!-.30.
.~ ?flJJterine r:tnotnaly; 8) Faulty placentation. seconds.or more~ 1 Qft~"":itimes; 'titeline.:COntT.a~ti"on
su.eli. ,as~p}aeenta previa a nd abruptio placenta; is m.i:sleatling. Contraction~ are co-Oimohly'.felt
9) Retain~d . intrf;luterine device; 1 OJ -Elective during pre~anc;y E;ll"lQ. neither ~~~iJie:ito; b.or
ind1,tction of lab~r. !needing as in the . cast .of . pte<\ic'Qv ~of pr.eteri'n lab..ot and orily 25 - so
placenta-1>revia -~d -a:broptio plaeenta -oftentimes percent""Ofthest! women willacnHillyfiave pret:e.rm
w~ts-' preterm. ,deliv.ery:Seriolis"infectic:frrs, , ta:bOt:-~Matenni.rpercepitori e>rc-ontracaon:s- 1s
abdominal surgery, fetal abnormalities -and unreliable,_ P!ltients missed .;m average of &5.7
. asymptoqtatic bacteruria may .predispose to percent .Qf their ~ntra,ction$~3+ rn 1986, l{atz.and
p.reter:ni delivery:;1:4 . At times; etiology can be co:worlcers used anibulatO'ry ti)(;Qdynamometer to
unknown . . arid 11) Periodontal :disease. .detect.preterm laoorand fbund that the frequency
Offenbac~rrJu).d associat~sin l996foU:ndwomen of c ontraction was ~ignifi~tly _g reater.34 Women
with perilontitis hada sevenfold risk of prete'tm could only identify 1.5 pereent cif eontra~tions
bir.th.3 1 This was confini:H~d by Hauth and recorded by tocodyn~ometer, an<l about one-half
colleagues in 2001 in a prospective trial in 1300 of the w.omen were able to identify less than 10
women assessed at midpregn a ncy with . percent of uterine contractions.3$Jn anollier study,
. periodontal inflammatiqn. 32 women correctly id~ntify 17.2 . percent of
c.o htractions recorde;<;l by toc 0 dyl)amometer. 3 6
Softening of the lower segment. and effacement
were more predictive of impending labor than
Infections stimulate the production of features of cervical ex-arilination including
endotoiins artd jpfiarn-matory .cytokines such as dilatation. 37 Cervical assessment for the prediction
interleukin~ 1 (IL-l) and tumor necrosis factor of pteterm labor has positive predictive values
(TNF); 'l'hes~ ey-tokines act by: 1) directly occurring in the range of25 - 3o perce~~oetween
stimulating the fet~l -membrane and de.cidual . 24 and - ~4 wee}<s gestation.38 ~
prostaglandin expression, and 2) stimqlatif!g the .
.~. .

release of interleukin-'6 (IL-6) by the decidua and Heron and ascgociates in 1982 proposed the
chorionic cells. IL-6 increases amniotic and following criteria to -document preterm labor:

Scanned 8y: ~
628 SECTION VI: COMPLICATIONS IN PREGNANCY

regular uterine contr actions after 20 weeks Transvaginal ultras.o no:graphic cervical
gestation .or b efore 37 weeks which are 5 - 8 findings that have been found to correlate
minutes or less apart accompanied by one or more positively with preterindelivery include: decreased
of :the following: 1) progressive change in the length, funneling. and pOSitive stress test results.
cervix; 2) cerviCal effacement 'Of 2 cmor more, or Transvaginal findings ofwedging or funneling were
3) cervical effacement of .SO percent or more. 39 prediCtive <>f pret~ labor.~3 There are tWo cypes
of funneling: V~$haped and U-shaped pa ttern$.
Other signs and syrupt9ill.S that may aid in the Fifty five percent ~f patients With V -shaped pattern
diagnosis of women at risk for pr'!t:eini": delivery were not determined. 44
inClude 1) passage of cerViclU mucus, 2) low back
pain, 3)-pelvic pressure due to .t he descent of the P!'evenUon
fefu~. 4) me~struaHike .c ramps, .and intestin~
:cramps With o r without d!.iu'rhea. 3 9 Prenatal car.e should be centered in the
recogil~tion
.and if possible,. .e liinjnation of the
Tb~ nearest differen~ 4iagnosls for preterm risk factorS. Jf a WOQlan is fecOgrUzed to have .risk
laoor ili Braxton'-IIi(:k$ colitr~c~i<m. These are factors Jor pretertn 1~.bor, the situation shouid be
irregular, non-rhy.thm~cal apd painle.ss o.vith approached from ;,ill angles. The fu:stconsidetation
inteilsit;y'approxiriiately 10 -1S nu:nl:l,gand might i.s 'education t>f th~ .patient ~ to preterm
be diffieult to d~ffer'entiate from preterm labor. labor, its t atty signs and symptoms or early
Another di.irerential diagnosis i s a term pregnancy -.:;:~.waxenes$ and therefO"te ,early .illru)agement. 'fhe
.i n labo.r l;)ut .with growth-retarded fetus . .. , history an4physical examination .Should be :done
metlculous!y . and .la;bcra.tory- e xamination
requested scras to ide.n tify factonrthat:ean lead'to ..
preter:n1 labor.
Predictors
. . . The patieat at.risk:()f.. pretertp labor shouid
~iocll.~rri.!@l: .::. mar~e,::~ ,.:f.ot. pret~4abor,. a.t:e~ , . hav~restric;tett:otphysicat:~d:sexual:'act.lV:jty.:.:Bed
11. FetaL,~bf.oneC,tin , !(F.Fn .~~1~~se : lnt<>dhe . .rest<is,;.n~cess.ary. ::SJ)me.\l)alie.n ts
- m~y, be
cctvi~~seqc;tio11S;m.:-resP.ln,s~Wot.ionie-..,.. -ho~pitalizecljusHo,.::on.Urte :th~~to:bci:t Bed:rest
de;clc!Wlt .prQtease .~ctirita,:and 2):- ~YtU)' estriol especially for twin pr~gnancy 4as been beneficial.
(s'E3)~~ !iild 3). :SonqgrapJ'ijc findings can .a,lso
predict-preterttrlabot.- . :Re~mctioJ'Fof$~al:aetiVilj' is:also un . rtant
. ---'------ ----- . _._QO_ ---- .
beCliti-s e-:orthevery-h igh.eorttent o(.prostaglan:.din
Fibrooectinis a . glycoprotein pro.d .uced 20 in ~.Duid and tbe.femal~orgasm may trigger
different m()lecular foil:p.s by .~ vatiecy of cell type uterlP.~. contration.45 Reports have shown. that
a$
such hepatocytes, . fibr~blast ; .endothell.al cells sexUal .activity has a 5-fold increase in preterm
and .a,mnion. It i~ . d<:.tected in eervic,ovaginal l~oor:46 Use of condom bas been recommended t o
sereUon i~ :normal pregPiilnCy with; j.n .t~ct prev~n,~ s:emin~l prostaglandin to. initiate
me::ml>ra.ne. M.ea:su:l'ea l>y en~J':'me-l~nke9. con~t;io.Q.. Breast stLrn.ulaUcm likewise induces
immunoabsorbeht ~~say. ve\lues >50. ngfml are . utetine c<>ntr::lction and th(:teJore shculd obe
considered pos!tive. A pOsitive valu.e for. c~cal . avoid~d. -H
or vaginal feW fibronectin assay as early as 8-22
weels:iJ ha$ been a powerful predictor of pretenn Infections durin& pregn.a ncy should be treated
birth41 A po~itive ass ay re$\ilt at 22 to
34 weeks to prevent preterm labor. l3acterial vaginosis may
has a positi.;,e predictive value likely to deliver precipitate pre term labor by a mechanism similar
within 1 week of 30 petcent -or within 41 percent to that proposed for amniotic fluid infec tion. 48 .
in 2 weeks. A negative predictive v~Jue was ga Women with bacterial v.:tginosis whose vaginal
and 96 percent, respectively.42 secretion contained sialldase but not prolidase
has significahUy incrased risk of preterm
Goodwin in 1996,/and Hein~.in l999.and.their delivery. 4 .8 W-omen wit.h .bactedal . vagiJlosis
co-worker~ descrlbe.d the association pf ~aternal susceptible TNF:-tt .genotyp~ have a ninefold
salivary .e strioh:oncentration and subsequent .inc.r~se jn pre-ter:m:birth. 49 Smce GBS :can lead
preterm birth. This test needs further evah.tatio.n to pre term labor and PPROM and . eventual
before recommended for clinical u~e. 1 delivery., it is advised tha~ women with previous

Scanned fy: ~
 CHAPTER 41: f'RETERM LABOR
infection be cult'ured for GBS. It should b e
repeated ~because of the intermittent recovery of
the organism. 5 1 Those with positive culture should
be treated appropriately.
A cervix that-is more than 1 em dilated has a
20 -25 percent p6sitive prediCtive _value for pretenn
labor. Data suggested that vigorous cervical
examin~tlon may increase the Tisk for preterm
laber and PROM. So , a careful and gentle
examination of the :cel"tix is 'r ecommended and ahs
been found to .be beneficial. 51
. :";
The length and dilatation of the cervix plays a
tole in the d.evelopment ofpretenn labor. The-usual
presentation of incompetent cervix is a passive
cervical dilatation of more than 1 em. Oftentimes
there iS the buiging of the .amniotic sac without
contractions: or irtfeeti(;ms. Such condition may
lead to. runnionitis, PROM, or preterm labor.
Ce nnea'bcerclage bas been proposed for such
condition. :The MacDonald's procedure is advis-able
dluinffpregnancy. This is a purse-string suturing dilatation are.importaht in determjilirig the'fkn~tt
. of tht cerviX using a non-absorbable suture
matenal. It has ..been reported that apparent
i.uproV_et;leilt of pregnancy outcome in Wonien in
theJate':S'econd. t.-irnester or early' third triinester
. can .oorur~th cetclage; 53 The procedure itself has confraindica'tions for la bor inhibitiori~:such'a~:P~~-
an-iriberent risk of preterm deliv~ry by inc(easing
perlcerVical iflfiammation or infection. It is advised
that such pro:cedute be 'resei'vct for those with
cervical ~atation-but~wiiliout.-uterine a:ctivity:47
The.R iskScoring System was.used for the early
. ,.. identification of women tha t will go into preterin
labor. Stu.d ies found no benefit of this
progtammatic approach .54 The mean birth weight
and the inCidence of preterm delivery and low-
birth wdght were similar in.the idl!:ntified preterm .
group and the general porml;3.tion. ss
Ambulatory uterine monitoring was also used.
Utetine activity monitodrtg using a belte d
tocodynamometer transmitted by telephone daily
did not re.d uce the o~currence of preterm birth
(ACOG, ,1995). hi the Collaborative Home Uterine
Monitoring Study in 1995 compared the u se of
sham transducers 'in 655 women with thru
transducer in 637 women shoWed pretenn birth
wi.s -tpe sam~ in both groups. A. review of 35000
hours 'or daily home monitoring 'fn;>m 306 women
showed increase frequency-with a gestatiohal age
but no .pattern e ffiCie ntly predicted preterm
birth. 56
Scanned By:
~( -
Pharmacologic .Treatment of Preterni'fi'elivery
Phanna(;:ologic inhibition Of preterm labor has
not convincingly demonstrated a reduction in the
rate ofpreterm delivery or neonatal death. 57 Some
st\ldies have d.e monstrated a pr~longation in the
duration of pregnancy and a decrease in the
immediate neonatal morbidity b\lt still much is to
be desired. At the present time, it is still the
mainstay in the rnartagement.57
The principles. in the use of labor-inhibiting
agents are as follows: 1) there should be preterm
labor, 2) there should be a gestational age at which
the treatment will benefit .the fetus, and 3) there
should be no medical or obstetrical
con.traindication to the inhibition of lal;>or or labor
inhibiting agents. 57
The fetus -ofless than 32- 34 weeks-will benefit
mo.s t from the. irihibition' ofpreterm labOr.MatUrity
of the lungs, status of tnem embranes:a..,d cervic;!al
of labor inhibition ..s7 Motherswith' preterm:;:fubor
with ~ge of ge~tation ' less than 17 weeks are at
increased risk for g enetic abnormalit ie~. s 3
Obstetrics and _. medical complihatioii'$f ate
eclampsia, abruptio placenta an:d:V:c h6rimunffio-
nitis.57 Useful tocolytics .for. ruptured memb~es
have. .been controversil;il. They do not prolong the
J')regnancy:58 '
The most commonly used toc61ytic agents are
the beta-mimetic (!rugs. They serve.as an adjupct
to ~d rest ih the management Of :p rete ixn lab0r.~ 7
Another drug us~d as prophyiactic tocolytic is
. 17-a-hydroxyprogesterone carpoate (17-0HPC); It
h as been reported that pretenn la bor and delivery
ocC\lrred less in groups tr.ea ted with
hydroxyprogesterone carpoate. 5 9
Lah.ot-inhibiting Agents ,
fl.Adrenefglc Receptor Stimulants
Such agents a re ritodrine, terbuta liri e,
hexaprenaline, salbu tampl , isoxupr.ine and
fenoterol.
-~
.B~Adr~ne~gic agonists exert their eff~l on the
myometrial cell through a membrane' rrtediated
mechanism. The r eceptors a re located in the outer
cell membrane . when the r ecep t or s a re
~
 - - - -- -------------

630 SECTION VI: COMPUCATIONS IN PREGNANCY.

sth~ulated, there is activation .of the
adenylcyclase, the enzyme that cataiy~s the
conversion of adenosine trlpl:10sph~te' (ATP) . to
-~yclic. adenosine mono-phosphate (cAMP). The
c-AMP activates th~ .enzyme cAM~-dependent
protein kinase. An increas!! in protein kinase
rcdl!ces myometrial ctmtr..actility by decreasing
terbutaline ranges from 5.-~5 ng/ml. Peak plasma
concentration is 1.5 nrt/ ~after intravenous -dose
of 0.25 mg. and to less than 2 ngj ml by about
2 hour-s. Fol..!cwing a sing oral dosage to pregi:l,a:ilt
subjects, plasma concentration reaches a peak of
4 - 5 mg/ ml and ls sustained .for 1-3 hours after
ingestio-n . 62

intJ?.c~llul<.u calciUm an;d red~ing -the effe~t of

I
.calcium on 'royonietrialactivation. For pr-eternr'labor, an initial infusion of.O.Ol
:rug/ ml every 10 min .to a maximum of 0.25 mg/ I
Continued exposure to >-agonist lea4s to miti.. Higher infusion rates -qre 'as~ociated with I
uncoupling of the protein by wP.i~h the receptor;- signi'ficant side-effects and _d b not #nprove _the l
. agonist inttractiori -iric;rease.s the activity o-f-adenyl efficacy. Subcutaneous infusion is 0.25 mg. This I
.cy$se.'(des~nsitiZanc>il). V{het. tl):e r~c.eptors. .the . can be ;repeated 1-Q hours. later .depe.nd.ingcin J I
- :~oO:ger ~e:_get-exposed to the :ag'otiist~>, 'th~ number uterine contractioi'!-. 62
of ~,-adrenergic receptprs. d'ecre.ases (down: I
regUla9-on). thus-~reducing the effect of ~-agonist Side Effects . I
. on-the intrace'!lular pr.ccess.(,O I
The .m ost ~pparent ~id.e. effeds ~e mer~ l.n
. Tm:-~adrenergici:~pto:r:s ~timullm:t rqay also hsart rate, car~ac qutput andpUlse,pressure. The I
!affect ut~ri~e.. con tractili:ty.-,qy.:.tb.e.ir: . effei;:t .'.on. diastolic. b10Qd. p:ress:ure.?-Pd- peripheia.kvascUJ.ar . I
.pla~nta:l ,_prqgesteco;nei>t;~t::tiOn.; Progestx:cne' --resistance i$ redu~ed.. .Metabotic.:cffects i:O.~ude I
: ::reduces.tbi',g~:P"iu'l).:o~i."om~t6r.riia:ttc~-W:hieh. .fucr.easein :.tlOOO. glucos~, <insuJin~~lacta te' ~d_free.- . I
evcntP~y..inlu\>~ts, the ~trru;~m.i~Sioh- qf: unpul.s~s . ..fatty -aci.d~.-and. a d~rease, in :'plasnij:i.;pota:ssium~. I
:fr:!:>m.myometrkJ',c;.clls'-to-'IiJ.Yoetii~J:cell~. 61 Plasma rC,nnin and !J,t.gib.ine va'JC.pre.s sin are
increased 8lld/assoCiated- .with :svdi,um md water
I
:. . . ~- . . , . ..
'Bb.annacol(!g~~and~:oosage;;Reg~ep.:N
.. . . . . . .. : . -
.
r etention'.~: , - . . I
. . ~ .
--:--. :...~..... . : .. I
...
; ~. .:: - $-adrenet'gi~ agonist51;'J.)rod U:q~ :a ; v~:iit:f: cf
sympt om.s .w heri g~v~n ~ntravenousiy, _like
thls:can beadn;U:nist~'red .o'rnl)y;,ii;l-~v.en:ously -~?.i~~?::;:tr.?~?~-'~~aU:~;__'::?.~~~-h-~~i&~1..
ar'iritiiroliSflla:rry.-it-:i~,($onjuga:t~a::nime:p.:ver~fo nervousness and an.:":iecy. Less .co'ri:im.on side
s-u:rate :an.a. ghicoro!i'Hi'Fkor.m; "Free crru:g~a.nd. e:fficli ~e :tiies't .pain: ~she~~-~.; bx;e,3th and
co.p.jP,g~tep. .fonp. are. e.X9-r.e~ 'bJ;.the ,kid.n eys. The pulr_tiona.cyedema, Tb .av.oi. edma,.:L'V.-flUids are
ha:if,.:lif~:in;:pr.egnrutt .wo:niyn.:is 2 .-'1~ -~D.b.urs.. M.os t left to.~u:m. 63
. are ~oit~a :.:Wiil;l co:iie~.i;lb;cition .of ~;20 - 50 P.-ft./
-m1:.I$sioii.:is .st?rte:d:~f0,1, 'mg:f-i~Lan:~ il1g~s~9. The f>"adrenergic..:agoni's ts cro~s the .Pli:J.ceptal
_by O;~ -mg/i:rif ev.e_cy. i'O.. !lfib\l.t~s ;when 4~t>Pr.:i;3 barrier fredy, soan mere.ase in ):he heart rate and
ir:tb,ibit. J 'hen .th~ ..~q~~ .itip_ybe<n!duqed::b;Y. :o~os the physiO.l~gic ~d ,meta:bo1ic efie~t on ;the-~othe::
- ~i-~ ~ery B.O ~tn:;~ 2 9ra;t-:n'trodri.tle ;'i~ava,il<ible oe.curs also in the baby .. Unibiljcal bloOd .il9W and
in 10 mg 'tab. A 20 ;~g -a-~.~e P.~ ~k ..Pla:sm.a acid-base state are unchanged. ut'erine blood how
concentration is reacihed in -60 - oO min:utes by is also not changed. The Apgar score and umbilical
ave_rageonly lOng/rnl \v.ithir: 3 ,ho.urs.,.the plasrpa pH 'is not aversely c.(fected.6.'
concentration i.s l.ess 'than 3 ng/rnl. The
'recommended dosa:geregiillen,is'60 Ml-20 rntfml, 62 lsoxuprineht high cqncentration illcreases the
r,isk of neonatal ileus, hypotension anddeath. This
B .. Ter:butaline is not seen .in other. fl-agoriist. 6l

This can be administered inlr~venou sly, . f>-agop.i.st infusion to m other have resulted in
subcutaneously . and orally._ The ..half"-life- o_f neonatal hyperin su linemia, hyp-oglyce~ia,
terbtibiline is 3.7'.hours with a range ~of i:S-:4.7 hypOkalemia an4, fu~cken,ing of. :intraventri~ular
hou:~s. The .labor ~nhibitii?-g :):on<;:en tr~tio}l. of .septuin. 61

Scanned 8y: ~
 9HAPTER 41: PRETERM LABOR
Contraindications
IS-adrenergic receptor agonist should not be
used in situatio.n where . s timulation of
~adrenergic receptors w.ould ~ hazardous, such
as cardiac disease, hyperthyroidism and
hypertension. Diabetics can receive it as long as
glucose is monitored and ccontrolled. 63
Overview of 6-Adre~ergic Drug to Inhibit
J'.tettrm Labor
The use of parenteral B-agonist to prevent
pretenn birth confmned a delay ot deliverjr for at
least 48 hours as st>.idied by the Ca.!adiafi Pretenn
l:.abOdnvestigators Group in 1992;69 'rhe delay has
not been beneficial as in the meta-analysis study
Of Macones' and associates 1995 using oral
&~agonist. 70 The delay may facilitate transfer to
,tertiary .c-;en:tei'-o'r effect lung ttlatU:radon with
glucbcotti.~oid~.71
!ffagite.slJ!m. Sulfate
Mecfumism of Action
..-.- ~
.. :Magnesium sulfate affects 3 aspects ofuterine
...conttactiQm 1) excita:ti<>n, 2) exci:tation-
c ontraction couplihg, and 3) the contra.c tile
apparatlis ..itself. Extracellular and .m etilbrane
magnesium probably affects Jilyometrial
contraction- by:- moduJat:ing--~a:leium- 'uptake,
binding,and,distri}lution-of smooth muscle-cells.
Elevated ievels of magnesium block caldum
inrtu:x at the mettJbtahe by c9mpeting at the
binding site.s. Magnesium also activates
adenylate c yClase and increas.e cAMP which
redu~es intracellular calcium. Intracellular
magnesium stiplUlates -(::alcium dependent
ATPa'se wh'ich promotes calcium uptake to the
sarcoplasmic retiouhun. ~ Excess magnesium will
lead into a d ecrease .in n e t calcium available for
_light chain phosphorylation of myosih. 6~
Pharmacology .and .'Dosage .Regimen
Magnesium is predominantly an intra cellular
cation. A small portion is in the-extracellular space
and about 1/3 is protein bound. The serum level
in pregnant patient .is 1.8 ... 3 . mg/dl. The labor
irthibiting concentration of magnesium s1,1lfate is
betwee~ 5.5 and 7.5 mg/dl. To achieve a
therapeutic concentration 3- 4 g/hr is required.
Scanned 8y:
' 631
A loading dose of 4- 6 g is preferred. It is. unclear
whether oral treatment with magnesiumgluconate
is effective .64
At 6 - 12 mEq/ L, B;CG changes and
hyporefiexia are 'Observed. Loss of deep tendon
reflexes occurs at approximately 1 0 mEq/ L, .
respiratory paralysi$ occurs in 15 mEq/ L, catdiac
arrest occurs in serum concentration of 25 mEq.f.L.
There ar~ reports of pulmonary edema; chest pain
and s hortness of breath~ 65
Magnesiun\ does r~t. usually depress the fetus
even if it is freely ttans.t )orted to the plaeenta.
Neonatal hypermagnes~mia in the neonate is
usually manifested as flaccidity, hyporeflexia,
respiratory depression and weak or absentery. 66
Despite popular :opinion, there is..nQ .~q~nc~
of consistent decrease in fetal bean rate vatjabiiity
and developmcnt ..of ~neonatal hypocatcer:D.la.~ .'; ,.' .,
Contraindications . . -:......~'.''":: }Z,~~' _'.1:i.-..:: .
~~~..!..!'~: ;-! ~~ ~ ~:J
_:';';: ..
This should not .b e gi:ve..'l to patients with 'heart.
hlock, :myasthenia gravis or my~ d~e .
Because it is exoreted in ~e kidll,ey,, c~ution.
should .be taken with renal disease~ Thi$ shnuld
not be given in combination witlt,.barbiturates,..
nartotics or hypnotic drugs because of possible
depression. 65 .
Studies on thel:Jse of Mawr.~sium SU1fl:1-te
There are two randcmized controlled study on
the use of Magnesium sulfate as a tocolysis. Cotton
and associates pointed out few differences in the
use oi magnesium sulfate .. and dt:Odrine and
placebo. Cox an.d associates. pointed no dif(erence
in its use and placebo. 7273 In the Australian
Collabcrative Trial of Magnesium Sulfate as
reported by Crowther and colle~gues the n eonatal
mortality and cerebral palsy were lower in the
magnesium sulfate group. 7 ~
Prostaglandin Inhibitors
Indomethacin is theprototype of prostaglandin
inhibitors. It has anti-inflammatory, antipyretic
and . analgesic activity mediated . thro.i_gh the
inhibition of prostaglandin ~Y~~hesis.
Prostaglandin inhibitors .l;>ind .and itiactiyate the
enzyme ~yclooxygenase. This enzyme functions to
~
 632 SECT:ON VJ: COMPUCATtONS .IN PREGNANCY

regulate the . pr:odu:ction of prostaglandin Pharmacology and Dosage Regimen

intermediate PGG2 from arachidonic acid.s7
Nifed.ipine is ~ost completely absorbed after
At the eellular level. prostaglandins are oral administration and peak concentration is
integrated in 2 levels: 1} PG ~nbances the observed at 30 minutes. Bioavailability is. 61-6,8 %.
production .o f myometrial gap junctions which ate It is .a lmost complcl!ly metaboliz-ed in the liver
nece~ for the tr:ansn;lissjo~ of smooth ID:Uscle arid 7Q- 80% of the drugs excreted by the kidneys
contractiOns~, .2) PGF2 e.t intulates the influx of are inactive metabolite. the elimination half..,life
catclutn -intb the ceil :a nd release of -c alcium from is a.pp.roxi111a:tely 2 .5 hoursY Read and- ~lby
the Sjlrcoplasmie :reueubun::s-rthe-inctease in free administer an hiitial do:Sage of 30 mg (lO mg
intrac1lular calcium .stimulates lJlyosin light tapsules) orally followed by 20 mg 3. times pet day
chain Md leads to musCle contraction. At the for 3days.
:-coellular lev;I. indoJJiethacin ..decreases the
~~en~tiqn o.fJnti'J;lc.e llulat .UciUttlleading .to Side Effects
.iJ)luojtioh or .ip.yometrial.cont:ractility-57
The calcium channel blockers produce
.S~>Xne :s.~(ii~~ .~aye reported a decr~ase in vas<x.Ulatatio.n ~d decrease peripheral vasCular
utf!rlrie ,blood flow. So. ther e is a cort~ern for . .resi:;;~ce. The diastolic blood pressure dec;rea~
oligoh.ydtatni.c:>IJ to. t;levelQp. Precaution :of .studies and the hea."'t.r ate iney~~e but lesser in degree
limits the :Uf;e to. 24 tci 4il hours.t vthers have than ritodrine. Other effects are transient facial
. q.r.m,ed .oQ.i~~ ]~Psmhili.ty of :bleedit;lg. tendencies. flusp, n~sea and hea-dache. 67
Hypejbillnib.inemia-cf. the newbof!}..w~s..,more .
conunon:. ~use . indomethacin,...,competes~ .w it;h C~n~dications .
corijugatiori of .f ue. liver.~ 'l'here . are confUcting
repott~ . <m .-:the : as~l)..Ciatio,n . of . neo'n.atal The only known contraindication is
i~traven;tjjjn~:lar he.roort:ha,g~ ;... n .e :rotizing byper$ensitivity..to the ..drug.57
~terQu
,..,...,.. .;:ti~an
d pa
. ten.t .d q:,..
.,.tu "'-+ nosus
. s -(>..ne . 1...
Studies <in ,u~e of,NUe.rlipme a~;Tocotytic 1\g~ts ,
~-P~c,ii.a:tio;ns., . : .. ....... ' ._ ..., . ,.: . - . ...
The C.ochtane Databa;~.e conClude-d that
..Thi3. l~ JiQ~.M~ m
rnR~~r.s mth:g~.$IDC Al~e.r --:-'- r-: - ....... . _tre
nifedjnine - -- ..~
....tment
.. . ..... . -"'- _ . "' _th
:""td.uc,.d 1 .. .e~ o.f
brth
. e....
or .hc:morrh~ge. ren.a l .disease. kno'Wn .bleeding. neonate:;L.oLles:s .than ..2SOO .g ,:compar.ed .to
.disorder, or. fiistoty ot all~rgy to ptosta.glan(:lin~ fr-ag,o nistm the studyofK:itrse, i995.7~ King~d
Cborioamnitmit~s may he ma$ked by the coll~.agues . SU,ppor_ted .the effeetiveness- of
,antiPYrUe-~ffect_,oUn99nlethacih. So, precautions nifedipipe aver other tOC(;Jyt;ics.7 5
~en. are to u~ the 1Qwet do~ and not tq ex;ceed
48 h outs. -it$ u~e ~~: avoidd beyo~d j4 weeks New~r :Drngs-.]fJf P.retcT711: 'LaborU
~use 'of -dl!ttu,s Closur-e in ,t!ear.:t enn f~tus~s. s7
Atosioan

C~lelui'it Channel
. . Blockers
. is a pure oxytocin a ntagonist and has a
~~ific, reversible effe<;:t on
myometrial c:;ell~
in vitro.
Side effects reported include i:lausea, vomiting,
The calcium channel blocker~ (CCB's) inhibit h eadache, chest pain Md arth~gias .
the influx of e}ru-acellular calcium acros.s the cell lt ha~ relativeiy short half-life (16.4 'minutes)
m~mbrane durfug the slow inward caldumcl;lrrent in ntm:..pregriant wotnen. It c.r osses the
of the .-a,~tion potenti~l. .The. r:eceptor~operated pla<ienta but no
evidence Of mutagenicity has
charinel is re_gulate.d ..by receptor. occupation by t>Ce~ .ob~rved.
.neurotran.s:ni~~r:s. prostagland,ins.hormones- or . The use ;didnot.irpprove neonatal 'o utcome-:a nd-
.Qi:herdrugs. Ex;:unpl~s oftl.le.CCB's ar~ nifedjpine, . was linked to neonatatmorbidity ba ses 9n the
and nicardipine Hcl. 57 .' st:udy/6

Scanned 8y:
 CHAPTER 41: PRETERM U\BOR
Sulindac
is a prostaglandin syntheta.se inhibitor.
It is administered orally 200 mg at 12 hour
interval.
Recep.t studies showed su,Undac constricted
the fetal ductus arteriosus. Jt has also caused
significant decrease -in the amniotic fluid
. indeX.
Nitric Oxide Donot
Acts: iP. cqncert with pr.oge.s te!'one to regulate
uterine quiescence and cervical .rigidity. 1t has
potenti~ as a tocolytic agent.
studies showed that it was not effective and
not superior to other tocolytics.77
CL1Nt~ lrlANA:S:E:MENT-OF -I>R.ETERM
DE~i'V$RY
..~ ....~~
. -J
Mate~'bansfel' of Pr~term P~Uvery:
Th~ firSt consideration of pc,_eterm delivety is
the adequacy of the facilities and the capabiijty of
the personnel to ba-"ldle .a gestational age below
terin;7 ! Another b _a:sifi is- the. size of the fetus.
Because"<.o f\ the complexity or neonatal intenf::ive
.c are- unit artd the hazatds of transport of
premature neonates, .maternal transport prior to
deliY~ry 'more d1pabte in&ti:t\ifions is d:o.n e.
Perln.atal-'centers 'are s~t~,up to 'b'e llie referral
certter.fcs-r-su:clr-s'i:tuatiorH;~- -situations a'fumes
mak~ it difficult for th~ physician to transfer the
patient~ s.uch as not arre-s ted preterm labOr or
conditions of fetal distress.78
O.ther factors that have to be considered in
1;he transfer .are separating the patient from
family because of the referral to another center
and more expensive cost at the tertiary .c enters.
Transport s hould be considered only if it is
highly bene fici al.
Communication between the referral center
and the referring hospital prior to transport should
be done so there is ~gteement 'i n the management
and {he ava,ilability of facilities of the center. 78
Estimation of Fetal A-ge and Weight
The decision to let labor go on or to arrestlabor . in patients with multiple _g estations, PROM a,nd
depends .a lot on the accuracy of the weight.
Scanned 8y:
Ultrasonography will be helpful as if'allows
measurement of the bi-parietal diameter, humeral
and femoral length and even placental grading.
Although it is not timely for patients with preterm
labor to do arnnioc~tesis, in conditions where
labor has bee:n arrested ~-:1d there is doubt it) the
accuracy of the gestational age amniotic fluid
studies to determine the maturity of the lungs or
development of the surfactant. may help the
clinician decid~ -o n giving the <;ortico$teroids or
arresting labor or rtot.
Communication With a Neonatologist
Communication.with a.neOnatologist prior .to
delivery is necessary. At times. they .may be
involved on whether to m-rest labor or transfer
the pregnant mother in a ~rinatal renter. The
neonatologist is also.:Fe$ponsible for preparing -the
nursery and
assembling a t'iam to ta,ke ~e of
the Jj:ewl:iorn: 'l'hey are also mu~hcinvolved : iri.
enlightening tt'1e family regarding the~outconie: of .:,
. the pregnancy, prognosis and even:ihe _' co~tiof .;;;
carinf?i. - ~ ---- .. : ~,,; __,,.
.:
Ant~padum Corticpster,ohls .to :IJ:npto'Ve
Neon"W :Outcgme ... -... ~, - . .--..._; .
The most common and major probl:ern
besettin~ th.e pr.et~rm neonate is, the
f~~~~r~~~~:!a~~ti~iiRe-!
1
1:.-i~~-~~!:~~;
---- -------- ------ ------------------------------- -------------- -------Y-- ..
Howie and Liggins that usil'ig corticosteroid
prevents the occurrence of RDS: Majority of the-
authors believe that there is little dou'b t that
corticosteroids adm:iilistered to the mother .w ith
preterm labor :reduces the incid-ence o.f
respiratory morbidity in subs~ntial propertion
of:cases without incurring significant risk of
immediate complications or untoward long term
hazards for the mother and the neonate. The
drugs recommended are betamethasone 5 m g
. I.M. every 12 ho-q.rs for 4 doses (total of20 mg)
or betamethasone 12 mg 1.M. - repeated every
24 hours. The effect appears to be limited to
thos e cases in which the drug is administered
at least 24 hours but not more than 7 days
before birth. Repeat administration of the drug
after7 days when the delivery has not occurred
has -not been proven tb: be valuable an~afe. 44
The effecUveness of antenatal cortico$\eroids
under 3 0 weeks ~~station is uncertain. 79
~
 634 SECT!ON Vl: COMPUCATIONS IN PREGNANCY

.. ~
' '

Intrapartum Monitoring fetal abnormalities such as neD-romuscular

defets. U:p to 32 weeks gestatio n, the fetal head
Preten:n. and low bir+..h weight fetuses lack the . is larger than the :alX!om~::n or thorax.. Theie is
. capacity for .autoregulation of.cerebral blood flow . greater risk ofdelivery of the lower extremities and
t:l.n.d the. perivascu.l~ :support of the germinal body in an incompletely dii'a ted carvix .and
matri;: vessel~. This .p:1akes them sl,rsc~pti:ble to therefcre tiapping.Qf the. fetal head. Some author-s
the c6nsequences of ~istrihution of blood .flow favor cesan.~.a,n sectio-n .for "the fetus less than
which Cur: in resp:Qnse to intrapartum hy;X>:ria 1,500 :gm, .and vagina.ldellvery for :more 4'1.an 1,SOO
c <J'tilpared to the t~tm ;n eonate. 30 It +s but gm, 'This has been cotltroversial. 52 Cesarean
reawnabie th<1-t .t;h~y are und~r -continuous feW s~ction dt>e~ not alway.3 avoid trauma to the low
heart rate monitoring.to predi<rtfetalhypoxia. One birth weight infant- An adeq.uate uterine incision .
study demonstracted that the neo nate with is 1mportat-"lt. If the lower uterine segment i~ not
pron~ va.Pable-.decelenrlion, .or :deceleration. well forined, a verti~ inc~sjon is consipered. 61
combined wtth d~eased baselizye variabiiity Current con.sensus fayors a ~~ean d~1ivery_ t
-Q:urin:g:Ja~rnio.re:f.reque~tly died due to:dev;cloped
intraventricular- hemorrhage than those with Vertex Presentation
n~nPat; l?ttapartuip. heart. _rate p~tterit.~ Other
.-illias~to pr-a~nt fetal 'di~ti;ei>'s- during l)J<~t6:m 'l':bePJanner .ofdelh>'erj of the pteterm in vertex
laoor:iii~cka.voiillg'th ~upme po~ition;:a~fgin presentation faii"brs'.a ~ginalaelivery.lt ha.s been: ~
a(,inlinistration and.:irtiri~oinfuSion .t;-o prevent eortl shown in ret:I:o$pet"..-e studies that there :is p_o '
compr-<;SSlO~!.hoinpt~~Sar:e:i:tft:se<:tion;isd<:>nei"or . :d emc>nstra:ble.differen:ce.i n,m ortality.or sh9rt term
e,. -~-:
fital
.wsU;ess. ... . .. . . ....
. . . .. ....
. .. . orionglefinmotbidity.:.Ptween.~ean:rlclivt.:rJ.
am:l. vagin:a:I . :{le1iv.~ti-~P. Ce:s.ar~an. section is
Manageent :ofPain. reserved:f or Jet<disfres~.
. ,. .
..~ .Pret~nn~l;>Or. is :6 ften an ~AA~eted :~sis . .; AU.~Qt:s'.fawi::~F'4rigthe - ~ of-w:3.tenf-to'
e~Jor. the. :~rilo.tiohru.iy;,\lpp:t;ep~d~:~eat . pr:ev:eht: c~rd .:cOmp~sion; ,~tl r.edu~:::cep~c
ai:ia .anxiet'y.: ~il(nt":<,>niy. m.~~~ey. -tl).e pai:Q.',b~~ cpmp.t!!. ~~Jon:~lf:h.ic~ 'is'~a.:~soci2ld:
with vagal
Will ~So. mediate :the-~ r elease ,of.:-catliecol.a:ini.ne& .stimula~ ~tor.y." :a:dj~~tm:"e:rit and stress on
P am :~~i~:.e~n~i.rl such .patieri~. V:Lrtu~ly the ceiebral vasculatun:::n
.. ali-.tii:~ns,:,~~r-:p~reiief..-~~~>s~thepia'cerita . ' . .. .; :..-:. ..
;a.il.diaf,f@t;lle-fet\1~-A::n.cern: therefore-is-m:the :,Ihtt~:partum ,~ph~-is .- the:most-rom..IP.on,
d~pressive effects ;Of an~ge~?;c. medications to. the deterrtP'Iiant. of re;s .p ipatoty distress and- eNs
fetils-.~1 hemorihag~,. so -ther.e sll.9:uld.. be .pro_inpt qelivery
in, th~.mosttraun+<1-ti.c Jriethtxi ~t]l Jibe~ u &e of
~jl.tihuous epld~ra:l,an.eslliesi~ is .a safe .;;tnd cesa.r,elh-1. section. .'fi.l-: us,e of{orC~JilS to pr:qtet:the
ci;f."e~\!l!.:meihod ,of'-pa.i.."l:. cpn~ol as :long as ther.e heaq :is .not .confir;r,net;l ip. r.ece nt studies. S~ch
is adeq~~e -hy~ti0n. 'lnh;;4atipn :;anesthesia {or prooeu'ur4! can cr~t~ fr~uma to. the nec>nt\te-
em.er-ge.P.%-o_()!!ta.#ve .deli:Y.er.y -~.lje :given. a,s lori.g .Epi;rloro~y ,mayaupw Jal'iter.d eliv.ery.
a~ -:th~.. mother 1.s prec>xygen:cated: -well prior -.to
in:bJ.ba:liioti. ~. is '}':>Os.itione<i properly to av.o id Re susCitation of .the -Nepnate
:supme 'hJI>O.t~I).~ion. . .
. It is iinporta:ri.t to prevent ~ot only intrapartum
Metho.d of D,elivery asphyxia:l:n1t al"so neonatal asphyXia. Personnel
-particularljrthe neonatologist should be pr~ed:
Equipment for resu&citatio"n l'!hbuld always bC
ready. Babi~s less than 1;ooo :gtn are quite
Ereecli presentjttion is a .eommoncompli~tion diffi.culno intubate. The neonato1ogist will be ina
.ofpretern;1.labor. 1'l:le younger thepregnancy, th(! .better positio~ to det~r.mine the extent of
gr61:lteds the-chancefor:lSreech p.r:es:entation: T:he . re su -s citation needed ahd-"the tran:sfer to '.a.
younger.~e pregnancy:, the.-greater:iS the chance n eonatal.inteosive .careunit (NI~U) . E2 Should the
for.-breech presetttation.: .At 28<w eeks, there is a newbom -require trans fer .to: a ter.tiary regional
2 !.) percent chance of such presentation. T~e other perinatal c.enter, communication be:tween
problem .associated with breech presentation is oersonnel is -very :important.

Seanned lly: C
 CHAPTER 4'1: PRETERM LABOR 635

SUMMARY AND PROGNOSIS Termination of pregnancy might be more bentr;.fi_~ial

The prognosis of a mother v.-ith pteterm labor
will depend on the age of gestation, status of the
cervix and the obstetrical or medical complication.
The closer the pregnancies to near term, the better
the chanc.e s of ar-resting .:Of labor. When
complicated by obstetrical or medicai conditions
such as placenta prena -and hypertension,_the
lesser is the necessity for arres ting labor.
to the.mothe.r and c:ven to the baby who runs the
risk -of intra,;uterine asphyxia or mbrtality.
Neonates of mother with obstetrical .o r medical
complication are at times believed to fare. well.
Management of preterm labor has non~~n vexy
promising. Such management has been
technology and: resources _d ependent ping rise
to very expensive consequences. So, enticipation
and prevention is the key to better m~ent.

POiNTS . TO REMEMB.ER

Prem~tu:ity is a signific.;~nt factor in the survival of neonates. The :Jess premature the infant. the
greaterls the chance of survival. The objective is to prolong pregn~ncy .as muchas poss_ibl~:lonear
term. Survival will depend on -care affer delivery of prematur-e neonate requiring expettise and
" technology.
.<The-~imtrt~diate cause of -preterm birth are pretennlabor, ~pretetm premature ruptureof :membrane ,,
.. (PPROM), mat~rnal medical or obstetrical complicaiior:s such a~ pre-eclampsia .or,placenta:-previa; ,. ..
andJeti:lldi$tress o r demise.
. Current pregnancy compiicationsthatmay predispose to preterm labo~ ~re history ofprevious preterm":~
blrth.Qr:'~~bc:iion, spontaneous rupture of membrane, and cho.rioatnnionitls or amniotic fluid inliectiOn,
.iocci~tent cervix or dilated cervix. Other: complications are anomalies .o f -conception, overdislended ,
..,.'-'tell).S,~I;!Ch
.. ' ~~:.;;;~,..
\ .
as multiple pr!=lgnancy and Polyhydramios;
. . . th:ichh~uterine
fetal .. . anomaly,
~- .
fc.ult}f.pl"il
. ,.
't&itatibn"'
. _ ' .
sucti:as,placenta prev1a.and abruptio placenta, retamed mtrautenne dev1ce, and eleciive lndti::!ion 'cf ..,..
. ..
.
labor. :c~. ,.,;:~ ,.
Infections stimulate the .production ,o f endotoxins and inflammatory ,cytokines and ..act ~ ...actly.
stimulaJ!ng--the-fetal-rnembrane-and.decidual.,prostaglandin..expressjon,.anQ..Stimulating.the reease..of
interteukirH3{11::..:G)-and release:of endothelin ,by amnion causing. uterine contractions;-
Pret~ labor is diagno.seci when there are -regular.ut~rine ccintractions after 20 weeks gestation or
before-~7- weeks which..are 5-.- 8 minutes or less apart acc6nipanied by one or rhore of the ff:
1). progressive changein the cervix, 2) cervical effacement of 2 em cr more, 3) cervical.effacement
of 80% o r more. , . -~--
Other signs and symptoms in the diagnosis of .women at risk. for preterm delivery include 1) passage
of cervical rnucus, 2) tow back pain 3) pelvic pressure due -to the descent of the fetus, 4) menStrual-
.like cramps, and intestinal cramps with or without diarrhea.
The predictors for preterm labor are fetal fibronectiri (FFn) release into the cervicovaginal secretions,
salivary estriol (sE3) and cervical sonographic findings.
Prenatal care prevention should be centered in the recognition and elimination of the risk factors.
The use of labor~inhibiting agehts is for existing preterm labo~ a gestational age at which the1reatment
will benefit the fetus and no medical or obstetrical contraindication t o the inhibition and the.agents.
The side effects of s~adrenergi~ tocolytics are increase in_heart r.ate, cardiac output and pulsepressure,
increase in blood glucose, insulin, lactate and free fatty acids and a qecre.as_ e in pla~ma potas_si.!'!m j

with sodium ahd wat~r retention. :;-:-- I

;~,:. i
I
Neonatal hypermagnes.~mia is:_ usuai!Y manifested as .flaccidity, hyporeflexia, respiratory depres$ion i
I
and we?k or absent cry. . .
j
I
i

~
l
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636 SECTION VI: COMPLICATIONS .1~ PREGNANCY

ChoriOamnionitls may be masked by the antipyretic effect of indomethacin. Its use is avoided beyond
34 weeks because of ductus closure in near term fetuses.
The first consideration of prete~m deliverY is the adequaty of the facilities and the capability of the
persvnneHo handlea gestational age-below term.
Thedecisi6n to let tabor go on or to arrest labor depends-a lot on the accuracy of the we1gtit
The i:son3toi6glst is resp6nslble for prepanng the nursery ;3M team to take ~re of tl)e .newborn. They
are also muqh lnvolv.ed io enlightening the family regarding the outcome of the pregnancy. prognosis
and even the cost-of caring.
The most common .and major problem besetting the preterm neonate is the development of respi;atory
distress
. . the use of. steroids is need~~.
syndrome. (ROS) so . for iung maturity.
-. Pretet:m and low birth weight fetuses Jack the capacity forautoregulation of cerebral blood flow and !he
other bf(X)d vessels Which make .them suseeptible .to the consequences of redistributiQn of blood ftow
wbicl\ .Occur
.
in r.esponse to. intrapartum
. .
hypoxia
: . .
compared to the term
. --.
neon
.
ate. .
Virt!Jally aM medi~tions for pain relief -cross U:le.placenta ~nd affact the fett!s.' A con<~ern therefore is in
the '<fpre:ssive ._.effects Of.analgesJc medications :to the. fetus. .
Intrapartum .asph~-:-~ia is the most 'C()mmon determinant of respiratory distress ~nd CNS hemoriha9e, So .
~rlfshO(lfdb~r'.prompt"(felivery{fn the most-traumatic method-:w.ith,liberat use of esareao sectiQn.
It J~ !MI)Ortant-~t~~,pte.<,tent.,~bl<hnty":inttafjactum. :aspttyx1a~but,a1Sn;(le0ncital::asphyxia: ,,:.:'"':;.

8 . .Bottotil $F~ Pal,ll RF, iama J.t>. et aL Obstetric

det.e rm.inants or .n eonata.i su:c yjval: lnfi'\tetl~ of
~pe~to :prl'Q.rt;o ~$a!'~ d~livery on s-.tr.iiv$.1 of
1. ~ FO LCVetio I.1 illoom S{.. Hauth .JC.
. Gils~-~Vien~tro)n.,~-Willi~s '0.bs't~~~s<12nd -~~F.!.~~I.~l<r~!~B~.;W.~iz~! i~~s. ~ J-:Pl?~tet
Editi6rh. McGrowHiJ.l.:-~00~8-5-:SS.l; . q~~~~}:~:?:!l ?~.~ 2~9:... .
9. Doron.MW~ V~nn~$~~eenan KA, MatgolisUI, et al.
2. Baj~:.:~lL 1:1pdates in~~t~andpuin,at.:U <UUe DeUvezy Ji)()m t~uscitation de.ci:s ion fer ~ely
.for fu.t 'h~th woi'ke'r 8. Phil J 9bste.t GJn.eql ~990; premature mf&.p:ts.; .P ediatrics i~8.~ 102: 574.
14[~). . .
10. DePahnii RT~ Leveno KJ, Keliy,J.4..A, .it Q.l. tJirth weight
3. Festin'MR. Epi4e}Iliology ~d,wpact. In Clinical Practice t.b:-eshold forpostpqn:l.ng preterm birth. Am J Obstet
G~.{\~ in-17etetm La;bor .2000; .1 ~41.. Qynecoll992.; .167.: U45.

4. Main DJ.t, The epid~miology .6t pretrm birth. Clin ll. RM; P
Q'.liiliuri:pr . hy~Jogy and etiology. In Clinical.
Obstet Gyti.ecol l988; (311: 3. Practice Guidelines on Pretenn Labor2000; 6-10.

5 . Vohr BR, Wright -LL.., Dushnick AM, e t al.
NeutQdevelopmerital an4 fun ctional outcomes of
extremely loYi birth weight infants in the National .
Institute Q( ChUd \{ealth and Human Development.
Neon!\tal .Research. Network, 1993-1994. Pedia trics
2000; 105: 1216.. . 255:82.
6. Wood.s NS, Marlow N, Costeloe K, et al. Neurologicand
d~elopiJlent disabmcy after.extremely premature bi:rth.
N .f;ngl.J Med 2000;.343: 378.
12. Ri:vera EF, .A'guita r LP, Quinto HC. Incidence of
prematurity in.the Philippines. Phil J Obstet Gynecol
. 1976; (ll. .
13. Sh9no PH, Kl~banoff MA, Rhoads GG. Smoking .a nd
drink;ir)g during pr:egnancy. .J Jim Med Assoc 1986;
14. MacGregor,SN, Kei~l.G, CheonoffSJ, et al. Cocaine .
. use during pregnancy. Adverse perinatal outcome. Am-.
J Obstet Gynecol 1987;157: 686.

7 . Al:nerlean College of ObstetriCians ~d.Gynecologists . R,

15. , Zu~ke-(mruiBS, .F rank DA, ~g~ri et al.:Tbe impact . J
Perinatal ca.re at the threshold of viability. Practice of maternal work on neonatal o utcome. Pedia,trics 1986;
Bulletm No. 38. 77; 459.

Scanned 8y: C
 CHAPTER 41: PRETERM LABOR
16. Hedegaars M, et al Psychological distress in pregnancy
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.22. Neggers.;y, .G oldenberg R, CliVer S,.et 1'!1. Effect$ 9f
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. . .
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.Syinptom-s, uteririe contractione,cezmcal
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2s. ll!m~ JD,.Goldb:;rg RL, ?-.-!cis PJ, et cl. n.e length of
. t,he cervix and and ri~k of .spontn.neou$ preterm
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31. Offenbacher s,~Katz V, Fertile G, et al. Periodontal
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33. Ka:nayam~ N, Terao T. Otanulocyte elaste.ee in cerVical
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length. Am J Obste.t Gynecoll990; l63i 859;-867.
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Gynecol. . . " .
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n ,.2z... .... -
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43. Castro VB. Scr.e ening. Ultrascund i n the cervix. In
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27.
44. Go met R, Glasso M, Romero R, et al. Ultrasonographic
examination iit the uterine cervix is better than cervical
digital exami.t{ation as a pr.e dictor of the likelihood of
prem~ture defivery in patientswith .preterm labor and
intact membniri.es. Am J Obstet Oyrtecol -1994; 171
45. Andersen LP, Fuchs F .Sexual activity and preterm
birth; In; Fuchs F, Stubblefield PO (eds): .~terin Birth,
Cause, Prevention and Management. New ..York:
MacMillan an\l Co. 1984; 112 . .
C
 SECTION VI: COMPLICATIONS IN PREGNANCY
":: ~ .,
46. Brustman L, Raptonlis. M, Langer 0, eta!. Changes in
the pattem of uterine contractility irt rdationship to.
.coitus during pregnancy. Abstract No:tss. Presented
at tl)e7th Annual Meeting of the S ociety of Perinatal
Obstetricians, Feb 6, 1987.
4 7. lamsJD, Johnson FF, Creasy RK. Prev:ention of preterm
birth. Clin Obstet Qynecolt-988; 31 {3) . .
48. ~.:Christe'QsenjJ; Mattsby-i?altzet I_,Thomsen P,et
a1. End~toodn and i ntetleukitll -alp'htl.in cefvica1 mucus
atld .~al tiuid -bf pregoQ.tlt wo~en wit)l ba~erial
v$ginC)sia. J.rn J O~tet Qyneeol1993; 169: U61.
r: 49. Hitti J, C.uci S, Noonan C, .~t ~ V~ bydrolytle
.e:n%.YQl
.. .... ~..,.~'.?.u 'bacterial
ac. ~ . . . . .ya...;..,osis
~ .
e.bd.
. -~
... oi' early
pre~ birlh-.among pretenn labor..(abstract) Atn J
Oestct Gyneeql2001; lM: Sl93.
SO. Maconea GA, P:uarry s .. ~lkaou-s.y M, .e t .at. A
P..,}ymor.phism in the pi'Qm.oter region of .TNF and
~ v~o$is. Ptel.im:in,my -of _g~rie-envU'Pnment
in~Cln'in the eti~gy or sppilW1eous pntcril! birth.
A!D. Jbst~.t- G,yrtecoF~oo4i t~: l.tM: .
s1. Bobbit JR, De'h;lato JD, : Saklikini J . . Pet:inatal
..coiDpU.~tiou, in cQro~l.;'B' $treptoe()4cat t a,.-rleta. A
langitudinal iltudy. ~r prena~ pati~ts ..Am J Obstet
()jr.#!"l985: 151: 17i . . . .
.52. 'HOll>rookRH, F~on J, _Het:on M~ e:t :Ql. ~valu:atioJ:l. of
-~~~tio~~-Ptet~birthpreverition
.pro~. Am J i>etinat 1~s~~ 4: 2.w:
53. Crombleholm~ WR. .MinkOff H:L. Cenical.~~ge. An
., aggtea~aive approit,ch to threaten.e d QT 'recurrent
.pregriaii'Ci-:wastage.-Ain .J~obstet Gyn-ecoll983; 146:
16.
5 4, Mercct BM, ColdenbergRL; D as,A, eta).. The preterm
. nredic;ti-;>~ .s tudy; A Glinical ~sk a~~ent s ystem.
' Aui J Obatet.Gynecot 1996; 1'74: .i885~
55. Klerman :LV, Ramey SL, Goldenberg RI,., et Jll. A
. re.!ldomized 'trial of.augm_e nted prens,tal C!l.fe for
mqitiple risk, Medicaid: eUgible Afriqm American
wom~n. AinJ PuolieH~th 2001; 91:105.
56. Ame~ CoUege of-Obstetricians and -Gynecologis ts.
Preterm labor. Tephnical Bulletin No.206 June, 1995.
.57. Carlis SN, Darp.y MJ, Chan L. Phe,rmacologic treatment
ofpreterm labor. Clin O)JJ;tet Gyne coll9~8; 31 {3).
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t .reo.t of
ritodrine tQCOlysis versus .expectant
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.59. Meis. p.J, Klebanoff M~ Thm: E, .e t al. Preveptlon of
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ireatment of pretenn.labor. AmJ Obistet G~ecol i 987;
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. . "-, .
66. l..ip~tz PH. The ~:and1>ioehe:lhical edc:ct, of ~cess
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67: . Raem#ch.,KO... So:uuner.,.J ,. .:f'h~cokinetics.-and .. .
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m~ - . .
68. C~gay~ A~ !\nd ~abrera :M. Tteile~t: Other
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.
nt~~~ .-~: ~~r-t: Mri.4J~~r321: .308. ..-
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. agorust,maintenan~'therapy in:prtten1labc:-~ A ~eta
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71. Kiet3e MJ:NC. New pe.rap~ctiveoa .fQr Ute effectiv~
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72. CotteinDB, S~ner HT, Hill LM, et ~ Co~parison
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Reprod Med 1984; 29; 92.
73. Cox SM , Sher.tnan M~, Leve~o KJ . Randomized
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~ystematic review o(.evidence and .aprotocol for .:
administration of nifedipine. Aust N Z J Obstet Gynecol
~
 CHAPTER 41: PRETERM LABO.R "" .,6'39
----~------------------------------------------~---------------------------------- -~~

76. Mountquin JM, Shennan D, Cohen H; et aL Double-
.hlind randomfzed controUed trial of atosiban an.d
ritodrine in the treatment of preterm labor: 1\
multicenter.effectiveness and safety study. Am J Obstet
G)rnecol2000; 183: 1191.
77. Buhimschi CS, Bu4in1schi 1A, Malin9W AM , et al. Effects
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and term parturition. Semln"Perin:atoll98l: 5 : 192.
. 79. Collaborative Group on Antenatal Stetoid Therapy .
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Clin Obstet Gynecoll988; 31 {3).
81. Moral~s WJ, Koerten J. Prevention of intra,vastular
heJD.orrhage in very low birth weight infants by
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1986; 68:295.
82. Bowes WA. Cli."'lical management of pretenn delivery.
C iin Obstet Gyneco1 19R8; 31 (3). ~-:

. .: . ' . : -~~l'::!<; : '

,,.. . : .:.:_,;_._ .
. _;;.j~. :-
' 1'

: : :~::.:~-~.. ..~ -
. ...
. - ,->..,
\ .

Scanned 8y: ~
 .;i;

....

Scanned By: ~
 42

POSTTERM PREGNANCY

MA..~VICfORIAS. VALMONTE-TORRES, MD

Definitions

!ncider.ce

Maternal, Fetal and Neonatal Risks

Pathophysiology

Management Principles

Patient Counseling

Antepartum Management
EstablisMment of Age of Gestation
Monitot.it1g..
Pelvi.e -Examination
Ant~natal Fetal Surveillance
Ultrasound
Delivery Options: When and How?
Conservative versus Active Induction of Labor

Intrapartum Management
Macrosomia and Shoulder Dystocia Drill
Fetal Hypoxia and Close CTG Monitoring
Meconium Aspiration Syndrome and Amnioinfusion

Scanned 8y: ~
 ' ....

642 SECTION VI: COMPUCATlONS IN PREGNANCY

DEFINITION births, 0.34fl ,OOQ live births and 1.31 i lOtiO

births, r.-es~tively .~ The 5 year review of our dA-ta
TP.e term post term, prolo'nged,." p<)stdate and: fJ;<?t:p. 2002-2006 by T.0rr.e s and Montaos shows 8.n
p qst maturity are often used intcrchruigeaoly to inddertce of .0.83%, .a nd post term :;tillbirth, .
signify pr-egnancies that exceed a duration neonatal death and perinatal mortality rates. of .
considered to be the upper limit of nonnal (that is 0.32/1000 births, 0.12/1,000 live births andO.+l/
.- . the. ~cted Date of Delivery- EDD}. Postdates, 1,000 births, res~ctively. With the intn:,duction
. , pOs~ ;term and prolon~ed are terri:).s to describethe of ultn,isound i:ti the local hospi.tal'ir:. 1992. the'
. ..' ag<: of pr~gnancy. Where.as .po$t, ma:t.utity :is used indqei;l~e ofpost tetql pregnancies has gon.~ dO\m .
.. :h ):de$q1De an inf~'i}t ~ re~gr~ble c;li~i<;:al . ~ignifi~tly to 4.8.% {1992) to an avetage of o,S3~Q
a
. feaw~s .fudi~tiig" patif:ot~~~'!illy ,proioljg~d : ' {~2:.:.2006). :frt>in 1.n~2~~ :~.fdrt~:,l$.~~2 :' . .
.piJ~~cy~ ,poi~t .pe(~ t<) 1;he4~e :otpre~a~ncy : . .' . . :. , . . . .. -. < . .. . . :v ..,. . .
.tha,t.h~,ione ~y:qnfi'e 'F)DD '{4:o~weeiciJ:hut1e$~. . Ji'~;'~~ ~lfATAL.Ri~ AND
.: :than.~4
. ~ W~ks.( . . . . ... . . .. ':::'COMPLtCAT'lO'NS ::' .. : ... . . . . .
.. . . . ::: ...: . . . ~ . .
.
- .
nus a~sumes that the LMP was followed by Maternal risks a.s~ociated with . p:olon~td
. o~tion two ..;ee'ks 1ater. .Based o:n thi.s cop.cept, pregnancies are:
. . :iU;~gnment of AOG m~y be etrOilWllS at times
" . ~~: 9f:faulty t:~ 9.f men~tr'.J.aLd~tes by the L Operative dellvery.(i.ncreas~ -cesaiee.n delh>ti)'
; :piii'ie:n.t or ciel~y:ed ovulation. Muil~tet and ra~es becau~e of'.:nacroso.mia, faill,lt,e . of.
. ..a:S.sb(:Sates and ..Bby.ce, ct 111. h2.ve. s!loWn. in their induction b.t .t1w <;ii~.tress).
.st:tclies-tP.e reas!'>:ns w11;y .l;-MP miy li9t always be
..: , ,a: reltble- ~:r.d~tick::f&n..-ilie~...o..s!):igmtl:en.t"of, :ADG. . .2. :I nieetidn an:d 'hemo.:r;r-h~g~:due:-to. p~lo~geti>"_:-.- =; .
MunS"~rs ~d assodates.sh{?We<i :a bighin~dence labor. :. ':
, ~f~1-se varia:tioils mth~ menstrualcrc~sot::l,Ormal . .
.W:oiD.-&1.. 1 ~e B9yce, el :aJ... showed that o~tiQn 3 . Cons~de,ra.Ple, :psy.clipl ogical' morbid.i ty -... :
:. . ;d()ea' ~not ~ys..ensue :.t wo;week:> ::fro:t;n the first : passed EP~ maternal anxiety. ,.
.. .... .fui.Y#.tp.e tMP-~ Reeht studies:by :Blondel~ et aL
:lia'ieJ.shown thh.t .fherewa:e:a .sigilifiant-.c:iec}.ine ip. Fetal and -neonatal risks and complications:
., . .,.'thtdn.c idence ofpostte~P.r~c;iesWhenAOG
'": .i~t~,.l)y ear-ly Ul~und d.a:tm:g (L9 %) as
:. ,:croin~ea~:wnen xon% basea-sOletY on LMP
;;.: ."J'6T.f%).3~rus v.;a:s -~ter:on-confuiii.etfb}r :a: Iaige
.~~ study .c ()ndtided by Bennett, et. al. _. '2. FeJ~.lli.mxia (.dlstre~s and death) .
.:~.e'f~fbre, some pregnancies de:signa,t ed as .p<>st
terfil;.may.n.otbe biologically prolon,ged. Conversely, 3. Oiig:ohydrall1'1:1iOi and. .associated . c'ord
: .a::r~:that-areciwt conslqered so mightbe truly pos t . accj.dents.during labor/delivery.
. '
c ::: . t~~:.l~ is therefore, .im:port,a.nt.to ~m~mb<!r . tha:t
: . .;..~Uyl accurate :fetal ~g by e9.rly )iltrasound 4. Meconium asp'i ra:tion syndrome and nevnat~l
:4~:UJH~ esp.e ciaU)' in the first trir:nester. 'is pneumothon~x. . '
r@x:hmended so 'as tq prevent false designatiops
of post term pregnandef? with all its attend!lrlt S. . Intraute~e G-roWth Restriction (IUGR).
upJi.e cessary psycholo.gi~al ai).xieties arid .. . :., .

:eps~:tri~ intervention. 6. :Post maturity ~ndrome.

: -'. INCIDENCE Post maturity syndrome is a specific S):n!l ~me

of IUGR associated with prolonged gestatio.n
. If1ternational data show a 4-14% inc~dence of. (5.- 10%}. Fetuses are characterized by d~--eascd.
post; term pregnancy with Stillbirth r ate of amount of subcutaneous fats and wrinkled ~ldn . .
:L9/ 1000 births in the UK.5 In the locg.:l.settirig, because theylose the vernix caseosa and aie m= ... .
based on the POGS Anrtual Report (20'04), our direct contact vritll the .amniotic fluid .. The)''li.l59.: . .
. sta.U stics show.e d <the following: Post term have long hair and.nails and the skin I:flaY have :: .. >
. inciklen~e - 0.83%,..Pos t term stillbirth, neonatal greenish I yel'lpwish .s taining .if ther have :. :. > r
t;lea~ and perinatal mortality rate~ of 0.98 /1,000 prolonged exposure to meconium. These fetuses

Scanned 8y: C
 CHAPtER 42: POSTTERM PREGNANCY
--------------------------------------- ::..;.:-; "643

are generally fragile, poorly tolerant of labor or leading tO'macrosomia with all its consequent
intoleraAt to labor and frequently aci!!otic at birth. complications (shoulder dystocia, CS delivery,
(Figure 42. 1) etc.)

PATHOPHYS!QLOGY OF .P OST TERM However , if the. placental undergoes

RELATED COMPLICA"'!'IONS
Whc::n pregnancy becomes prolonged, tY:o
things can happen to the placenta.:. it can still
remain .h:::s.lthy or undergo degeneratiVe changes
in the vessels (fibrinoid ilecro~is an4 accelerated
atherosclerosis) leading to ditninutioJi in the
caliber c>f placental ves~els. a-nd conseqti.e nt
decrease in. _the delivery of blood to the fetus.
:If the placenta
' remains healthy, i:he.re will be
progressive deliv.e ry Of nutrition to the fetus
degenerative changea as described, this will lead
to pla~tal insufficiency -7 fetal hypo$ ~ fetus .
responds by reflex redlstilbution ofbloed flew from
less vital orga.rrS (J,i.v~r. soft tissuea, .kidneys, GIT~
etc.) by vasPCQnstriction, to more vital organs
. (brain, .heart, adrenals) by vasodilatation
(especially in the brain]. Inthe fetal kidneys, there
will be decrea$ed renal perfusion -7 decreased feto.l
urination-a decreased amniotic fluid volume ..;
. oligonydramnios and associated . risks of cord
compression. In the soft tissues includipg the liver,
there will Pe not only ~ypoperfusion but cilso a lot

A- ~'

c
Figure 4.2.1 . Postmaturity syndrome..

A. Wrinkled skir.. withdecreased nmount.o f subcutaneous tissues with long h air.

B. "Old man's* facies.
C.. Desquamating skin with absence -of vernix caseosa.
D. Long, greeni sh .nails~

Scanned 8y: ~
 ::

644
.. ....
~

of catabolic processes (glycogen~lysis, proteolysis;
lipolysis) to create freeglucose to sustain the Vital
organs particularly.the brain. Therefore, as far as
organ size is .. concemed, there will be shrinkage .
of the ~ve'r c..nd ioss of soft tissue mass leading to
IUGR. Fetal hypoxia also results to reflex
rel~tion of the ancl spb4icter with c.onsequent
pasii<i.ge of meconium mt~ 'the arimiotic caVitY.
During the firsfbreath a:rid cry. at d~livery. the
neonate' may aspirate the m.ecpniu'~ .present ill
the oral cavity into .the sm.?]ler bronchioles
(Meconi'um Asp:iration 'S.Yr;ldro.J#e). The mecoriium
lodge<! into:.th~
. . 'lungs..may not only . .
ca~~e
. ptel&bc:r, 18.oor . delivery and early ?eo!}.~t:a.I pericd.
pneumonitis but aiso serve a ~all-valve effect,
Wherein the :V8.}Ve of meconium Opens Oll
inspiration but closes on e.-xpiratiort causing air-
pressure build-Up in the alveoli which might
consequently res-qlt to fatal Spontaneous Ne<>r..atsl
Pneumothorax. (Figure 42.2)
Note: A clear U:~der.standing of the.
pathophysiology of these risks assOf;iated with
postterm pregniu-..cy is 'v.ery vi~ for th~ will be
the b.ases of Ii;itul.~ge.flient ~trategies - 'from

'P.A1HOPHYSJOLOGY
POST TERM.

Normal Placenta Degenerative.~~ in the 'rJ acenm

... .
- dimiDish in :the diameter
., Pri:>lon~~~ :~an~y -.: ' .tind:~gih.:~(crorlonic'villi
MA:ffiOS0M!A ;., fi'lt.ioolii nc:Cros is .

;.:-~~~: .
. . : ........ : : . T'- .

:fitA:tTRA{~- .. . .. . ...
:(sho.u!&r
..,
iimocia)
. .
.piininu~onln,t!f:~;ory~~ .: . .,
.
. ,;
. ;._
. . :~~~r~::~~~~n~. . , ..... ,
ifetaJ ~
;. ' .
xit ..
. YP9 . . . .
'
. . . ' . ..
Rtflexfetai ..Red!stnilunoo.{)'rbt o6dAiow~w .
energy from ..Jc:ss ~vitalr9.rgans . (kidaeys;:.Gtr,.
s uba..rt<m~w tiss~ etc.) ..:> mere-vi~ .organl
(bnilit, heart)

K.i~~eys S~cutaneous Tissues :Rcf!c:X.M~ of Anal

.. ~
:. . f . Sphin.ct.cr~.t.O Hypoxia
: .: . "-t. t .
.Decrease(l..Renal:Blood . ,Meconium P.l!Ssage
. , ::fib,;; . .
+
.,Decr:eased:Fcta l Urine
(Glycogenolysis, Proteo lysi~ etc)
. t .
Output ckcrcas ed 'Subcutaneous Mass
t l
Decr~?:(.m nio\~9Fluid
oq~ ~;WtpRAMNlOS
1
1

CORD ACCJD ENT

t POS1MA TIJRITY SYNDRO!yffi :~tan co us ,
ANTFJINTRAP ARTUM ( 5-1 0%) Pnc:umotno rax
DISTRESS :(Neonate)
(25% of prolonged pregnancies) .
-;
F~gure 42.2. Pa tl1ophysiologic algorithm.

Seanned 8y: C
 CHAPTER 42: POSITERM PREGNANCY .645

MANAGEMENT PRINClPLES performed. Despite absence of evidence, it has

Patie~:tt Counseling
. Di$cussion of risks. and benents should be
done witb the patient and her family. Likewise,
n1anagement options should 8.J.st)' ~- thQI"QUghly
explained to them. Currently, there ar~ two
management opt;iops to enoose- conscn.Yative
management versus active i;lductiort of Jabbt. U
after the discussion, the woman and he.r family
choose conservative mana.genH~~t . Ireque nt
xna.ter ital and fetal antenatal evalu.atlon is
-m$datoty.
Estqblishment Of A~AOG
. . Emphasis has a,lteady ~n :giyen -~ the vi~
role -o! .early ulQ1J$0)l.nd da~. _-or .pregnancy m
decreasirig the ine$den~ .of f~se.Jy assigned post
term pr~ancies; The ~~la~ EDP from LMP
can be -conirrmed by .u ltrasound performed
between the fir;St tritnest.er up
w 20 week$. "The
most .a~urate a$sigmrient of AOG by u1~sound
can be obtained by Itl~the ~Cr:own'to Rump
Length '<(CRL)spechi~ybetWeen 7-n weeksAOG
Wit,h an acceptable error .o f+1- 3- 5 days..
become an acceptable standard of care even with
a lack of consensus as tq a specific regimen of
surveillance to be offered. The perinatal ortality
rate! increases gradually through<:>ut p regnancy
with the greatest .risk affecting pregnancies
continuing past 41 weeks, more so. at orbeyond
42 weeks. Options for monitoring include- non-
.s tress test (N$T}, .c ontraction stresS test (CS'f), full
biophysical proflle (BPS), modified biophysical
proflle (NST and amniotic fluid index only) or a
combination oftQ.ese modalities. ~uatlon of the
amniotic fluid. index has been shown to be
...especially importan t because of l:!emo!rstmted
increased 'adverse pregnancy outcome (please see
pathophysiology of complications). Therefore ..
delivery should ~ implemented in the .presence .
of even oligohydramnios alone. Modified BPS has
. also b een shown to be as sen:s itive .as tile full BPS.
Based on these fmding$, ACOG {2004) suggested
the "Use of mod.illed l3-PSJ~tic fluid index .ap.d
NST) two ti:I:nes a week for p~cies ~ntinuing
past 41 Wee~s is .r~asonable. Detection:cf.any
problem/ s related to the post term condition
during :the antepartUm surveillancemay.wa.rra.nt
delivery at once. 8
Ultrasound Evaluation . ' .

M~ ofAntenlitcd Monitcti.FJ{J Ultrasounq is primarily d9ne fu:

'-

1. o~t~::::t fetltl abn~ttlfalities (e-x~ neura.t tube

c:rereds; etc.).
Ripeness (induCibility) of th.e cervix is
important in :the qJ.anage:IDent of prolonged Presence of abnormalities detected by
p~ancy. .Cervical tipeness is best evaluated by uttrasound may not warrant further antenatal
using the Bishop.Scoring. _A~re -b f ~ or.more is surveilla.11ce.for fetal well-being. .
. favorable
. for induct;io.D. i>flabor. . (Table
. 42. 1}
2 . Detect abnormal fetal growth _patte.rns
Antenai:al Fetal Survei.lli:mce (macrosomia or r.JGR).

Antena tal fetal surveillance is sliggested in 3. Monitor a mniotic fluid volume (oligohyd-
p ost ter~ pr<-;.g rtancies when delivery is not ramnios).

Table 42.1. BiShop Scoring.

Dilatation Effacement Station Cervical Cervical

Score {Cili) . (%) {"3 to +3) Consistency Position

0 Closed 0-30 "3 Finn Posterior

l 1~2 40-SO . -2 M~dium Midposition
' 2 3-4 60-70 "1 Soft Anterior
3 ~~ >80 +1,.+2

Scanned 8y: ~
 $46 se:ciloN v1: -coMPliCATIONs IN PR!=GNANCY

dilatation. Methods used for this purpose primarily

1 depends on the ripe~ess {inducibility) of cenrix as ..
dictated by Bishop scoring and the parity of the
..i woman. It is important to note however., that ..not
O _,...,.or ~~ooc~ Pruanooo(~tLki>llow'..a

G>t~ u.np....m. properli' done induction can most like~y result to

Docr-..1 ...,.;,.;chi!""'- .~~lhli<l~l.<ne
~ N<oal fctOi .....
~)lST/tiT Nccmol NST".'tst
~ fetal~~) l:lc>rmalfc!il~ .
.,..
CeM<ol-~- ..
~~ ~~~1-.i.)
T. .
..JU~.;.,..>i< .
~~-n\lidw~.....,
~NtrkST .
..Q~~~~
. If~ ipo~;'(id ... ~
. (~Ooly IC{~.iDil~:ioe:)
~ 42.3. ~~6.nth.rnl'n the1dj::n@cati6n.o(patients who .
.Jft'e1~.fuiiY~ . .. . .. . . : . .. . . . .. .
. ,.Jn su-II_ll:Q.'ary; in ~nserv.ative ~anagement
opfiob; :Pl'itient)>4-<?d be seend:Wo ~es . a week
st:arfiiig at 41 weeks; ~t an out.. p .atient basis
primatiJy:.:!o,cdP..tpelVtc'"e:Xamination;;to.<assess:~ ..: There .are several g.Ui.d~lhies recoinmen ded
ce~ induc~bility b~~<;l O.Il; B.i:'!h~p. ,corin~ ~d bas ed on the i:esu:l t _pf the Ieview completed by
M-odified BP..S to .a~.sess possible onset of Crpwley and publishtdi,Jf t!i~. ~-hDill.e..Li;.brtQY..~ 0.
dlig:ott_yar.1tffin,tp~ an.aIe to-~prom:rse-" Inoi1..:
reltefive-NST):' '"Def ectl.on :of a.:uy-_pf.()f:,_
i d:ii"j s
expecteQ.ly related t o po:st terril concl.itjon (please
. se.e :Pathophy,siolqgy of complicati(),n~) during
.momtodng wm ~date <;leliv~ry ~t ,p11c~.
After kno\'ring the modes a nd re~larity of the
.;:tnteD.atalfetalmonitoting, v.rhen how.should and
th~se. patleri~s. 'be d~liv:ere.c;i? . the cesarean section rate .f-or l )Qth nulli. 'a nd
~n:serv~tive -versus Active Indi-J.ction of-Labor
G.o nservative management approach a s
mentioned earlier, advo_c ates non-delivery until
the .c ervix is favorable .for indu ction (Bishop score
of, at least S) _o r in the presence of any problem/ s
expectedly related to the post term condition as
detected during the antenatal monitoring.
Active ind~ction on the other hand means.
'!~cially'" initi~tiilg labor by giving medications
or dbing clini.ccl maneuvers that w ill p roduc e
-u terine contraction s an.d eventual c;ervical
failure of labo:r induction and consequent
abdominal delivery. Several acceptable methods
of labor .induction are as fellows: -
l. Sweeping of the merilbranes starting at 39
we;eks A0({9
2. tt a case pf J;l.On -inducibl~ cer.vix .(Bishop store
4 or less}, opt to insert intravaginal/ ~cal .
application of Prostaglandin E2 to ripen the
cervix first before giving uterotonins
{Ox-ytodns).
3. If cervix i s ripe {Bishop score of at least 5),
may directly give oxytocins to.ptomote uterine
contiactions.
4. Ao:n;i:btpmy .(artificially .rupturing the bag of
me.mbran~) -may 'not - only . stimulate the .
p~.oductio:ri.. an,ti i:-ei~~,of'PG~ an:p. oxytOcins
.. but can' .als6)1elp-.c:liriiCipn:stodetect possif>le
.me.corifum . sta.lping. of" -~h~ . amniotiC; :fluid:
.However, if ~me too .ear~y, tJ?is :m(!:y leatl to
'intr.f;).~~-niP;:t;.ic a-nd .fe.taVeatly. n~bnatal
.. in!eetioil.. :
. . . .
-~ . ....... . --.. -
1. Inducing labor in pregnancies of least 41
.yeks res ult.s in a lower rate ofnon-r-easS1.1rlng
feW . heart rate r.attems, me\!on~uni .stained
a.p;lq:lo:ti_c flu-id,, JetaJ,- ma,.crospmia (>-4-,t>Qogj;pld
re4u.On ln. the pe.r lnatal mo"rtality -rate :by
primariJ.y .nid\lcin,g ;;tij)birth rates_.
2. Routine induction of labor does not i..crease
:rn,ultiparous women in post term pregnancies
a s compared to .th.ose who undenvent serial
ant:~nata:l m onitoring. {conservative
.managem.'e.nt).. .
Intrapartum Mauagep:tent
Several complications expected to happen
during-labor and delivery has been discussed. How
do we deal with these problems?
~
1.. Fej:al.Trauma (shoulder dystocia). second~ to .
macrosomia. We should be prepared to ci1hhe

Saanned lly: c . . ..
"s h oulder dystocia drill" durmg delivery
.,,
CHAPTER 42: POSITERM .PReGNANCY
2. Intrapartum Fetal Distress
This is secondary to possible com compression
(variable decelerations) due to oligohydramnios
and other.: electronic fetal monitoring
manifestations of fetal distress {poot variabilitY,
la.t e decelerati<ms , increasing FHR aJ1d
tachycardia) in cases (){ poor fetal reserves due to
IUG'Rfpost maturity syndrome. These fetus-es
musf be monitored very closely during labor and
.delivery~
3. Meoonium :Aspiration Syndrome
One of the most frequent and morbid
complicaticms of prolonged p re.g nancy is
me<;:onium aspiration SYndto'm e. Until recently,
.this prob!efil. has a mortalit-y rate of as high as
.60%. 'ro date, it .i$ fottu.nate thal. with !he use of
combined techniques of trans.ce:tvl-cal
:a.t:nA.iqmfusit:>n before delivery. nasO'ph~geal
aspiration before the first bre.a th and direct
. e~dotrA'Cheal s uctioning irr~mediately. following
birth, :tile morbidity arid mortality rate have::
~onsiderab1y declliled.
l't~~J;erv,ical a:n:mioinfusion is infusion of
stetile:4~SS warmed at 37C :by 'bolus or
contmoil.~ly ~through the cervix during labor ,was
first q~.scribed by Miyazaki, et al. as an
in~ procedl,l,te ro.r the
relief of variable
d.ecelemtions:aue..to ..oligQhy:d~os-J;llldj....Qt:c.to..
dilutethicklY,:meconium,~tained.amniotic-'fluid-to
prevent meconiu,n a~piraticri syndrome.11 Recent
evidence from the COChrane Library by Hofmeyr.
demonstrates that amnioinfusion significaittly
decreas~s the .incidence of mecortiul11 ,aspiration
and relieves severe j repetitive . variable
decelerations CO'mplicating ,post term .labor ~d
thus1 decreases the need for ab<;iominal delivery
for fetal intole:r ance of1abor. 12
Therefore, transcervical .amnioinfu:sion during
labor in this .c ondition possib~y offer~ . the most
recent, simple, safe at;1d a fiorciable approach to
POINTS TO REMEMBER
Postdates, post term and prolonged pregnancy are terms to describe the age of g~station. Postdate
= AOG of.40 week.s and 1day up to 41 weeks and 6 days. Posfterm =AOG of at least 42 weeks
Scanned 8y:
!~~..,
optimize outcome in post term pregnancies
complicated . by thickly meconium staining of
amniotic fluid and/ or variable decelerations .
.secondary to oligohydramnios.
CONC!.USlONS
1. Definite/ a.c curate assignment of AOG (if
possible by early ultrasound agmg) is very
importa..11t as soon as pregn~cy is established
to p:revent falsely identi't.ied . pos t term
pregnancy w.ith its associate.d obstetrical
anxiety . and unnet:es~ry medical
Lry.terven.tions.
.2 . Thorough.discussion on ~he risks 2;Uid b~nefits
and management opticms. must ~ .done with
.the patient and her family.
3 . lfct>nse.rv.ative ma.."lagement w'as cht)~n by the ,
. pati~t, intensivefetaL.tnotiito~~J~ ~ial
focus on NST E,Uld amniotic nutd:yol~);l;,hust
be done ~ tim(:!s week starting: at 4i,:.weeks:
Decision to 'deliver must be done at;,ioD,ce in
the presence of problemj s detected dliririg the
monitorin(for if the cerVix is , fu~_udble by
. "Bishop ~ring. . . ~:. <, ~ \;;,, ~
. ... -......,:::.; !~. _.:.:
4. $everal methods maybe used.-f~l'tftt:(:tive
induction. t>f labor.a~hneptioned;., Prosta,:gtandin
ripening of the crvix is proven ~ffettive in
~Ses.when-induGtion-:is'iJ:ldicatedirt-a..setting
of.l ow Bishop score.
5. Overall, in . :depth knowledge on the
pathophysiology pf the inherent problems
assoCiated with post term pregnancy
(macroso,mia, traum.a tic deliv~xy. olj~ohy.dr~
amrrios, cord accidents. fetat distre.ss, IUGR,
post rilaturity syndro'me, meconiUill aspiiation
syndrome , neonatal pneumothorax) will
l'!ignifican tly guide us in planning our
management s tra t egies for optimum outcome-
in th~ antenatal, labor, intrapartal and early
:neonatal periods.
C
 SECjioN VI: COMP.UCATIQNS JN PREGNANCY

Po.stmaturityfs used to descri.be an .infant with recogniZable clinical features (thin with wrink~. greenish
oi yellowish skin, long hair and natls and generaUy fragile:. intolerant to lat?<>r and. acldoic at birtp),.
indicating a pathologicallyprolonged pregnancy.
Significant decline in the incidence ofpost term pregnancies have been seen When AOG is assigned by ~ .
early ultras~:>und ~atlng as compared when-AOG is based .solely on LMP.
The most accurate assignment Df.AOG b-y transv~gimil ultrasound can be obtained by ine;'!suring th"e
Crown to R:,~mp Length (CRL) $p:ecifJCaily between 7--1'1 weeks AOG '-;lith an aCGeptabfe .error of -!-/-3-.5
days.
M~temal.risks essociste.d With .prol~r:'lg~ ~pregriancies are operative deUvery{increased Gesarean rlerNery
rates bec<luse of macrasOt:rila, ta:nure qf ind~ticn or .fetal distress), infection and hemorrhage .d ue to
prolonged ~or and .psycho"lo_9ical mcroidity epassed Eoc matem<:<lanxie.ty). .
Fetal~nd n"eona\:al risks-assoCiated With prolOnged pre;gtlancy-are nK~crosomla and possib1eofetaltrauma
I
due-ro s..~ulder dystoc~.Jetat . hypoxia (!fiStress and deatttJ, lntrauterlrie GrO'I-Ith RestrictiOn (IUGR)I
PoStmatUrity syndrem~. oligohydtamnio.s ar.dassociated cord accidents dtiring labor/d~ffVery, meconium
I aspiration -syndrome -aP.d neo~tal pne1.unothorax. .
Patieht-tounse.ling isimprtant 1t incl.udes d1s"Cussion of.risks aM management nptions With the patient
and :Jt~r.fcimity.
... . ,... . . .
. : :...Currerrtly; .th.ere~.are:two .marl?gem~nt op!Jpns: . conservative malia9ement v~rsu:s at:.."'tiv~ ".inouctipn cf
. la9of.
.Cons.ervative- maq~g.eme.n.ta~tes .non-:.OeUVery- .tmtif ~e .<:ervoc.is favorable .for induction ( Bishop .
sc;ore,qf..~t..least,s) ~!!>r. in the :prese~:ef.aj"iy p.roblemlse;.:pectedlyrelatedto the pesttertnconditlona$.
de~~ d!Jrlng the ~nt~n$.t:~tiitQting. ..
ACtive induction means -~a~fida~y-:':tiihi<iti~ tabcr-~y. givihg;fn~ications or dqir)g dinical :m anewers:
that ~ ?foduce \lterine n.frac;ti<:)n$ .a:na e'lentuai:~Nfcar ~ila~ticn. Methv<!s (sw.eepif)g. oFttle
eo
menibra~s; ,~mni6frny, '0Xytoct_ri$'~ P ros:ta:gtandin geis) 'ttl:!)e us fot this pUrpcise.pri~nly depends . .
.
on. th.i-n~i)~.={iil9:t:J9pifft1H# \th~- :ceivix :a~ dictated ~by.,eish~p scerin_g. :and:thepa r:itY of:.'tbe~wpman.
rr-cese~W~;;man~~mefit o~li~ .~. n9Sen; snes~a:~-~f\;2~firn~.:a~w.~ ~{ ~s~ta-rtin:9 -~t .::i1- :. .
w~g-ornpauenfl5:?$1$ P.{irnafifYJQ~a9;~iViC:XaminatioriTo asses5.:cirvicatTndu~ibility ~bised .pi)
Bishop ~ring_. ~n"d Mooified;lJPS ;to aSSe~:P,ossible Qr iset of .QUgO.hydran:;nios and/or:fetaf .@ promi.se
(non~~e1)lS1}ahd t,.d:tr~und,to dett~eta! g~-~t.nqrrnalities (IU<;;R orma.<::tosPro~J, De~
.ot.anyP.fobl~rnts.expeete(lly.r~ta.teq ;to.~term ~n.QitiOn {pJ~~s.e seepathophysiologyqJ.compr~eatiohs)
or f.a~~ cerv~l ihdiJ~ibilny-.d.t.iripg mo~itqring wiU :man.clate delivery-at .once. . ..
-lntraparfuftrmanag~tne('lt'is ,g a!)gea:tomfds :preveriting cqmplicationswhich <~re expectedly :associat~
wtth..proloilged. pregnan~ as.:fOitciWs-:
:a. Sl)ouJ9er dyst~ia seeqn9aryt omact.osomia, should be .prepared to do the Mshou!der dystocia dnlr
during deli~ery
b. Intrapartum fetal distres~;'khich :m9y~ due to cor~-=compression due to :oligohydramnios and/or
worfetal reserves dl!e,to placentalvessel-obstt).lctionrelated tQ aovanced gestational .aging..should
do intensive fetal monitonng duriri:g labor and delivety
c. Meconium Aspiration Syndr0me- m<,ly be prevented by the use of combined techniques of
transcervical amnioinfusion before deliv~ry, nasopharyngeal aspiration before the first breath and
direct endotracheal suction.ing immediate1y following .birth.
Transcervicai amnioi.nfusion is infusion of-sterile NSS warmed .at 37C by bOlus or:Continuousty, through
~f-JE; cervix .during :labor, for t.'w primary purpose of .resto.nng" physiologic amcunt of amniotic fluid
dt,Iring labOt.and delivery.to ultimatelY -relieve variable decelerations .due: to oligohydramnios andlor:to
dilute thickly meconium stained amniotic-fluid .to prevent meconium aspiration syndrome.

Saanned 8y: C
:;;:
CHAPTER 42: POSTTERM PREGNANCY
1. Munster K, et al. Length and variation in the menstrua!
cycle- A cross ~ctional study.Jrom a Danie~ country.
Br J Obstet Gynaecol 19~2; 99: 422.
2. Boyce A, et al. Cla-ssical and true gestational
postmaturity. Am J Obstet Gyriecol1976; 125: 911 .
3. Blondel B,et al. Algorithm for :::omb!ning menst.--ual
and ultrasound estimates of gestational age:
Consequence&.for rntes of ph~term post term bi.'"ths.
Br J Obstet Gynaeco12002; !09: 718.
4. }:)ennett KA, et al. First trimester ultrasound .scanning
is effectiw".: in red uc.ing post term labor Lr1duc tion J1ltes:
a randomized controUed trial. Am J Obstet Gynecol
2004: 190! 1077.
5. Murr.a y JML, t al. Prolonged pregnancy. The
Obstetrician and (1ynaecologist 2000; 2 (1): 39.
6, POGS Nationwide StatisGcs in 2004. Annual Report.
-..... ...
.'-.-:,." ......... . -
Scanned By:
649
7. Sumpaico WW. Post term prewancy. Ttxtbook of
Obstetric~. 2n4 ed., Quezon City: Association ofWdters
of Philippine Textbooks of Obstetrics and Gynecology,
2002;430.
8. ACOG Committee on Practice Bul!etir.s. Management
of post term preznancy. Clinical Manag ement
Guidelines for Obstetricians- Gynecologists. .NUlllber
55. Sept 2004. Obstet Gynecol 2004; 104:639-646.
9 . Bouvain N, et al. Membrane sweep~g for induction of
labour. In: The Cochnme Library. Issue 1, 2005.
Chichester,.UK: John Wiley and Sons Ltd.
10. Crowi.ey P. lnte.-venticn~ for pr~ver.ting and improving
the outcome of delivery a~ or beyond term (Cochrane
Review) ln: The Cochrane Libr.ary, .Issue
4,2003 .Chichester,UK: John Wiley and Son~ Ltd.
11. Miyazaki E$, et al. Saline amnioinfusion for the relief
of variable or prolonged decelerations. Am J Obstet
Gynecol1983; 146: 670-678. .
12. Hofmeyr OJ. Amnioinfusion for umbilical cord
compression in labour. Coc_htEJne Database;,Syst nev
<2000; 2: CD000013- CD000013. ...
.. .::
~
~
 . .:;:-:

.J

.,

. - .. . . . ... --
~- - ...... . ....
~ ,., __,. . .
- ....
. :,,.,-;;.......... .....~

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 43

INAPPROPRIATE FETAL GROWTH

MARIA LOuRDES B. COLOM_A, MD

The Small Fetus

Definition
Small for Age (SGA) ....
Intrauterine Growth 'Restriction (IUGR)

Etiology

Clinical Implications .

Screening

Diagnosis
.. .
Antepartum Management
Surveillance

Timing of Delivery

Intrapartum Management

The large Fetus

Definitions
Fetal Macrosomia
l arge for Gestational Age (LGA)

Clinical Implications

Pathophysiology

Diagnosis

Managemer:t

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 r

65.2. SECTION VI: COMPUCATIONS

. f- 1;'
IN PREGNANCY
..
.

-'J;he fetal growth potential is determined the 10th percentile at a specific age in population-
genetically. Its realization is modified thrOughout based gr,owth curves. This c riterion yield a
,ge~tation by maternal, fetal 'or plac~ntal heterqgeneous population that includes th.ose Whc,
conditions. This results in clinical ~M.!ios of have not achieved their growth potential ,(f~
either approprla~ or ir1appl"opriate growth being growth restriction, FOR) as w ell a~ .lh~
identif)ed as the fetal size as compared with constitutionally small. The lower the threShold
sele~ted standards at certain points during used, the greater the .likelihood of FOR an~ ihe
pregna,."lcy. . . greater the associated perinatal morbidity'~d
mo~ty~s;6 . . .. .
- 'NORMAL IIU14AN GROWTll
. . .. . . .Jntrautetine .:gt;owth~s.b;i~ti.on .is .a 'flUlC.~
. - _ ,- :Three =t)~s~s- ~f'!eial ~ ~- ~ (lefi.liitioiih\~iled toidentify'the:sti~t()f:fetUses
. --eeu~ h.Yl>eiP.Uisill. -(:luttaoterlgS_. the -~t-}5 .. _. tndY. at risk rot
a,civet~ mtc(>~~ l>Ccit4~ of a
.- vied.ca oHetat'Ute. Fl'()m :the 16aa t:o the 3~- w~k, ho$Ule i:nttiniteri:lle en\>iroru;D.ent but wbt>. nmi
., :>tl\ct~ . is concurrent cellu-lar hyp~:q>ia$ia and ben~fit from intensive surveillance and tbn~ ,
.- _l,iYPcrttopby; fro.m 3.2 weeks till term, rapid cell delivtry. . ,.,
. Jl~~phy. 1-
Not .all fetuses that ~e_. SQA are patholo~ _ ,_._-
. . . -the-rate of growth h ,e:pp:rpxW:ratelys gJd.~.y-at growth restricted. Likewi~. p;ot all fetuses d iM .
; '.'i~'fP 't5weeks ofgstation to -JOJtda,y at:20 weeks have .not Ini!t their geneti -grO\"/.th potential_~ ui :_ ~
_and::ao to 35 gf day :at 32 to 34 weeks .a(ter~v.r:bi~ less than ~he roth percentile for ~stima~:fetal ..
-- ~~;;igl-o:wth ~te d~s~ r~chmg._~m weight . weight .(EFW). A-ccurate identification ai.XI1$ ~t.
.~;p,,.~ or,;-even .wei.ght:..ioss,-__.-aL41..:,42.;-. :\1ieeb;.-..1'b,e. only. at.mcdifybg.-an-ad:v-erse .C()urse in lUGRbut ..
-:~~w'D.:gro'Wth-ra.te in--m\lltipl~-g..t.t.atiorts1dower -.-- also _in . ~V.oidihg -iatrogenic. ~p.a.$ .a tnon'g --tbe:
--~-thaiof smgleton~during :t he :thlfdtJ.:ime$tcr;:l . healthy and a.tllong those -whos IUGR i:i: n~t_:
-- . ~ problems t\:l3U9:Uy beeoine ~~tin -the- -a menable to interve~>Ji,d~~. 7 - _
. third?triiriestei; when the n~e<l Jor sU:bsttates ''i s .
ry~in~t -- . -- Combining fetal weight e$t-i tnation_-''Wi.th.- - . -
I . . ':DQppl~r 'Sttlcy ofthe mnblll8.1:~ inlpro~~.tnc . '. .
: ~m:ct dating :of.pregnancy is c~sen..tia.l., as aCCUracy _o f -the diagnosis ~d tl~ to ~)b~:-:
._ ()9,qi~so~ iS made ~tw~en aetuat -~t an~ ~t m:etllog of d.W.gno~g-a.t\4 ~$o eveluatiJ:ij-thC..
.. ~eli. .weight, ..stratified ~Y -pet:Pentile$-; M a fehl$suspected"6fmt:tatiterine growffi r6sfii&Oii..
. . ,::}l:~cul~- age - ~f -g~station tbe- teter cnee:dr :~~;:;soo--'ort llio~~'tliiilier :rustillcti()ii~~
~~dard ~hart- has l)ee~ populat;ion.:based. there _
.. i_$' #icreasi.ng ndv<>Qacy though to use instead
. .cu$.toi:n.ized charts- those where the welght$.fac$>r Noqnal SGA .f etuse$ are _those.identified--''l:!Y,a
_. ~ ,~aterna:l height, weig ht. pa:d~y,. ate :a:Il4 negative screen for abnotn1al anatomy alid_.
:e tlfu.icity and fetal sdt. With th~$, the optl.n'J,al .ch:rom. o some-s, fetal infect:ion and -g~"Qetic .
. we~t -for the fetus is . ba$e~ ~n its O\V4 groWth .
s yndrome, :a normal \u:nb-Ui~;al - artery .l)()pP)er.-: -.-
i;)teiitial tather thah at ot the J>OP~tion:. '"rl)e stu~y and a nox:mal ap:miO.tic fluid volume .
--ap-.~1-ica,tion oi individualized fetal growth
Abn<:>rll1-al SGA are those with abnot.mal ..
;j1lt$'$dm1d curves results 'i n increased detection
:P.(mte growth restriction andin reduction in false- anatox;ily on detailed sonogra,phic examirlation,.
. positt'"\rc diagnosis'for $GA. However, more ~tudies . syndromes or-effectsabnormal karyotype, featutes of g~netk .
tire r-equired to determine if their Widespn<ad u se of fetal infections. .
.... . . ..........,~[-~:' . .
. . W'oU;ld . bnprove further the detection ot"sfuall
True intrauterine groWth restriction (IUGRl;is _
!~.1\ises at -risk for stillbirth in cbmparison with
identified in small fetuses bY abnormal umbilical
s~dard population-based curves.3
artery Doppler study associated with red-uced.:
. 1'tiE SMALL FETUS am-nioti-c fluid vol).lme,- largely from chronic . . .
placental insuffidency.9 -.-

. -.D~flnttlons
The term ldiopathic IUGR is used .for-_ :small' , .
- .The fetus is small for gestational age (SGA) fetuses where no ma ternal -abnormality is present .
when its estimated sonographic weight.falls bP.In'"' -h"t th-...-... ;n an abnormal fetal Doppler.1o
Scanned 8y: ~
 CHAPTER 43: INAPPROPRIATE FI:TAL G'ROWTH
According. to the growth pattern, . gr-owth
re.striction
.
may be symmetric or as:fm.metric.
.
The former is attributed to impainnent of fetal
.c ellular hyperplasia oc:Curring in the first or second
.t rimester from intrinsic factors such :as
chro.m.osoril!ii ab rtonnalities.. congenital
'ft:1idf9.rm~tiotui, andmf~tions. Ali thl!. feW o-rgans
are decreased proportionately. The fetus -has sm.all
head and abdoin:inal .size.
The latter, ~eanwhile, is believed to ~ an
adaptation to extrinsic insult later _in pregnancy,
when cellutar }lyperpla'$ia is the dominant process.
Co_m monly associated eon:ditions are the
hypert.ensiV~ :disorders of pregnancy.a..'ldplacental
infare:t.s which caus~ d~creaseq uterop1acental
perlU~n. Head .circumference .a nd femur length
.a re :riot affected but the abd:ominal circumferente .
falls Qf{ on :::<~rial evaluation.:z , :>
. . i .
Etl>IJu .
.......
-Miltemal, fetai and placental di~rders may
aftect:~dversely the ~ression and outcome tir.t he
.groWth pOtential. These .ca_uses reflect . -3 po.ssible
. me~!inis: 1) abnormal 'placental function, 2)
_-,:i~~degliate, maternal supply of ()~ygen and/br
nu~ts; and for 3) decreased ability of the fetus
tO .utmze the supply.h {Figure 43.L)
, Chromosomal .ciis.o.t:de~s. .and._conge nital
lnalfor:mations .account .for about- 20PA .. of...SGA
fetuses; .maternal v.ascular disea~e. ~he most
-conin'ton cause of IUGR in the non-anomal.o us
infant. for 25-30%.
. The fetus may be deprived of substrates not
only from maternal, underfeedi..1g but also from
mal!:l.b:sbrpt~on of nutrients despite adequ<.\te .
intake in case of intestinal disease or by-pass
~urgery. Lifestyle fac-t ors include alcoholism,
:cigarette smoking and use of 'illicit substanCes.
Persi$tent JAa,lemalhype>:ria may be <;l~~to hmg
.. di~~. cyanol.tHieartdi8-ease i;i.nd sev.ere an~mia,
or to:U'ving at high altitUdes.
Abnon,nal develo,p ment. inadequate perfusion
. and .dysfunction or placental vill.i are often
res~n$ible fe>r the development oflUGR. On the
other hand, pla~ental insufficiency may be the
.c onsequence, instead of -ca~ se , .o'f subqptimal
growth: oxidative stress, infa rction; -cytokine
damage and hypertension further' inhibit optireal
Scanned 8y:
., 653
. ~-~~-
~~~~:~{~J!~I
. ......~ ~. . j !;
. ~ ... j_;_. '
~.~i/~,. ')
~~
. . ..':'o.~...,._
.F.lcure 43.! . Pathop~ysiology of ~trauJt:~ growth
l"es~ction (lUGRl~ The _pOtential factoi<ii' I~~~- ;lUGR
iJlnl:l~Pee'the II\8.tema1 supply to .the.t~lusi.' ~~ty of
:the fet\is touse the.tnatemal. supply, .arid1~ ~~tal
functio:ll. 1f :WGR develops, there u"~,nubi~~.f~tal
a~tatior.s that mar-incur peri..'W.tal, cl'~~ ~-adult
: eft::cts. RDS "' res_piratory distress :$Yndru~ _Ntc "'
.necrotizingentQ"Oeolitis; IVH ~ illtravent!i~~;
.SIDS sudden infant death syndrome. (R~ ..With
pennissmn-fromSAGEPu.blications.)u -; : ;., .
.. ...~~!.<
... :
function of placental villi. The . respopse . of
pla.eentid villl .tc damage from hYPOxic and/or
iseheJriic injury may involve erratic ~ene$is
wl.lich limits the pos sibility of pla~~ntal
:te.:oYery.'~;l,
Cllnlw slgnlicance
Perinatal morbidities associat ed with fetal
growth res tric tion include pre maturi t y ,
oijgohy_dramnios. .honrea,ssuring fetal heart rate
pa tterns with a higher incidence o'r-cesarean
delivery, birth asphyxia, low Apgar score. neonatal
hypoglycemia, hypocalcemia, polycythemia ,
hypetbili.rubinetnia, hypothermia; apnea. seizure
disorders, and infettion.
. ~' .
SGA neOnates have high morbidity~d hig her
.risk -o:f respiratory distress . ~Yndrome,
intraventric\,lla r h emorrhage and ntcrotizing
enteror::olitis a t 34-35 weeks in a la r ge
r-..
~
654 :sECT~ON VI: ~QMP.UCATIONS IN PREGNANCY

retrospective study involYing 1.4 million Between the 20th-32"4 week3, the tape--
deliveries. 13 Perinatal P'lGrtality depends .on tna.r1-Y . measure-cjistance . betw.een the ~hysis po.bia
factors., including severity flf :growth :testclction, !llld the uterine fundus is equivalent ro age of
tinling 'o f onse~. gestational age, and cause of gestation in singleton p~~cy. The sensnmty
growth re:Striction. The lower the. birth-weight of this method ranges 'Widely l;>etween .28-8;20~ ..
percentile for gestational age, the higher the Simliarly, estimating fetal weight by aMominal
mortalicy rate. p alpation m.isscs.up .to 74% of the SGA'fe~
with serisiqvi~ .r:~g .R~tv?"~I1. 3:Q-WX.~ .Both
P-$stnaW. growth ap.d develo..p ment of the . method's lose -a.::cu~aqy when ther~ is tbick
gT9wth restricted fetus is influenced by the maternal abdominal fat, uterine n~growth, .
etiblogy Of restriction, nu;triti,:oh ID in:~cy and distended bladder, pOly- or oligoby~ and
the soclal envi.to:nn:ten.t. The L."l.dividuf.d remains multiple pre~cy~11 18
sreaU th.roughoutlife 'W.hen the growth restriction -
~
is .du :to . conge.n lal. vi:r.a:l. ch:rorno:so:tnal or A. recen~ 1','1CHD cohoti ~tudy found r>ut.fua:t
rna:~~.at~~ C~tc;l;l:.-up growth typifies' those pr.egnancy:..ass~ted plasi:na :protein A '(PAPP-A}
w.Q,o~~ .,gt!:>wtll r~sfr:-i:t:t~on is s;~ccm~atY. to < 1"'- .percentil~ and free peta hCG <ipC:n::entik
placental i:nsaffie1ejl:cy, .:Rew.er .develop~e,nt in: the first trim~ster were associated with
ptob~em.s ~are tro~ed am.onrt~ose bern to :f~es incr~:ased risk.of iUUR,. With ix>sitive ...predictive
ofhlghrS9cioeconoinic st2.tus th:an .t hose borp. values ~f'24~
.
l% ~d . :f4..3o/G.;
. .
res~r;ly.~
. . .
.to :L~igent fatiillies. 14.
D~gno1>is Of FGR
. iit:a:lY.:.:ep~d~ologi~.~-vl.a~ce, 'sl,tgg.~g
;an. ~~~~-betW~fl.,. S.~~;~~bitili:~~Wkcy. Qbmbiumg. data f~~. :history . .~a:p~ysicil
rui4~~.ri:sk .o.abticn;~:nai'l)l~~'li:pid~~.:. . ex~min,ati;()n with t:ho.se bom ~oi.u)graph.ic:
di~bet~~~- l):~~~~sra9' .. an:d 1?:heti1J:C':h eatt . ~alua:t:i?n.o~fuefetu~. p~~n~'~~ticfh?.id
4-i~se:in;ad;W;tlifeJecjliBatl.ce~~d~s.~s tO - .. ~$mi:the.:d}agb;o:srs .:s:tro.':hcltys:.~bli.Sh .the
:J~ro~.~:-~~~!.~Jitl."~~~s.::~~$~~~:S . ... ctiology .of ~e..~9Wth it~trkfu>il.~ .
. :. : ..
~~nlni-. . . ..:-s:Qnqg;~~Ji.ic. . me~~u~.e~~~i ...oi< t)l:~ .:J~tai
a.b;doptinal .c lFcm#eren;ce. {AQ} a:nq :es~ of
Fir-st and fore;nost, t:he ;;tCGu:tacy of the feW weight are the'bestpr~cror:s oft;ii:rtli~weight
g~ta&o~_;~~,_shqllid..lie..e.$.ta:blishe4:,.:1llnce.Jthe beilo,w.. -t~e.~--tO!h -,p ~,Fcentlle- in:-,iiigh.~risk
:o/eigh..CQ.f .the_.:fet:u~ ._:con:~med. :wil! ~~. comJ?.<;WesJ. .p:re'~cies: 21 .. ..... ...... ......... ..

:with (ef!ises offu~ same.ge~tational e,ge..:A.rellable

estipla:te'snomd 1:>e :inad~ :~1Y. .id~y #i .the ~first
triwes~t:. 'the ~en~trttat .his.~~tj :ID;ay ,~ .t.eli.8:ble
ifw.e11 ~ocutiH~nte<;t. te.gu~ar. and tivul~tt>,cy.,
c:tifferin:g by no Iz;tore .tb.a n 1 ..W:!!1:<: Iio~~ .th.e
sop.ognipp:ic gestatio1'}al ig<;. Qther-wi~e. early-
pregri;~.n:~y. ultr:aspu.nd-b'as.e~ .: a:g.~ i~ :w.:or.e
acct;lrate. 16
Q.h~. gQod d~tes ~re esta:'olished, :>cre~!ling
.proceeils ihr:ough ~sses~PJ.erit f o'r ris}c f~~tors,
meas'.lr~r:n;int .ef 'iundal height, . and ~dtn'i'cal
estinuition of fetal weigh~..
Allgravida? s hould be a:s.s ess ed. for riskfactt;>rs,
niindful of the n~me:t'ous co~~itions as.~ted
with F.GR. The ris k is als o 'incr.eased when there
is a previous SGA baby, the rp.o.ther's '.pre-
pregila+lcy weight i~ 1ow. the parity is high; orthe;re. .
is-chroni~ ;n<itenial Ulne$S. . . . ~ ' '
The Ae ,pred:q:~tly.-assesses livtts'&:eand
thusreflec;:ts glycog~n storage' ,a.l:id he~ .fetal
nutritico:al status. AC :is more reliable. the wni::::l
inte~al.betw~en n;1eas.~~me~~ts is mo~ ~two
week~. This W;;tsffitls:tr'ated.bj a.:stuqy :~ ;~ .
. ~'!-at:thefal.Se :p;O~~uv~ -~te~ f9rmter~~niip.ation
intei':Va1s of' otie, two' and Jour wee}ts Were . 31, 17.
and $%:, respectiye1y :21 / The tnea~u:rement has
be~ri. show:n to. 'be more 'S~nsitiY.e :for~t;ric
.group (73%) than in
symi:ne.t fic. {S9%).il th~.
sensitivity' and ihe positivepredictive:y.al~:SJ..f~9'-
3 1 weeks l4l ap.d 41% respecU:v.e~y} J:w.ve ~n
found increased at term to 88arid 71% .~
Ultrasound estimatibn of feW weight :(EFw}
g<i;nerated.. from CO!Ifbined measurelents of the
he~d (BPb or HC), AC; : apd FL .yie1ds.-.fue.best
. resultsi25 Yet~ i~ may dlfre.r from ac~al~~eight by
a~ mqch as . 20%~ The~e are
J.ntrac:: arid inter~

Scanned 8y: ~
 CHAPTER 43: INAPPROPRIATE FETAL GROWTH ' 655

observer variations in measurement. The malgin no~ ensue, such as in hypertensive disatders of
of error is greater in the l<;>wer and upper extremes pregnancy.
of fetal weight <iistribution and in the presence of
oUgohydramnios. Coun:;eling and remedial measures may help
in curbing unhealthy lifestyle habits e uch as
GroWth velocity re{ers to th~ rate. of interval smoking, alcol:iolism and u.se of illicit.substanc~s.
growth, using serial measurement3 tWo weeks Few fetal infections are treatable in utero. Treating.
apart. .R egardless of gestational age, the rate of the mother may .p revent transmission ofsome viral
charge over time of.the AC or EFW in FGR fetu.s es arid parasitic infections to the fetus but may not
is significantly lower thM .t hose of ~ppropriately treat the infected fetus. Aggres~ive mtervmtions
growing ones. Small fetuses with 11-ormal growth and intensive surv.eillance are not ptir$Ued if
velocity. amnictic fluid volume, and Doppler lethal anomalies are identifi~d prena~y. as these
v.elochne~ry a,re at low risk of complications may expose the mother to unnecessar:r '<Ianger. 16
a~sociated with FGR.26
. . Cochran~ reviews . have -shown no
.
Body proPQrtions- HG/ACratio, FL/AC ratio,. improvements on ietal growth restriction with
r
ilnd :ponder!U .ind~x .: .. have .also been used to stricthospiW b.ed rest compared with ~tion.
.identifY p~pula,rly the asymmetric FGR where Likewise, there insufficient good ~~t .to is
Uvet ~iZe tends .to b~ d-is.p roportionately small recommend maternal nutrient sup}Jleril~~tion,
com.pared to the head circ'l.llilference f~mur or
oxygen administration, p~sma volumeexp&n~ion,
leP.gth. abdoi:Ii:irtal decompression, and phlumac:ological
agents including hormone.s , ca,ICij:rm.:tfl;(nn el
.,, '' the'~'HCJAC ratio decreases linearly 'blockers artd' beta mimetics.29-36'
.. throuihout pregnaricy a nd a ratio gr~ter than 2
. :: ~~{.f.':i;
.'
~:. ~=,.~--~ . . ' ':<:'
... . :. .
S:ta.n~"'ti deViations (SD) above the mean for GA The Collaborative Low~b~se .AsP.ii'hi :~ay iu
~is con.side.red ~bnotmal. The FLJAC ratio includes Pregnancy (CLASP) trial, which fuves~;both
. ~ relating to both w~ight andiength and prevention arid treatment of .JUGR:~ ;$~~d .no
is .;g~tiitionalage:7~d~pend(mt. An FL/A.C r4tio changein the ,r ate oHUGR in ~ated and ~Atfol
:.~ttftlum .2 3.5% has~ sensitivity of St}-()4% patients with the admi'nisttation;,o r :66[rlig of
wid Weclficity of 74 to 90% for identification of aspirfu~37 .A more recent meta..ana1J.:sis9f.lltrials
asyrimietrlc FG~.P.28 fo:r proptryra:cti<: amYtrin therapy fo:und~ that
~-- -~- - . l:J:eginning~tJ><F't5o- mlttd-of a:spifi:rr1it"lBS"l.ll'~
- --Aft-c3:ses:offetal-..growth restri:ctio1rsht>tild 17 -~e-kS' ges tation decrea.'s ed the rn.te OC'WGR
undergode.tailed fetal anatomic s\,\rvey since .major by approximately 65% and the rate of -perinatal
c6ngenita1 anomalies a,re frequently a;;sociated. mortality bY: approximately 60%. ~n w.o men
with failure to thrive . Feta:l karyotyping is treated, the odd~ .ratio for lUGRwas 0".;82 (95%
. recQJ,llmertded if there are structural anomalies, CI, 0.; 66-1.08,) . .Am.ong tl).ose trjals in which women
FGR noted before 32 weeks or estimated w~ight were'
hypertensive or had other risk. i~~. tb,e .
below the ~3r0. perceP,tile or po]yhydrampios . risk of IUGR was clearly .d ecreased:38
(suggestive of trisomy 18) smce each of' these
findings is associated with ari increased frequency The role of aspirin , if any, in the prevention of
of karyotypic .abnqnna.lity. If the anatnnesis is IUGRremains unclear to date, warranting .a large
. highly suggestive of viral i.iUection, maternal sertl,m r a ndomized controlled trial using a high-ris k
should 'tie examined for evidence of population with a standardized treatmentregimen.
seroconvet~itll'l'; 2 .. '," ' . , . ..

Ante~artum Management
Etiologic m.anagement is difficult since many
of the cal,lsative s::onditions ar.e not amenable to
therapy: genetic, chromosomal and Q.evelopmimtal
anomalies. Even when treatment may alleviatethe
II).aterrtaJ status, irnprqvement of fetal growth may
Antepartum Surue.illance
Fetal ,nortitoring ~ growtll disorders aims at
delaying delivery as 'tong as j,ossible tQ. achieve
fetalmaturation while a'Voiding ad,verse~uelae:
at identit'ying those high risk fo.r in$uterine
demiie and thus would benefit from geliv&y, albeit
pretertn. . ..

Scanned By: ~
 856 SeCTION V1: COMPLICATIONS IN PREGNANCY

Monitorio.g protocols include biometric tests Diagnosis ofll.J<3R at ~32 weeks

to measure size and biophysical tests, i.e. Doppler
studies, AFI, NST or the BPP~ to assess fetal
wellbeing, specifically, ruling out fetal acidemia . . .. l
I,Jmbillcal arte11: Dopple.r
~
~
~
elivar at fenn
The distinction between the two sets of test direets
and BPP weekly .
that the ditignoSis ofSGA would rely on.biometric I
. te::ts while abnormal "'Qiophy$ical tests a re more l ' .. '
indieative of dysfunction in ~GA and therefore Reverse EOF Absent EOF -Oijg_o N.ormal
J J. : J ~er
FGR..2,16 :...

Ser:ia1 biometry .i s continued.:ttt :t wp to to.ur

Deliver ~ Delivery T
weekmtervals. the likelihood ~.IFGR is s~ppPrted
I
Delivery
~33. weeks
1
.D .1 .. ;11 ep
a1y u . P
by persistent ~uboptimal ma~ments~ Results t Deliver if
$hould be plotted w ~the progress ;of growth Dahy full BPP abnornl<)l
:or lack M it.. .Also, tb.e A,C ,or the sonographic Deliver if BPP :>6
.es~te'$ of ie~ weight ttrl.ght be ,abov-e. the .l.Oth
perce:PtUe but wh.e n .compared. with the preVious Fi~ 43.2; Samp1e protoeolfor evaluatii:mand~ent
m~~t; pic growth eu,rv~ Jot the fetu-s is of l~GR !Uter 32 wceb. l:(na,ge rep0r1tel:l w.ith per:mi$Sion
from ~M'!P.iclne.co~. 2Q08 . Av;i.i,lable at: http: / l
fabipg.
. . or is bed)uiin-g. a ~plet$1i.
off . .
WWV.\ et!ledicbe.com frr.~(r.OPI~247,fi1'M.
. . .
Uinbili~ artet;ial l)o.p.,Pler $0il9graphy 1s t.'le
c_urreil~ :~:ta~dard <Q.f . pi:ltnaey teat . in
~l':logmp}iictdJS(c:JO\.uiicm~;:.~Wh~ri:strittion;6 inworst.co,ndition.:and!.:.d eatlt.'is::i:l:nipjj:rent,when .
~ :Wh~ti;the-::l,;')oppler,t;y.stQ:lietdll.:sto.liC;.rS.tio..-.ei:ilains Doppler:abil,onlUilitie$ .C:Ve.;o.b~rved in the venol\s
"'N.i~~ortJJi~i~ i()rdbes~not.~~vely.ris.e, ch:'ctilation ((luctusvenosus andum;bilical vein).41
the ~~~~ :mainwn..e~h~~~~UQwed,up With . . . . . . .
~~fitls:shP.Wd_:$\lffice:. #Jth.:tPcN.S,T,Qt_:a.PP Tlie bio~;>by~iC.i;il profile..(~P.P) ~xami:q:es
a~ . ~p;-.~~. bi~.ot:hi~~g;~~:ind~ . niultipl!!! ~cute: ,an~ ~ cbpmic.;:'feful . j>.hysiologk-
.w.~tli.;-"'MQ~ . .4ltf!t).1ii-V~ -,fetil:1 'i-tr}irvelllan:ce panuneters:(ainniC>Ucil.uid \f6l\une, noristress test, .
:coiisiStlb:g'Or~:i.Un.'blu~;~.,J;}O.pp~:aind' fetal ix!.a:V.eiilentf.ton.e /l>rea.ti$g) far eyidene>e of
:c>nce.: .f>t-:'~~weeJcly NST- a~?-d ,~rp, ~tn tetal hypona. u .ia usu~ly perl'onne<i .priee u~...tWice
nUiturltY..-} .:sample-:.pi-Qti)Col$ ~is-$bQWJl-'iJl-~~te weekly. More fr.equ~nt t.~st;ifig i:. inlli&ltearor
43:.-2. ... teto:~g arhlgll~sr-nsR;mcufdffiift:>urn:onrniited
to, sev~re FGR {less .than the :fl{th ~qentilch
Th~ t~mt>Onu sequ~n~ of nhm~nnai Dnppler severe oligd}iy(iJ.:anuiiO.S; absent or .reverSed .floW
ebangeS i rt ~e ~dphc:iala:nd -~ti$i circW'atory on Oopp.i et velochnetry, or .equjvbcal BPP &CQre
systems ~f':~e udWth-rest,ritedtetUs :}lave 'been (Le., 6i 10). . - .
dSciril,led: AAr.iy,~bnotUlal :DQppl~r fin~gs Jnf ue
i.unbilitil:i$(l.~ddle:~ri:b.rat/~es-are..folloW.ed. Uick:lpg benefit rom ~d<nnized trlai:=$,o SPP
:or
\Jy revet~al now in the ,(l\ilus venosus .or i~ . n~netheJes~ recobi;D,l~hi:;led pt#larY when.
pulsatile v:mblli@ v~nous 'f10W. >40,u.42 sutveillance with umbili~ar:ter.YDopp1ey is found
to .he abnormal because of itS good negative
Absenc~ or teve:rsal p f .e,~d+dla$tvlic .flow i1.1 the predi.etive v.alue in high':rlsk popu1atipns. This is
. -umbli"ical artery . is sug.gesti:ve of .poor Jeta l further corrqborated l?y evidence that-in ~gQ.~risk
copditio~. whereas nurn1~ or sUghtly dec-reased women, the BPP was rarely abnormal . whe n
umbilical Doppler flow is .r:a,rely associated with Doppler findings were normal.6
sJ.gnificant.m orbidity and provides strong evidence
o( feW well..being when. delivery i$ dl~ye.d to , Amniotic fluid volume assessment is critically
~c4ieve.fUrther fe(:ai mat;urity;a. rhe. oddsratio for imi>ortant. Perinatal de;:tth rises sharply when
Perinatal mortality ln pre~anies -complicat~d :by FGR i.s com.p licatec:f b y oligohydramnios.
. al;)se!lt ~d diastolic flow ..(A$0) and reversed"end Conversely, normal amniotic. fluid volume is less
.diastolic flow fREE>.) wer~, 4.() .a~d ..~0.6, frequt;ntly .a~sociatecf .With. .either FGR or .fetal
"respectively; com:P"iired withwheri ertd (iiastolic . demise, unless the cause i~ a congenitai
flow was present. 13 The growth restricted fetu's is . malformation or aneuploidy:

Scanned 8y: ~
.

CHAPTER 43: iNAPPROPRIAT-E FTAL GROWTH . 657

Doppler studies serve to detect cardiovascular strategy in fetuses with AED/RED is u.nclear. ., ..
deterioration while the biophysical prqfile reflects Options jnclude daily CTG/BPP and/or venous
the behavioral manifestations of fetal hypoxia. Doppler. Delivery is. indicated when the CTG
These signs of compromise ip. FOR fetu~es can becomes pathological (deceleration's with reduced
o.ccur largely independent of each other hence the variability). the biophysiCal profile becomes
possibility of discordanee ~tw~.rl t)l~ir .res~lts. -abqormal (~4), there is r-eversal o:f Doppler.
vel()cities in d \.lctus ven-osus . during atrial
Finally, both :1pontaneous and in4icated contraction or there are umbilical v ein pulsations.
preterm deliveries ate more common in growth . If gestation is over 34 weeks, ev~n if other resUlts
.restricted fetuses. Laige stuQies on the efficacy of are normal, delivery may be COnSidered. MS;~
antenatal corticesteroids in the Di<Vlttge!llen.t of
tbe pretenn grolYth restricted fetus show The interval behve.en first occurrence of AED
conllicting results. Until the c()ntrovriSyis ~ttled, and an abnormal CTG/biophysical profile has
it would ~ pn:i,dent to administer a course of rang~d from 1-26 days. Gestational age, . the
antenatal stero"ids when pteterm delivery looms presence of hypertension. and venous ncppler
in. the FOR pregnancy. (l.bnqrmalities {notably pulsatiorts in the umbilical
vdn) ..are the key prognostic faCtors af{ecting this
Tlinbig of :P.eti"e~ intental,-47 Doppier study is.txtended to the venous
ci..-culatio.n in the effort :to b uy more time for the
. . _ Pregnancy wi1tl FGR is rulowed -to :continue for Jetus. Amniocentesis m:ay_ be 'helpful in
as lon_g as fetal growth continues and fetal estabUshbig. fetal .lung maturation. .
-evaluation results are within nonnal.
A recent tntllticenter rando~~ -C:~il:trolled
The.~term or near-tenn growth restticted fetus trial, the Growth Restriction Intente.tit ibltTrial
is.de~vered i1 no growth is .a ,pparent QVer a two or . (GRI'11, compared two strategies: .'&ii~e~~thin
four-w~cl.jr.:tetval, the biopby$ical score .i s low 6
48 hour~ with steroid administration .or:d~livery
:with.uug()hydn:un.tlios or nonreactive NST; .and/ . de:!;w~as lo~g as fetalst atlls .Pe.'tJfflk~~}~~~ ~than
or.rumbiliciU arterial Dopplet velocimetry reveals . 90 Yo ..of the. women had, pregnanq~.:C?PIARg~t~d
absenCCJor reve~ of flow. by FG~. No signifiCant differenc:e,s.:
. . .. .... -:Wer~~noted
~ ... ....,. .. ,..' ...
~, \ ~ ~

between the 2 gro~ps in stillbirth. rat,ti~.':' The

Tbc lntllti~~p.t~ ttU'D.1Gl'l'AT is -gather.itlg _ population consisted .of high-risk . gra,v.ic;las
bet-neen 24 and 36 weeJ.<sgestAtion. 4a - _._ . ..
eYid.tllc..e .:a~...t9 ..whlcl:l.~tr_ategy_J~.tb.~. .~-~t.. .wb.~n
lUGR..at.tetm..Js_susPf<(:.ted:...__w.hether~_to_.:iil.duce
labor or to .await ~_l)Ontaneou;:; labor under st,rict lri&apifrHim -ra-anagement
fetal and maternal tnonitoring. Pt.elihllnary data Growth-res tricted fetuses are high ris k for
from the small pilot study in participa-ting asphyxia so they should be delivered in a facility
hospitals s~ow that the interval between with neonatal expertise and facilities readily
-randomisation ,and labour was two -weeks'shorter available .
. .and birth-weight w~~ '100 .grams less ili the
pregnancies that were directly'tenni.nated by Current data are not sufficient to justify a
iridu ction. The results of the present D IGITAT trial policy of elective caesarean sectiop of all small for
are ~~d in 2009.~ gestational age babies. Any confmned signs of fetal
compromise indicate cesarean as the optimal
Remote from term, !he riskof intrauterine fetal mode of delivery.49
death mus t be: wc iighed ..agamsi' the h~rds of
is
pretenn birth. Observation recommended when If the patient is allowed to labor, continuous
amniotic fluid volume and fetal sut:veillanc.e are electroni'e fetal heart rate monitoring should be
:n ormal. WheO: end diastolic flow is present (PED), used. The ability of the fetus to tolerate the uterine
delay delivery.. until at leas t 37 weeks, proVided contractions is likely very limited. The: frequency
other surveillance .findings are normal. of nonreassuring -fetal heart rate p@.erns is
. increase.d . Variable decelerations ar~requent
When end diastolic flow .is absent or: reversed, . .because of cord compression iri olig()hygranmios.
admission, dose surveillance and administration Intervention should be rapid: if there is any
of steroids are required. The optimal surveillance evidence of fetal intolerance to .tabor. .

!nanned By: ~
 658 .SEC"TlON VI: COMPLICATIONS -IN PRE<?NAN9Y

A .systematic review of nandomised triaurfoun,d fetal trauma, uterine ;atony~ postpartum

that continuous cardict~<igraphy during labor.is hemorrhage. Maternal and perinatal risks
associated with a reduGtiop. in ne<;matai sci:wr~s. increase w ith increa~ing fetal siZe.
],nci-ease in caesarean Se.c tions and 'inst::rumen,tal
v:ag:illal births and rto -signifi~t dllferetit:eS in Reeent:ly repOrted.-wereperinatal and postnatal
cerebral palsy, infant r:nor:(:aiity or other standard .info~tion. of 3356 :women ~he deliver:ed during
measure~ .of neonatal w.eU:-bein,g. Substa~tial a: 10-::year Period.- a macrosomic fetus {>4500 g) in
b bser.vational t:ho.u :gh. sugg~st tha t .'dp.t~. v~rtex pr-e~tation., 2371 of.whom were~~.dmitted
int:rapc.rrtt.un CTG in high""~* populati.oiis ~ likeiy to spQiltap.eous.~bor. 776 \ID~etwent an,inchic:tion
to ~ ,Of benefit 41 red1;1Ch').g peri!:tatal deat.'l;:;o.Sj ofli:tt>or, a_4d.207' ~.an-.ele:tive cesarean ~n.
All ease~ of :shouideidyst9cla:(n""3.10) ~d braclnai
~HE LARGE :F.ETUS pl~sinjucy{~4} ~ired ~ong womeu wlio
'delivered. :vaginall;y--: The ~~e .o f bra~ plexus
Def inition .~uj.ur'y 'W!'ta hlgh.er in c.a ses .who ll.ad ~bOulder .{

d~~tha.."l}n.th~ who did no~ {S8/3fO W-sus

Fe~
macrosqrrria 'P,i.s. ~~rt defi.ne.d variabJy 3q{2g29. P.<O.<'X)l')_ Th:e .incid;ence of'bni.chlal
a:~ having-a ,b irth w6ight:Gf ~~'8; 4. 4.5 or 5 kg.. The, plexpsiJ?;jury:incr.ea:s6;1.ste.adily from 0.8 in fetuses
riiq# ~in'onzy use4::.$t'eih:oldof4 :kgt~~ts weighing 4500--4599 g tq 2.'8q.%:1n ihosewe.ighing
. the ~00. cent& at .40 'w~k.S P.f st$.1Aard ;_grQWth :more:than sooo :g.f.P<O.t;.H) :3:riP.from2.1 in women
.c harts. ibi's . is 0hsistnJ with ilie itefuiition:of t;ali~rtl:i.an l~O.ipl tn l 2 .:S% in those :sbm:~r ~
l al:ge ;tor. ge~ti9nru':1ge. {ht1-A),. ~~ :i~ ~Vi;n.g 15:5 em.l:P.~O.O$V
.an. aii'tetiata:l weigl:ft iitboV.e . the. 9{)th .eei}file. ~- .
. . .: . ;~. ... I ' I . ' ' - ' , , .. : ' : : _. " ' ,
0 1

: W#ght esti.l;il:atlon m.,]$ge;ba0ies.~, ~~: .

:b.eeri rtaugh'{witlr~ Uliill~ ~tes .-~~tatelJ:la1 P,yper:glyc;enf,i~is believcifto :ind~ce
.i;i:r~ :v.;eji.1t ~.p1~/$a~;1p~I. ~~~~n. ~d ... re.~ .4~ftly~ an:a.~hYP~sulinemia. TP;e
iu;rid'~::li~~gh't :tn~r~~n~~ ~.th: . supject. tp f etus .u:~s' th~~e .:amou~t-.of::glu~S<:-and
c;;k~~o'ility'Ul~MCi~eVii!Uatiohoothe ...am1nd.~acid;~.~foyg~~Yi;tb... ~r.. tn:sl'ilii:l.:-~e:D.Sitivc

. .:.s. b::_:~.-.:~~_Wrr.r-~'-.:".:.~.leno':~_.? :~t-~oihe

,1.n .c..~
. .. :_-~ar:.:._"~-~:._:n.\:'-~-.s-~ ~ ~_e.-.~~.:.~a.:u~'e =_:.l_:'U.,~m_!a_, .:_~_t~:a.~~
~ ~-~~ -
;. .._.b::_ .nL_. ...! .r._
..
. ;J
. ..:... ...
.t.e:U
.-~-eo_:_t: .ai~~ ~;:~ ~;;:d~;" =~;,:r'"~t.:~"i::cr:~<l
.. ....

+'
_
.
.
sq.bc.~J:im~tlS '(at.' 'P~der-*n'<5:. fiJ'lP.9_i.}i!#ri3W~S ,
. ~eigqL!~JLt:ectk.t i~tat;dis.b.mia_.shoW.s.:.l.t~'S% .. mu'<1i:l'i:d -~toti<:>whig--r.ecc.rgn~tton.--th'\3:t':"o~tne"f'
.:~Rsiti:Y.i.ty1 __,8~t:'.9..6.% -~~pe~ficicy;.. $.8"'67'.% -:~ siti;ve nuJ:ri.ents--lrave-l.ncr-e:3\~eirno1r<:entia:ficins:. 1n
:predictive valu~e 1:\;nd. '8 '3 ;:9 :1:% in 'tl}e g~~~i;al di'ab.ettc . 1Jati~~s ~:u,d.:thei~ pre~en~~ .al~o
;populati9n.; '4'8%, 95%, 77% $-d- 84~ ciia..b:etic .m .co'Q.ttib?-te.to feW, msuliJ::iem.ia...l
..m.ethU:s.2
. Fe:tal .~weight _~correlates 'Yith glycemic . ~ntrol
in :p:Fgnincy .:comp:li#tt{!d l!Y. ,dial)ete$ .meJ!itus.
-~g~::et'.al~: :pro~.~v.e -~ ~~Y ~how~ tw<r.!old
Whi):~ ..~~- co:Q"9,iijqp ~. Cl?~Q~y ~-px;iated inr~se ;tn :the .mCiden~ ~f ~A:whifl the trrean
wif.tlr' maternai di~1;1ete:s m~1\itU3; :Iii~ttnsom.ia plood. gr~~se level d~tillg pr;t_gnartcy was equ_al
Qc\lr.s ~~o ;Wit;h pP.s~tl).i:jty, 'IP-ttltipai:ity -~d to or g'r~ater than lOS m:gjc;H (high. ftrol1-p) and
Jliat~i.n~o?t~itr~ JAt?! m,at~m~ ~g~;.m:ile i~nder signjfiantly higher- incidence of SGA in the low
.of :fefu.s; preVious paby wdgll.g th~ '4{iO.O more group (less tnan. pr -~qu~ . to /86 :r::p.gj dl) versus
g ,are additibnal 'f isk '(actoI"s 'as . at:~ raCe and controls,~
.etb:t}idty. It sh9uld ~- r.e:Inm'ber.e4. how~v~., that
altho'Ugh xp.~terU;a~ <;l~ge~.s. al}4 oz;are g~n~tic The. itid~nce Pt ma.cro~0mia is 3-7 fold ~ore.
syridromesmay ~ fu.e cal.iie .o f }g 'fetal s~e, fr-equent _:i n postdates. th~n ~n term deliv~ ry.
.mo~t c(}f these pr~gri.I?Jlcies will
. in 'iac:t
. he. nOrn:tal. Contrary to popular belief, the majority o f ,babies
delivereQ. posttern1 do n <?t s~~r from dysmaturity.
. Fetal.-macn;>~o~~a ~vokes anx~~ty ~mo'Q.g R_athei::; growth COI;lfu;lUe S apace m many .o f them
clinicians because of the diffi.c\lltles .encountered .and -reaches maximum leels . ..'f:li:e increase in
in deli~ering larg~ babi~~ p.rolD.n ged labor, >- body w~ight is ~ue to cdlui.ir hyp~rtrophy.'.an~
difficult forceps, shoulder dystocia , m atenipl and -~yperp.lasia in -most organs. Ther e .is .mor e
. .

Scanned 8y: ~
 CHAF>TER 43: INAPPROPRIATt FETAL GROWTH
extramedullary hematopoiesis .and increased .
adipose tissue but not e<:tema.-sA
Diagnosis
(
Three methods of identifying a fetus weighing
equal to ore more than 4000 g are clinicai,
maternal ahd sonographic.
The measurement cf the fundal height in
conjunction with Leopold's maneuver and a review
of history for risk factors are standard procedures
in the prenatai ch.eCkup. A fundal height_that is
"3 "-4 em larger than the gestational ageOf.the
pregnancy in the third trim.e ster ne.Ce$-Sitates
further in-vestigation. Aside from eieessive fetal
gro~. the differential qiB;~Os_js includes wrong
datea, .hydiamriio,s, multife.t eJ pfegnanc;y and
\lterine t'.lmors. Prc~Pe.ctive studies de~igned to
eValuate l:,eopold mane:uvers With fundal height
mea..surem~nt for the pr;enatal ..dii=i.gnbsis of
pos.sible txiftcrosooiia r-el>ort sensitivities of 10
43%, ~pedficities of 99-99.8%, and p ositiv.e
preqictive. . v~ues .o f 28-S3%~ 7 .s_ .
. .
. The ~nd methcd involves asking the gravida
bM.ed oti~:lier experience with a pregnancy to . n:.iotbidity was not differe,nt .bet:Wee:tii;troup_
approxtm:i~l;.:-fue weight or the tenn .fetus.9
. - ..
~
Ul~SQn9gtaphy is the primary investigative
tool. pit>yj.dWg .direct; inf()mJ..atiQn on the cause .of
d.\~p.an:Lwcight- .:rhe;~study. ...oC....Jazayeri-e t-al-
showed.that.an .examination-within .1 -2- weeks of of cesarean""deliveriesto-vertOOo''foi'filin:aia"Detics,
delivery showing an abdominal circumference 9f
35 .em or larger should a lert the clinicial} to
anticipate a fetus with a birth weight of 4000 g or
more. lO Ultrasound biometry o( the feW head,
femur and abdomen in some coiribi,nation together
with regression analy3is ean predict the bit#l .s ection . ()r instrumental delivery, and perinatal
weight~H Beri-Ha,roush, efai. reported that
ultrasonography in suspected macrosomic
fetuses, tad a sensitivity of75%, specificity 65%,
positive predictive value 57% and a nega tive
preclictive value of 8 1%. 12
. '
Chauhan, et al. stress thatthe three methods
would be reliable if the ln~idence of macrosomia
in the..cohorts is at lea.st 20% (th~ reported Gynecology recommends abdo.minal delivery for
incidence Ior the US is about iO%). According to
them, with the post test_prQbability tha,t the fetus
suspected of weighing mo.r e than 4500 . g, the
newborn .is more likely (68:.88%) to weigh less'than
the thresh old. i 3 .Indeed, the definitive diagnosis
can only be made after delivery .of the n eonate.
Scanned 8y:
'659
Management
Naturally,. physicians are afraid of the
complications of fetal macrosomia. Hence several
strategies have been proposed as prophylactic:
elective induction of labor~ elective cesarean
section and prediction of shoulder dystocia.
Available evidenc'! to date suggests that planned
interventions . based on estUna;ted (etal weight do
not reduce the incidence of shoulder dystocia and
do not :d~trease the adverse .o utcomes arising from
fetal macrosomia. 14
The Cbchrane review of trials, .,a-ssessing
induction of non,~be~ wo)ll.enwhen their baby
was above 4 kg~ show~d no evidence of any benefit
in tenns of ~esarean . sec.tion or i~strumental
births, or.inoutC::o:Qles.f.orthebaby . .Ho'weVer, these
studies were too sniallto ~ sure ofthe outcomes.
There, js a s.in.gle random;ized coi;\tr.Qlled"trial
comparing elective delivery wi:d:{exp.~ctant
management at term iri pregriar.t womeQ.>with
ins,\1141-requiring diabe.t es. It :Sl'iowe(l.'biat
induction of labour re4uces the risk of
macroso.xnia .. The .risk of maternat or .; neonatal
ii,bP.t.
:g iven the rarity o'f maternal and' Ttei:ih'aial
'ikclud~d};~ll~es
morbidity, the number
~ .
o f wqmen ... . .:.
. ~\ ;
not penrut to draw firm con~lustons. 15 16 .
Stuclies have-shown-t!J,a.t=~~~s'!;i\re--rtu:moers
over 100 for djabetics). at s~ggering cost will ~
required to avert a single petmanent ,brachial
plexu,s. injury. 17 Compared to expectant
m.anag.e ment, inquction of labor for suspected
macrosomia did not reduce the risk of cesarean
morbidity was similar between groups. 18
Controlling for confounding variables , one
investiga tion showed an increased ri sk fo r
cesarean section pr~gnancies where macrosomia
was suspected, and failed inctuc tion accounted for .
the difference in section rate. 19
The Ame rican College of Obs tetrics and
diabetic women. whose features are est~ted to
weigh over 4500 g. 20 -Antenatal predti!on is,
ho\Yever, impreci~e. and L~e evidence to d_~te does
not . support intervention" in "hond1"abetic
pregnancies where there is a suspicion of fetal
macrosomia.
~
 .660 SECTION VI: CQMPUCAllONS IN PREGNANCY

Pregn.ancies complicated by feWl matt<>$9nlla and .o ther pertinent factors .should be taken .into
are therefore best managed expectantly. The aCCOUJ;lt when deciding on the mode '.a nd tj.mhig .
pati~t's o bstetric history and risk profile, the of delivery.
clinical pelvimetry findings, the progress of labor

PO!t'ffir'FO REMEMBER

ii:lcntificafi911 of growth -disorders is premised on -correct:dating of-the pregnancy.

&N!H~ gestationa1 age f etuses- thi;>Se :who.se weight ~ll-below the..tottr percentiJ~ .~.inctude notmal
ai)ti abnormal 'fetuses.' D.tstirictlon i s.po$sjble through ~~retuf'histootal survey for iislc factq~. -d~tailed
. s(>~raphic
., .
~X:aminciu6n .
ol:anatoinY, kar}rotyping and .bk>physical . tests.
.

The -~ ..f~1 growth r~mction:(FGR) iS. ~pproptiatety u~wnen :sman f~tusis ,shoW evidence tOf
c:ll!Pt\le :p!~cei9talinsufficiencyon.
. . . .. .. .umbHiq;f,sne;y Dop~er and::amnioHc
. .. . . . :fltiid vo1utn:e:
. _.
.
. . . . . . . . . '). . .
";, Correct .iqertJiticatioil of th~ subsets is import;mt:to avoid':iatrqge.nic h~nn;on the 'healtny.SGAand .a no
-. ~, -~whO WJll':not benefit'ttmm mtei'Veritions :antt tcn'nodif{the:adve::seoutQbrrie tor tnosa '.With tn.Je
.;.:-.-~:fa~1g~1tilf.est:ri'ti0n.~~-- ' : : . . :
-:. . . -:-: . . . - .- . . . . . .
~ . . : .

.1 - ~r~~n_cx-witt;_ F~a J5 .att6w~'t6~ ~n~: fur as 'ton~ . a~ 'f~~Lg'r()\l{th coh~ues ana 1eialevalu:auon . _.
< .. _,. resui!S are.w11:hm..nonnaL . . . . . .

{ .~,:~. ':;:,f.~ . ~~mia;n~sbeeri~efirii~<rvanao~~s

. 'I<fbe" . ed 'ft . .. 'f . f .
'havil1ga:
.
bj~
.
v;~i~htof
. .
.3:8;. '4.A? ~, 5 .kg~ The.tenn .
.. . . . .. ..
: .. : ~~-.: :! . ..~~.f :..)~- - er.b.trth.:o :tfie, etvJs.. . : . . .. .. .

.T~e:rnb~t ~mrnf1lyl!sed 'th'fi=SMid ~f.4'kg :fqr.macro.s0mia ts ronsj$tent v.'fthtn~ dfih.ilj_Qf! .o f 1;3,rSe:..

fo.r~tional..age - (LGA):..- havin,g"an ar.tena-talwefghbabove ' the,9QtlrcentHe; :Qf~taridarogr<i-:m
Ch~rlS~.:::at::4o-we-eks. . - ... ..

Maf~om!a'>oturs not only with maternal diabetes mellitUs, 'but..also wlth po!)'trhaturtty, m;.iltipatitY
and mcit~rnC!l
. '
obesizy.
.
. .

We'ih(predi,~ion
. . .
.in. large. babies .is quite iinpreci~e
. .~yen
. . .'sbnologiq3tly.
. '

g1i1ence to :date. d~ notsuppbrt intervention in no~--{:liabe.tio pregnanc'ieS'Wh~re .,thereJs a suspicipn

. o(fetal macrosomia. . . : .. . . . . .

~cES 3. ~en P~ Ogiili J~ Baa1u1ume LM 'et al.'.i>rediction o'f

intrauterine grow:reStriction With custbniizcd citf;na ted
fetal w~ght centiles. WOO .2003; 1i.9:411 -41_5 .
THE SMALL FETUS
4. Vr~chriis N, B1?ts'is b, rliod.romiti Z. the fetUs tha~ is
.1. Lin CC.andSi.lhtoly:i_.Forgas J .'Currentconctpts,offetal sinall:fOi- ge'Sta#onal.a~e. Ariil N Y.Aca:d sci 2006; 1Q92;
.grow$ iesfrictio~,~ Part L causes, ~lassifi~tioh. and 304--309. .
path9,p~ysiology.Ob'stei-G~l -199~;92::IP.44:... . 5 .' MM.~g":FA.. General principles -ab.d app&ati~ns"ot~
~trasortpgraphy'. In Creasy RK.a nd Resnlk ~R (eds):.
2 . .Re~rillc R. Intrfl,uterine.gr.o wth restrlctio'r.i. Obs tct Ma:ter:ria,l-feti'U Meilicine 'Principles -and P.r.a ctice..
ojp:ecot2002;.93: 490-496. .. . . Plu1adelphia, Saunders, ,2004. . .

Snanned &y: C
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6 . Royal College of Obstetricians and Gynecologists. The
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ges~tb~-age fetus. Guideline no. 31 November 2002.
7. Baschat M. Pathophysiology of fetal growth restriction:
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8. Ott WJ. An update in the ultrasonic diagnosis and
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9. Tlm T'fi' and Yeo GSH.lntrauteri:l.e growt.'lt:estriction.
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20()4; 16: 6.
17 ..Neilson JP. Symphysls-fu:ndal ~eight mea,suremept in
::pregnane-; [Review). Cochrane Database Syst Review
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detection of intrauterine growth restriction by
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Biochemlstry and Fetal Nuchal Translucency (BUN)
StudyGroup. Associatioo of extreme first trime.ster free
hun1an chQrionic gopnadotropm - beta, pregnancy
associated plasma protem A and nuchal ~anslucency -
with inttauterine growth restrictionj and other adverse
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23. Sim~n NV, O'CormorTJ and ShearerpM. Detecti9~ of
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2 4 Feram E, Nicolini u, Kristema:p. A and Pardi q. Obstetric
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6.62 SECTION VI: COMPLICATIO.NS IN PREc;,NANCY

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CD000109. DOl: .10. 1002/1465l858.Ci:XXXllOO.
46. BasehatAA. Doppler application in the delivery tititing
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CDOOOo~6. 001: 10.1002/14651858.CDC~0036.
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3S._s.;i.o~~g~u../.M, a.o~eyrdJ. ~~t:m h~pitat abn~rmal heart ;rate patt~ afterert<l"-diastolioveloclty
. for aus~ impa1rea:fet41 growQl(RemwJ. CoChrane in UI!ibilical arteiy: analysis ofrislc factors. Am J Obstet
D!ltabaae ofs-ts~tnati.c Reviews 200$,lss\le 1. Art. No.: .Qyneco11~3; 168:4'3-50.
CP000034. DOl: 10.1002/1465185a;eDQOOo34
48. GRrl'.Study.Group. A randomized trial of~ed d~very
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\;~- (qr ~ten~ ~p-a.ttea fetal gtow.th (ReViewj. Sayeaian interpretation. BJOG .2 003; 1'10: 2732,
_C~.P.a~~se otsYtetAatie ~evis ~098 taaue
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b9:t>y JRevie.w). _C oehnne D!l~base of S ystematic
~1: <:~_r;atiY.e r.ow":dos~ A&pifiA-stildy ih P.regMnci Revjcws 2001, 1ssue 2. A:rt. ~o.: CP000078. POl:
' ~llvc. OtQ'Up. a ran.dorriiscd triid cNow-dcse 1O.l002/14651858:CD000078.
:a..-~irin .ft:lr t.he .p.rev~n.tion: :an_d trea'tiileJJ.t -o f p,e-
eelamp'Siq. .!lmong -9364 pr egnant wo1];1.ep. CLASP -
50. Alfire<vic Z, Oe:vane . D-. Gyte GML. ContinUO<IS
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. - ' O:ilhlb0ilitive~Qr9ti~;,~c!!t.:..199!\<:>~a::{S898)f:fil9-'
- ' 629~ : - ~ . . : . . . . . . ... . . . . ~onitorln$:' (EFM~~for-..fetiU:as~i'ijjlent-.dUring. Jabom
.(RViw). ~e . i>~tabase 'J)f .Syst~tic: Reviews :
38. LeiticliH, ~er :c._ Hq.ssleit;l P, et a l. .-~m.eta~~$ 200Q,-lssue 3; Art. No<: C.DOQ61)66._.D01: .10.1002/
~1>1~\d~1iSpitiJi for ihe preventio:n ot:lnttaut#me ):4651-8$8 ..
'"~~bn.::!~r,J '0Wtet G~col l99't; l04:
i45Q-4!?~ -- :. : . . . . .. 51. -~ornb~ckle J, VaU /'., Al;)ram!lKR; T}lomt'(ln. JG.
. Be.y.esian-illterpreta:ti~n ..of,trlals: . th.e ~ple of
'3'9. /l(ra~er WB.-.Weme:r-CP~cMiiiJl.ag~ent '-bf~~uterine . .. .intr-apru:tum.ietal heart -rate .motor.ng..BJQG;.~()OO;
:~ testricti:on ,:C liti:O b.Stct Gyrteei)ll:99'7;-40:Sl4- 107:..3-10. .
. 23. . . . . .

40. -F~.:E;--BoZZ!),-M,-Rigane.; S1 .. et- iU. ~T-empo~at

a.eqrienee -oC.'"bnqtm~ DQppler .changes in the
. perl,pl}~;:.al .~d ceriu:at citt\llato.r y sy.sJ~ti of the
sevtdy growth~.restri~cd f~tus. tlltta~~d Obstet
Gyn~l2002; i~: 140. 1. W~ce S ~d. MeEw.an A. Fetal.Mari>s<>mia. Ohstet
. G}>necol RCJ)~ Med fi007; 17: 58- 61
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JCYe{C -te:W gro~ -~~f;idion wor-Sens. .Ultrasound ev.a.i uation o( fetai .growth. Iti Callen PW, ed .
. Obs~tGypeci>1 :2QOl; HW57l. Ul~soriography in Obstetrics a,ndGynecology~ .4"' ed.
Phllad~lphi,a, We Saunde111, 2000:
42. H~er. K, Bilalii_ 0, GM, Stigter, RH, et 111. Monitoijng
:oftet\lses With ;intra\l.teririe gr.o wth -r estrittion: a 3. RaioJ.., Ghc;zzfF, Di Naro. , Buttarelll M ~tal. Perli}atal
. -}ortgihidmal stu<$y. UltraSQUh\\1 Obstet G:YJlecoi 2001;
I$156:4. . outcome-of.fetuses with .a birth weight greater than
4500 g: an ailalysisj)f3356-case!j. EurJ ObstetQyneccl
43 . Kat~op 'VH, van 'lugt JM, :van (Jeijn HP, Kostense PJ Reprod Biol 2003; 109: i6o~I65.
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Cliriicaf. signifibance .of abs~t e>t reven;ed end
. diastblle~dPcltywavefotm$ mumbilical a,rtety, Ui:ncet 4 . Langer 0. Fetal macrosomia; etiologic factots. Clin
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44. VllJl den Hove MMl. Willekes C, Roumen - F.,JME,
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macrosoma: does antenatal pred.iction iufec{d~eiy
mute and outcome. Am J Obstet 1995;17.3:' 12:.19.
. -" ..:..,.
20. American College of Obstetrics and Gynecology. Fetal
.. .. macrosPPlia. Prn.ctice Bulletin no. 22...Ndvc:inber 2000b.
.... ~_
'" !,'..
-.~
~
 l .

. ~ -

. .....

Scanned 8y: r-..

~
 44

PRELABOR RUPTURE
. .

OF MEMBRANES
...
RUTH Vll,LA,NUEVAGUTIERREZ, MD

Definition

Incidence

Etiology

Significance

Diagnosis

Complications

Management

Term/NearTermPR0M

PROM at 24-34 Weeks

Antibiotics

Tocclysis

steroids

PROM.at Less.Than 24 Weeks of Gestation

:..;:.::
. '

Seanne4 ey: c
 666 SECTION VI: COMPLICATIONS tN PREG~ANCY

D E FINITION Taole 4 4. 1. Incidence of PROM in the Philippines' 1

Year .NUII;lber of Number of

'Prelabor rupture of membranes (PROM ) is PROM. Deliveries Perce.tlt
,rupture ~f membranes (ROM) prior to the onset of
labor. 191!3 750 77,768 0.96 '""
1984 1,492 92,296 L62
19.8 5 1,861 92,426 2.Dl.
, Preterm prelabor rupture of memhranes
1986 2.'8 47 104,761 2.72 ..
-(P:PROM) is rupture of membran~s prior to 37
1937 2.0.19 10.2,058 L98
':week$; gestation~ 19M 1,809 105,'708 2.7.1
.,

I9a9 8.29 14a;S4~ o.-59.

. pPo.n~'i.e<>Us prelabo~ tu_pb.:l;'t .q f tn~bt:an,e$ 199() 4,'5~8. .1~/1.9~ : ,2~13_-.

. ;{SrRoM) h ruptu.r_e of tnembtanee ,after or-With :199'1

19S~
:6 ;197'
"5;6-!:t9
189./l~S
...19:9;322" :~:.
3.28
2.83
: :the.<?nset .of labor. '
. .... . ... .... ~~~ "7.,_?251- 208,~ 3~~- I;
1994 "8,7:44 2.1"4;_749. 4.01
' ,.. t>io longetr' rupture of men.il)r.anes. is auy 1995 8",2"25 140;823 .- 5.;84
. :.:mpJ:ure of membrane that per-sists .f or mo~ tha..t1 1996 7 .,281 138,350 5.26
. . . :24:hours and prior to onset of labor. 1997 12,936 ~08~:0_ .. 6,"H
1998 H>/i94 243.~63 -4.23 '
1999 6,1"57 lSl;Oll 4.08"
.. .., TJie la'.tent.period is the .intenral between the
2006 5,784 212,"541 2". 5
:. :p.rita;~ rupture of m.embtanes and the time .o f 2001 3,483 287;579 L21
:deliVery. 2002 . 3;9.5 4 ..J50;669' 3.23 .
2003 4;208 2~~48 1.50
1 0
2004 2;439 264;49-3" 0 , 94;
.2005 8,21"7 .3 19~49 2.S1 ..
2006 4;925 31~.564 1:.36 ..
..
reported incidenc~ ,of.prel.ahOr rupt:Qre :of
. . .l:Th
:I,:Uen'1pranes .va,ries; .b etween 3~pe~n,t .and .1$.5. .
.
. :pI.'en.t: :. Approxiniately .8-10 ~~reent of -patients
. :;a{ t erm pres:e:d.t with . prda't>ot: n ...1.. pture. of
..mempr!.nes prior to .onset of l aoor. Pre-term or inflamma:"Qo.n may ~u~e .Ji>~e.t~rel. PRe-M: .'A ~ ..
:YiF"~r rupture of .i:G.e~branes atcounts ft>r 25 d~a5e -~ tl,le t:oJ,4\gel,l.cOnte:qt. oitb.e:meml:nine.s
.:pc.~nt orrur.cases pi"PRONr ana-iSf:esponsi.O\~ n:a:-s -ge:en. -$~gg:est~d.."",tO"~pted~~p6'~-pati:"ti:f~-"to::
.::r~r3a perce.DI or au pr.e~aJX>r oeUV:tties. pr~re::-w. pRoNt, ItT~ )iKety tn:armUiop~e-ra:to-rs- .
pr~s.pose -~rtll!l patients to pf;:ter:m PR0M..
- . 'E-'I'.IOLOGY
R,tsk F a .c to rt
,,Normal fe.~al memb ranes a r e extre..niely
-;r6";4~tant to ru.p~re ~ly in.ptegha:I!cy, that :.t hey .N umeroU's risk factprs are associated With .
t4n:Withstand rupture from :neaflY :a.n: caus:esof preten'n. PROM. PaP.~nt~ at "higher ris;k t.b' tbl!i:
nn;~~e.trat:ihg for ces. At ter.!Il,, p::'Ogr:an:mied cell cciqditio.t;l .ar.e :those.wl::to hay~ .lower .socioeeonomi~
.d.~-$,.-and activation of cataoolic erizymes, sutl;l status, are. sm.o"kets; have a history of -s~a:lly
~s oUagenases and methanial forces, result "in transmitted infections , hav~ h?-d a .j}r(!vious
rUP.~ea :rn~mbranes. Preterm .P.ROM otcu i:5 p~ete.rm . de livery, . have vaginal.bleeding, r ha.v.e
probably.i n the sar.1e mechanisms .anq pretnat\,lre uter ine di.sten.sio~ (e . g., :polyhydrainnio ~,
.... :~ctiv-ation of these pathways. How~ver; early multifethl preg:r:1ancy) .
PROi.i also appears to be linked to underlying .
P rocedures. that may. result in preterm PROM
pathologic p<ocesses , mo.st likely .due to i nclude:; cerclage .and amniocen tesis. Th~r.e
. injUunination and I or infection- of the m~mbranes 1 appears to be no single e tiology ofpr eterm PROW.
it i~ postulated that in the third t:J:i,mes:ter, the
..m e nit;>ranes undergo stresses as str-etching of the SIGNIFICANCE'
: sui.(aee area
of the u terine eavity Dccu rs; Oiher
:poten t;ial sourc.e s of insult are ~la;boraticp. o'f . .Eighty-five percent of neonatal. morbidity and
:' Proteases fr:om seminal fluid or from 'bacteria that mortality is a result of prematurity. PPROM is
.cau ses ce~Co\aginitis. Choriodecidual infection .associated with 30 - 40 percent of preter~

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i
I l.
CHAPTER 44: PRELABOR ~u"PTIJRE OF MEMBRANES
deliveries and is the leading cause of preterm
delivery. PPROM complicates 3 percellt of all
prgnancies. When PPROM occurs remote from
term, significant risks of morbldity and mortality
are present for both the fetus and the mother.
DIAGNOSIS
Evaluation of the patient begins with the
confmnation of the diagnosis of PR-DM. A history
of gush of fluid from the vagina followed by
persistent leak, is accurate in 90 percent of cases.
The physician shculd perform a spec\llum
examination to confirm and at the same time
evaluate ifany cervical dilatation and effacement
. are present .. Wh.en PROM is . suspected, it is
iinportant to avoid performing a digital cervical
eXainination; sucl). e.xa.minations have :been shown
to jnc;:rease morbidity and riiortai~ty. Digital
. cer\'i.cal:eximi nations also cause ~.aver.a,ge nine-
day deq-ease in latent period. Shortening of the
l~tent pe'r iod in~y lead to increased infectious
-mort.ldity and sequelae from preterm labor. Some
.:phy.sil;ians m-e concerned that not performing a
-: <Ugital .~ation . may lead ~o .the mis4ia;gnosis
.ofadVanced preterm labor with imm.ine~t delivery, '
which-ha'$mi.portant implications for patients who
rquite tr.at\sfer to a tertiary care center; however,
apro~Ye comparison found that the diff'erence
- betw.~ diitiW and speculum ~a.Uons was
not cllni~...c~JgRif!.<:a.nt. _ EhY.,sician's . ~hould-be
!~Ms:lir~4. that.carf:;ful :vis.uaL-inspe~-tie:n--via a
speculum examination i::. the safest method for
dete.rmining whether dilatation has occurred after
preterm .rupture of membranes:
.Rup;t ure _of memb.rane is diagnosed by
speculum examination of the cervix and vagin~
cavity. :Pooling of fluid in the vagina or leakage of
fluid from the cervix, ferning of the dried fluid
.Uhder microscopic examination , and alkalinity of
the fluid asdelennined by the Nitrazine or litmus
paper cosflrm the diagno:;is.
care :she~H1 15'e',ex-er.d~ed nott6 'contaminate
the-test stri:p -with cervical secretions and blood
or with secretiqns secondary to vaginal infections,
since theseare also alkaline.and give false-positive
results. Pooling.of fluid is by far. the most accurate
for diagnosis of ROM.
. If all fluid has leaked out as in early ROM, an
ultrasonographic examination may then s how
~
Scanned 8y: ~
absence or very low amounts of amniQti21lujd in
the uterine cavity. When the diagnosis ' reniains
unclear, as With concomitant bleeding and
oligohydramnios, an alternative invasive method
may be applied whereby amniocentesis is done
and a dye is injected; the cervixcan be visualized
for leakage of dyP..
Current studies on the detection for PROM
focus on the biochemical prope rties of the amniotic
fluid. The concentratiori.s of human chorionic
go{ladotrophin (hCG), alpha-fetoprotein {t\FPl and
crea~~e are high in amniotic fluid. 'Likewise,
-fetal fibronectin is useful confirmatory test if there
is doub~about the diagnosis ofPROM.(SkVigos JM,
Robinson JS, Vigneswaran R, 1999). In another
study, Rutanen studied the .diagnostic potential
of rtleasuring fetal fibronectin and insulin-like
growth factor binding p:roteln-1 {IGFB:P.::l) ir.
.cervical/va-ginal secretions -a s indicator's of
-ruptured fetal membrar1es.
History' Nitrazine test or libnus pa~f.~ and
ferning test can be used in combination ,Siirict: in
some studies, this can leaci to 93 percent correct
. diagnosis. HoWe'ler, testing for the presence of
biochemita) s11bstances found in the~~Ptlc'i'fluid
may prove tobe morea.cctuate in d:eteefuitl!iROM.
...~: : \~~;"
: <:
Endothelin is a protein molecule tha'tthas a
:variety otphysiologiqrl roles in the iniiliarr;'body.
lt-has- been noted to1Je)1te"S"ent'Wft11iil ffie atrinfotic.
fluidof -human~i'. 'Its 'exacl: roles' m-refation ..-to
human reproductiOJ]. are still largely an enigma3.
Maternal and fetal plasma c.oncentrations of
Endothelin have been recently stt1died with
respect to . pregnancy-associated - pathologic~]
procel>s. Endothelin has been noted to
ha._)-e the
capacity to generate-u terine contractions in ah.i.roal
models, activate: phosphoiip'ase A2 and
phospholipase associated with rupture of
m embranes. It h as been noted that Endothdin 1
and 2 are increased in the amniotic fluid of
pregnancies once premature labor- has occurred.
The study carried out in 125 women in their
second trime.s ter showed Ulat the an1niotic fluid
concentration of Ehdothelin 1 is elevated by the
second trimester in women who later develop
. pretentl PR()M or term PROM. 4
4 :
:;--
~-.
.C0MPL!CATl0rfS
One of the most common complicatio~s of
preterm PROM is early delivery. The latent peri'od,
 -668 SECTION VI: COMPLICATIONS IN PREGNANCY

'
which is the time from :membrane rupture until Table 44.2. Incidence of chorioamnionitis in PROM.
qelivery, generally is inversely proportional to tne
Year 11 of Cases II of Cases of %Incidence
gestational age at which PROM occurs. For
of PROM Chorioamnionitis
example, ~>ne iarge study of ,patients at term
revealed that 95 perCent of patients delivered within 1996 3,779 167 -6.87
approximately one dl:!-Y of .PROM, whereas an 1997 5,337 225 4.21
analysis of stUdies evatuating patients with pretenn 1998 3,751 ?.35 7.59
PROM betweeri 16 and 26 weeks g estation 1999 3,779 167 4.41
-detennined Ulat~~7 percent .o f pa.P,ents de.fi:vered . 2000 5,784 390 . '6.74
.within oneweek, snd 22 per~t had~ latent period 2001 3,483 170 4 .88
;>!four weeks. When P.ROM eccurs ~oo ~ly, 2002 . 3 ', 954 128 3.23
surviyit:lg neonates may develop sequelae :s uch.a.s 2003 4,208 378 8.98
m~l.presentation, .cord . comp'ressiO.n. 2004 2,489 25n 10.28
.oligoltydralhnio~. l'i(!~rotizing enterocolitis, 2005 8,217 345 6.42
heurologie . impalrme~t, intraventriul~r 2006 .4 ,925 331 6.84
}).etnorrbage, and respirator.Y d istres$.syrtdrom.e. s Committee on Nationwide.'S tatistics, Philippine Obstetrical
& GynecolQ,gieal SocietY
Most patients (90%)-enter $po.J;ltaneous .labor
within 24beurs when they exriene .ruptUre'of
membranesatterm. Th~major qUeS.tion. re_gard)ng a rn~h less important tole in the initiati9n of
~s,gernent"of the.s e patie.nt$1-s w.Qeth.er to aUow parturition-a,t or near tenn.
them tO" e'!;lter1abof' sporitane.OUS}J Ot .to ffidU'ce . . . . .
:tabOr~ The ri$k:ofi:p.tr.aute~e-.infePti<>fi:.in~ases Otga.nlsms that have oeeil . as~iated With
with the durati()n of ruj))ture pf t:neb$e$~, .histQlogic chorioat'!lnic>n;itis include -Ur-eaplasma
uteal,Yticum., Myc~plasPl'a hmn:inis, Gar:dnerella
.In t~~ WeeUon reQl.~. tb.<nn9~t.~ricu$ . vagj;n:alls~ ;pe.ptostre.pto.co-cc'l,ls, =and 13acter:oides
t<;>tn.PJ.i~tic)il.~$0i~t~:-~th=P~OMJor.:t. he.~other speeies ..~0
and ;th~ne6nat~.~Tlfe ris)t.'of..~ori~ioriiqa.'With '
term~ PROM,has,'Be~~~ ref>ptt~d::to P<::res$ tli~: to - in cborioamniOnitis .fever is the .only reliable
~nt:~'fii..to'.intte~se to
2'4. per.eent ait:er 24 ip.dicat9r wi~ a texn.~rature df38C 6r :higher.
.})outs of PROM, This ~ints ou-c1;he .impartance . ~Jth_~r indicators lntlude leukocyt~;>sis, fetat and
.<5(~i>!.P'.P?i~t~ --m~a~eiiienl sti'iit~ijlesJ5r :~~t}'~ i?~~:~!:~T J~~E'i.~~?:!~~ T~~~l::S.fo~I!I~i~!~~Ii_a~
at t~. disehatge, Uterine 'tenderne,s s or uteritle
.contraetions. D.efirtitive diagnosis how~ver;, fs
chorioam.nlonitis made op.ly on positive/cultures ofmembranes and
histo.pathological 'e:muri.ination of the placenta.
lnflamm~ti<;)p -o f the fet:al menibran~s :is
u~ally .tl)e'manttestation:o f irttral.iterme mfet tfqn. f .e tal .infection may ot:cur as. sepJicemia,
.. pne'Qmp'nia.,. or urin,a:ry traet infection ot as lO<;al
Clinicfil c}lori9fl.mniquiii$' cop:J;plic~.t.es .1,..:;5 iilfe9tlOn,. SUCh as Omphalitis or CD:njunctiviti:s.
perce.n tof.term. pregn.~Cies, but ne~iy 25.percent
of pretenn .deliv~ties~ IIi one stu(iy 19 , hist:elQgj.c Perinatal complications are principally
.ch<>rioiminionitis was mor~ common: in ptetevm secondary to preillaturlcy. and infection. When
deli;e.ries than in tetm ddiverie~ ( 32.8.% .ver&us comparing perin~tal mortality of premature
10%). Ari .i nvestigation of patients in pr~tenn infants, it was noted tpat premature rupture of
labor demonstJCI.ted. that positive amniotic fluid membranes less than 12 hours had little 'd ieet.on
cult\lre results were present' in =19 percent of m ortality. Howevet, :wh(m . the lateilcy period
women with .intact membranes with no clinical extended,beyond 12 hours; perinatal mortality was
spo~taneous p:r eterm labor. . an in~erse increased. ln f~tuses'exposed to prolonged PRQM,
relationship exists between colonization 'of the . especially earlyin gestation, with oUgohydra:tnnios
chorloamnion and amn.iotic fluid :and gestational treated conservativdy. pulmonary hypoplasia, low
. :age at deU:very. .In .o ne study, chorioamnion seat ears, sloping nose/ and chin, and flexion
. I
colonization was associated with 83 percent of the . contractures.of the extremities were noted. This
very e~ly spontaneotl~ preterm .Q irths, but played is the so-called fetal deformation 's yndrome. .

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 CHAPTER 44: PRELABOR RUPTURE OF MEMBRANES . 669

Table 44.3. Complica tions of pre term PROM6 management depends principally on ge~l:ational
age. In the pa tient with PROM who is not in labor,
Complica!ions Incidence (%)
and without evidence of infection or fetal distress,
Delivery within 1 week 50 to.75 especially in premature gestational ages, a grea t
Respiratory distre:Js syndtonie 35 deal .of controversy remains regarding
Cord compression 32 to 76 management.
Chorioan:mionitis 13 to :~O
Abr\lptio placentae 4to 12 Management Based on Gestational Age
AntepartUm fetal dea~ 1 to .2
At tenr./-near term

At .. tenn, infection remains the most serious

A. parallelism exi~ts between the :relationship complication a $S6ciated with PROM for themother
. of n:tat~mal and J?ili .morbidity and the iatenL ... .and neonate. . The rislt of cho1ioanmionitis with
period: of PROM. The best results occur when term PROM has been reported to be less th&n 10%
PROMi:iless than 1.2 hours, and 1.6 -25 titnesmore and to increase to 24% after 24 hours of PROM.
thereafter. For the 'fetus ;:dter 12 ho~rs, morbidity 'this point s out the importance of appropriate
is .irtcreaSed .mQre .than 20 .times. management "Strategies for PROM at term. For
caSes .of premature ruptw-e of membranes atterm, ..
Based on the Tesults o f the, DOMINO$ Study~ inductio...."t of !~bor js a dvisable to r educe the risk,
a Ta:ndomized ~on:tr<>lled trial, out -of.471 women of ascending infection: Patients in ,active labor ..
recruited at a mean ~estational age .of 30.5 :t0.2 slJ.ou1d be .allowed to. progress an~(\!ii~~g~went
wee~, 170 .(37%) :presented wit..h a < 4.8--hlatency is the san;l.e as :for any other te:rni p~tiertt;/,c:; .
period~;alld 3()1 (~%), a ~4~-h latency period.
: : -J_: ... -~"'"":- .
. -,;,~'3: ... .:: . : .' ?A .
While prior to 30 .weeks' ge:station, .t he mortality When preten:n PROM- occurs ~(3 4-;g6.-~\ieek.s'
Tate was pjgber in neona tes. with a short latency -ges~t.itm, physicians should:- avoid .thf: urge to
"'rnxf.(i.~:a% vs 7 .3%, p <p.. o 1} with puhno_nruy prvlqt)gpreglla.ncy.. Sti.tdies have sho~lhat;labor .
di8e~--~~g "the .lfl.ajor- cause of d~th. a .. short mduction Qlearly. is bene.ficial at or--~ter.M;~e:~k~'
:}at'~ncy _period was a s sociated with a lcwer ,gestation. One 'study-a showed thafi.~~Qri~{i~tive
mortality:r ate after 30 weeks' gestation ( 0% :versus m a na,gem.e nt between 34 a nd:' ..36:\:;_i~eks'
3.7%. p=().-02}.7 gestational .age' .r esulted man irl9JC~ed .ri~k .of
chodtia:tnniortitis ~d a lower average umbilical
Jrf:ANAGEME;NT cofQ- pH:-:-1\no!ner~sffiay ol43"0 '":w omen~ith .
preterm p~lJM rev~a.ie'd ' that""there'W:a_
s.~n~
A ~tient with a histt>.ry s u ggestive of PROM imprOvement in major or niinor neon atal morbidity
.should be brought to t h e hos pital immediately and after 34 week s' .ges tation .9
evalua ted to confirm the diagnos is of PROM.
Tho~ -in whom the diagnos is is .conf'mned. shQuld On a~.ssion, a sterile speculum examina tio n
behospifuliiea until delivery. An exception wouid is don e to verify membrane rupture and .to rule
be theJ,a,tient wi$ PROM in whom the ges.t atiotW out c o;:-d prola pse. A s iJ1gle s terile .digita l
age is .below that of likely n eon atal suivival; in exa-mination is . do ne to determine c erv ica l
these patients, . fetal status is not an immedia te effacement and dila tation a nd fetal presentatio n
issl!e and outp~tient expectant managePlent m ay to a ssess the pelvis" In t erm patient s with a
be appropriate. In som e p a tients , leakc;t.ge s tops favoraQle cervix, inducti()n Of labor . is in d icat ed.
and reaccumulation o f n ormal a mnio.tic .fluid is In pa tients with unfavora ble cerVi,x, two modes of
no ted,on u~trasonography , their prognosis. seet.ns m an a gement m ay be followed: .
to be similar' ti> tha~ pf patiet1~i who h ave. never
. had rup~e pf membrane, a nd they can be safely l.n the firs t option, one can follow the patie nt
discharged from the h o spital once resealing of Con servatively w~th a ssessment of fetal well-being
the m embranes is confirmed. . by ~ltrasound or fetal heart rate: trac~lt Lpwer
gemtal tract . cultures a re obtamed ~~well a s
Pelivery is obvious ly urgent: for pa tients with monitoring ()f maternal WBC and differen\i~ count
advanced active la bor, cliniCal ch orioa.mnionit).s. . everyday and vital' s igns especially tempera ture
a nd irrever s ible fe t a l dist r e s s. Othe r wise, every 4 hours. If the mother remains afebrile and

Scanned 8y: ~
670 ' SECTION VI: COMPLICATIONS IN ~PREGNANCY

fetus is stable and cultures are negative, then one Antibiotics

can wait for spontaneQus labor. At least 75 ~ss
percent go into labor within :24 hours. If maternal
fever, fetal tachycardia occurs during the pe:dod
of observatio~, adrninisttation of ant;_biotics and
induction are indi~ted. The alternative scheme
management is to induce labor de spite the
-u.nfavorable cervix. However, the latent pha~ bf
. labor maybe long (16 - 20 hours). and vaginal and
other insfi1.lmental examinations shoUld be
minimized. -lf at any time 1 the .mother shows signs
of chorioamnioriiti~. or the fetus display$ :;;igns of
distre$s and-vaginal4eliveryisnot ~ted within
few hcur~. then termination of pregna.JlcY by
ab<.tomina1 route may he warranted.
Medications:
.C.Orti~sttroi<l'S decrease perinatal morl;>idity
andimortalit;yafter,preterm: .P ROM;''A rece;nttneta"' .. p~gnant for .3 :weeks. despite _discontinuation of
maJYsis1 ~Jo.und.fbat:~tt.iCQ$tei.'Oid:,a~~~ti9n-.". . ,the cl!m~i9tie~-aft~r 'J. days, ...:It. ds;advi~Qle . to.
after pretenn<PROMo'vetsus no: a4mitli$tr'a~pn.. adnrltiisteN~.ppr:Qpriate antibiotics.for intrapartum..
.r educed th~riSk'of~pjt.atoty:i\i$tf:esS.sytidtQme
.(20%,vet8u$ 3$,4%)-. illtta.....-entrieulat benttJrr:hagy ru:e atrlrs, even:1f these; patients :haye previously
{7.5~v.~~~-l$9'%)~:~~.u~tith)~ente~Ut#...
.'{o~s~.,V.~uS!?4~6%):-~~th9Ut.- ~Jnerease ibi,ithe . .PROM. .
risk ofma~.or.neonatal;infectiOn; atcause
roc:oste~i~s-~ettective.~t d~Slng.~~tal
moibiwb' :1ID~mo~1Y...n, :pl.)y~~~a~~ '.~g: for
:pre~t~m ~s:bottld~'l:tp:de~d tlie:'dosfug
a.nammcal:ion~rot,~001;1t~Toltt'll:~tta"!ib:rt
duringpregnancy . The 'most 'Widely used :and
:reeomm.en4ed :regimeus irtcl;\ide :mtta:mu:sctrhtr
'betamethasone (Celest<>ne).l2 .Ing:e:veey Q4 b~~rs
.fOr two dayl$, or mtramU'Selllar .d~ethasone
{D~drOJi).~ mge:-.Jq'y 1~ :ho~~~ :(or :twQ,days. The
National JnstittHe$ of ;Health teco.nunend:s
adlnhiistration, ~f..rt:icostet'Oids l>efore .30 to 32
~ks' gestation, ti.s$utni:pg fetal via]jffity rurd
.no
eviden.ee .of intraaml)ioti'c infection. Use of
cortioaterojds between 32 and 34 weeks is
conb-ove~ial. Adlninlstraf;ion .of corticosteroid'S
after 34 weeks' gestation ..is not recommended
unless there is eVidence of fetal lung immaturity
by amnipcentesis. Multiple courses .a te not
re~mmended .beciause studies have shown that
tWo or mQre course$ can reau'lt in .decrea$e(\infant
birthweight,. head . circumference., and. body.
'1 . gth
en . .1l..
Antibiotics given to patients with preterm
PROM can reduce neonatal infections and }>l"C)lb,Qg
the latent period. A meta-analysis2 sbowed.that
patients reCeiving antibiotics after preterm PROM,
compa-red with those not receiving antibiotics
experienced redueed postpartum endometritis,
chorioamnionitis, neonatal sepsis, neonatal
pneumonia, and intraventricular hemorrhage.
Another meta~analysis 12 found a decrease in
neonatal inttaventric\ila,r bemon'ha,ge and ~psis.
A number of ~tibiotic regimens are advocated for
u~ a.'le'r ,pretenn PROM. The regimen studied by
th~ National Institute of CbUd Health and' Hfunan
Development trial uses an b:itravenous
colribination of 2 grams of ampicillin and 250 mg
of ecythtomyc;tin :e very 6 hours Jor 48 hours,
followed by 250 .m:g o f atnoxidillin and 3,33 mg of .
erythtoroycltfev~ry 8 houts foi" five .days. Women
given thi$ combination were more liketi' w stay
gro:up'B $t:i-eptococcus prophylaXis.to wom~n who
teceiv~ a .course . of. antib.~otics after .pr.etenti.
In the ~tudyofFlenadY V~ .King,. they ~ed
the Q>qJ:ltane Pregnancy and Childbiith Gro~p's
speciaii zed register of controlle&itials -(30
September 2005) . the Co.chrane ControlledTtials
Regi$ter (the cOChrane Library, Issue 4, 2001).
The tesuti:spf two ui.als. involving. a total of 838
women .are included in Uleir review.. The use of
antibiotic$ resulted. in ~ statisti~y si!Wifkant
reduction in materria l infectious. morbidity
(ch9rioamriionitis or en:dometriti:s): RR 0.43' (95% ..
Cl0;23, O.S~), RD A% .(95% .C1"'7%,1%). NNT 25
(95;o/o Cl 1.4 ~ 100). No statistically significant
diff~rences were shown for outcomes of n eonatal
tnorbidity. 13
Tooolytic Therap y
Limited, .data.,an~ g'lailable . to_ heJp d~termint<
whether tocolytic thera py is indicat~d alter.
preterm PROM. As described above,
cortiCosteroids and antibiotics are beneficial when
adniinister:ed.to patients with preterm PROM, but

Scanned 8y: ~
 CHAPTER 44: PRELABOR RUPTURE OF MEMBRANES
no studies of these therapies combine with
tocolysis are .available. Tpcolytic L.~e'rapy may
prolong the latent penod for a short time but do
not appear to jmprove neonatal outcomes. In the
absenci! .Qf data, it is not unr,e asonable to
'a dminister a sliortcourse of tocolysis after ptetenn
PRO~ to allow initiation of antibiotics,
corticostero.i d .a dministration, .ap.d . maternal
trartsP9f4 al~ough this is controversial. Long
term tocolytic therapy in patients with .PROM is
not reconu;nend~d; consideration of this .should
await further rese~ch. 14
.At 32 - .3 3 Wteks
For patients w~th preterm PRO "tv~ at 32 or 33
weeks' gestation with . dpcumented pulmonary
..maturity, induction .o f lal;>ot and transfer to a
facility that~ give cwe.J qr premature neonates
f>hou.l<;l be coxpiideted'( Prolonging .pregi)ancy
after do~umenlation of pulmonary maturity
~~yjncre~~s the likelihood of.tnatetnal
airmioniti~fU:JD.bilical cord compression; prolonged
hosJ)ltsl!ZR"tio'n., .a nd neona tal L"lfection.
.T o .d ate11; only 3. s.m<;ill, ra.ndomized clinical
tiials ha;ve"'c :;o$pared the m:ater11al and ,neonatal
ou~xn~;reJat~to' Uru'n~.a:te delivery c ompared
with expectant management in women with
preterni PROM between 30 and 36 weeks'
gestatibn. Mercer, et al. randomly as~igped 93
worpen With pretenn .P.gOM bet-.veen 32 and 36
weeks..-;gestlftt"'n marna<f coiifinne<f 'iefaf1ung
~tilntYraete~ea:uyv~gu:;ari,)OOrtoa.m-st:abiliiy
index) either to ir.t:unediate delivery or expectant
management. .These ,investigators demonstrated
.a signUicant reduc tion in the it1ciden.c,e of
ahQrioamniopiti~ ( 11o/o). .in women with iininetiiate
delivery a$ .compared Wifu. mose in t he expectant
rtiana_gernentgroup (28%) .(P<:0.5). Although there
was a trend toward decreased incidence of sepsis
workups and confirmed: sepsis, there were no
signific~nt diff~rezices in a ny o.f' the evaluated
maJor neon,atal outcomes betwen the 2 study
gr.o1,1ps. CQx, et al. randomly assigned 129 womeIi
with .preterm PRO,M bet_w.een 30 .a nd 34 weeks'
ge~tation to either irii-me.dia te delivery .o r
~pectant management. No fetal lung maturity
testing~ tocolytics or cortico$teroids were used in
the study participant~. Similar to :the .Mercer
stu~y; the incidence of chorioimn,ionitis: was
Scanned 8y:
significantly less in the women in the inif&wiate
delivery group (2%) as .compared with the
expeCtant group (15%) (P<.OS). No significant
differences. however, were noted . between the 2
groups w.ith regard to ~ny of the evaluated
neonatal outcomes. N.aef, . et aL evaluated
aggressive compared with conservative
management of women with pre term PROM at 34-
37 weeks' sest~tion: In this .prospective
investigation, 120 women with pretertn PROM
were randomly assigne4 to receive oxytocin
induction or obsertation. Chorioamruonitis
~i>ccurred more often {16% co11wared -;lith 2%,
P=.007), and rn~ternal hospftal 'stay was
significantly iof1ger {5~2 . 6.8 .days .compa,red with
2.6 1.6 d~ys, P=-.006).. in WQmeh conserv;it:ively
managed as compared with the induction group.
No significant differences were m)ted in the
incidence of major peoria.t:ru m.orbidlti~s betwt:en .
the two groups ... AlthoU:gh the$e ~tudies stiggest
that nec:nafal out~;:om~s are Similar,- between
women who were managed: eX:pectjantly. com~ed
with immediate induction, these;,.iftvestJ&flions
lacked suff.iclen.t statistical power~'&'at\late
neonatal outcomes. In addition; 'tnese-';titdles
have not evaluated:differences)n mm<>nnorbidity
rates ,o r 'l~ngdi of}io;>pital stay be,twee,ih:itifants
bom .after .itnmediate :delivery and.?those~liO"are.
managed :e xpectantly. :.,_,.J,;:.> -':,':''':~?-.:
There are few data to guide the care of ~ti.ents
wit.~~!It c!~l:!t;!lJ~.!!t~d p.u)monacy.. matudty.. . No
s.tlJ..Q:i~. ?..re av.ailable:.comparing.deliveiy with .
expectant ma~agement when patients receive
evidence-based therapies slich as cortirosteroi.ds
and antibiotic~~ Physicla:ns-mustbalance t...h.erisk
of respiratory distress synd.rome and :o.ther
sequelae of prelabor <;ielivery with the ri'sk of
prolonga'tion such as neonatal sepsis and cord
G<.CCidents.. PhysiCians should admiriister a course
of corticosteroid~ and antibiotiCs to patients
without . documented feta1 lung ma turity ~nd
consider delivery 48 hOUi"S later or perform a
careful assessment of fetal wel!.. :bf!in't~. obSer'!e for
intra-amniotic infection, and deliver at 34 v/eeks.
~onsu.Itation whh . a neonatologi~t in the
. management ofpretenn PROM may be beneficiaL
Patients With runnionitis r equire broad spectrum
antibiotic therapy, and all patients should:receive
appropriate intrapartum group B streB~occus
prophylaxis, if indicated.
~~:.
';~'+ :: . .
~
672
Table 44.4. Based on evidences.
Evidence
Rating
Antllik;tica j!hould be administered to patients
withpreterm PROM beeau5e they prolong the
. late~ period.ad improve 9:Utc;ome .
Corti0$te:roids ~ould be given to patients
~ 24 ~d ~2 ,we.e kJ' se~t:a.tiQn to
: ~the risk of intraventricUlar hemorrha,ge,
.m piratory distre$$ syndrome, p.nd
n~tiziilgtnterodoliti~
~~ouldnotl>onJuligital
en~Jt!.ation~ onpatteJt~ Wi~ l>~tc;rm PROM
~uae they 'deetease t11e latent peJ"iod."
: s~ &11Xri'iMtlon.is preferred.
t.cmg"tenn ~ys~ is -~otiJ:l~tecHor
. p:~ti~ft,t'~~~:PI'?t~rm'~ROJ"i.ttltO,:U~ shorMenl;l .
~-be .Qtl~(!ere.J t!)faciU~t: p1atetnaJ. tr<).Jispbr+. ,
10.~&the-~sttatio'b 9l:ari.ti'oi0tics'aitd
~~stettik\s. . .
.
. ~ M~tipl~~Ji."SS:~fi.cor.ti~~J.ps,~d:ilieu-se , :- . .
of~ afiet34:w~';gesUitiori ate .
. . not-~t:nd~
: . ' . J: - t :: . ' .... ' .... r. ..-. _
A ~~t; g09(l:Q\!alitt :patertt:.~~ted_,evjdencc
_: . )': .; ...... , ._, ...._i : - . .. .. . . .
B ,.O:~oflh~ut~l.(JU~itYP<iti~t~n~~~ eridepee
-c .. ~~~~Qited~<iente:usuai~;mu:titt=,
expert opinion .o r case seri~
l)elj,veey before ~:2 weeks ,gesta.ti,on may lead
t.O .SV~ .-neopatal. Ii;lor;blCi~y an~ .mo~ty. ln
.the 'sb:$eilce .o f intiaa.m~iotic .i~fetti'i:m, th.e
phy.s.~(-~ -s~~uld ~tte~pt to, -pr.pl9ng th<:
p,:r~ey ~til 34..w~~s_. :ge~tiition. P.hy~~s
.,sho~ ,~d.-'4~ ~~eut:!f ~d f~f')i,~y :Jliem~f"$. that;
dspite these efforts; m.~y patients .deU:ver Withill
Qne w~ .of pre~erm .P,RO.M. Contr.$.d;icauons. to
~<;>nset\!ative thera;py ipelude d:~opio~mtiionjti:s,
placenUi} ~bi1Jption and non~rea$suri'ng fe.~a.i
testing. PhysiG~s should adminis ter -~ :co-urse
of corticos~ert)ids ..and ;;tlbiotics and perfonn .an
a~sessm~nt e f fe~ w~U~~ing by feta). . ~onitoting
Qr utt:tasonography.. After 4'ansport to a faci,Uty
ablc .to ~ for patients with .p .retepn PRO~ ~f()t..e
~~ weeks' .ges4ttion; .patients should r,eceive:.daUy
ior COtllll1\lOUS, :if indicated}: .(e.tal IDQnitorin:g .for
contractions and fe4U well-being. Vmbilical tx>r
compre~sion is common (32 to 76%) with pre term
Scanned 8y:
PROM before 32 weeks' .g estation; therefore, at
least daily fetal monitoring is indicated. In
addition, the physician :sh9uld observe closely for
fetal cr J;natemal ta~hycardia. oral teJnpen\ture
exceeding 100.4F {38C)t regular contractions, .
uterine tendemes.s , or leukocytosis. wl:lich are
A possible indlc.e.tors of amnionitis~ Cortie<>Steroid
administrationmay lead to an elevated leukocyte
count if given five to ~~n days of PROM;
Evidence suggests that prolonged laten.ey may
A increase the risk of intra-amniotic inteclioii. A
retrospective analysis 17 o.f 131 women with
pretenn FROM at 24 to 32 weeks' -gestation who
received . steroids and antibiotlcs . found a
A sig:Qificanttrend tbwatd mtrauteriile inflammation
in patients with a .latency period lol)ger th.a..-.1 one
. week. l>.e livety is .necessary !CJrpatierits wi.th
eVidence of amni:onifis. lf :th~ diagilosis of ari
. intrauterine infec.tio.n .ls ' 's uspeot.e d but not
'
. -c established, .anurlocentsis :an be perf)nn.ed to
cheek ior a d~ glilcoSe -level or t\. po~tiVe
Gram --;:;ttdn=.;and:c;tiff:e:t.ent:ialvtount 'tail- be
performed, .Fotpa.tients.:Who.r~ch-'32 to:aa ~~
B' gestati~n. 'aniriiotent~sis for .tetal hui.g II:lf>turity
. . cndtidiV'e:ry ~r 46ctintentati.on oJ ~
:tnatuticy, evidence :o f jptra-~hiotit:t.irif.~. oi
'at,34 :.wee~s~,ge$t:ati6.n ' should be :eoQ:si~
... ..::-
, 1\l~f'oru.Y
J . ~r. p.
aiieiit~
. ... --
wul..
.deliv~r-~thin t>lie
-- --
week:wlien~preteonPROM,oocurs befote24w~ks
.a-n
geS,tation; with . a verage 1ate11cy< '~q(i .of;$ix
days. Many infants who -are delivered after
preViable ruptur<H)f tln~. fetal me.in~~ ~er
from numerous lang-tetm :pr oble$ ittcl~ding
~chro-nic luJ;lg dl~:ea;$1!_. develp-p..menud . and
n:u:rologic Bbf,Ol11l'aliti S1 nydt(>,~j).h~.U.S; .and
cere~ plsy. Previal>l rtl:Pture of-membranes
.also canlead to Potter's syndrome, which re~mits
in pressur-e deformities of'the i.Unbs and.face and
pulmonary' hy,p oplasia. 'The iilddence of this
syndrome is related to the g e stational a g;: a i ~liich .
~pt'.lre :occuts:and .tO .th~:levelof-oligobyd.ra.rimios.
Fifty percent of. infants with rupture all9 weeks'
g<fstation .:Or earUer.,are affected by 'Potter's .
syridrom~, wher~as 2,5 % born at 22 weekS" at1d
10% after 26 weeks' .g estation .are affected.
Patients shouldbeceuh$eleda oout the outComes.
and benefits andrisks ofexpectant .managemesi~
which may not :c ontinue long enough to: deliver a
baby that will surviv.e normally:
C
 CHAPTER 44: PRELABOR .RUPTURE Of MEMBRANES ' 673

Physicians caring for patients with preterm Cervical c erclage

PROM before viability may wish to obtain
consultation with a perinatologist or neonatologist.
Such patients, if they aie ..$\';able, m ay be.nefit from
trarisp3it to tertiary facility. Home management
of patients with preterm PROM is controversial.
A study 1' or patients with preterm PROM
randomized to home versus hospital management
revealed that only 18 percent of patients met the
criteria for safe home management. Bed rest at
home before viability { ie, approxiinately 24 weeks'
gestation) may be acceptable for patients wi~out
eYiden(:e of infection or active labor, and
' physicians should consider consultation with
experts familiar with home management of
..preteim PROM . Consider readmission to the
hospital for these . patients after 24 weeks '
.g estation to allow for close fetal and maternal
monitoring_.
Cervical cercl~e has been considered as a risk
factor for PROM and other associated adverse
pregnancy outcomes. It has been found to be
associated with one in every four cases of preterm
PROM and fifty percent of cases a..tter an emergent .
cerclage. As of tOday, there js no prospective study
regarding treatment of pre term PROM subsequent
to cervical cerclage in situ. Retrospective ztudies
on cervical cerclage in association with preterm
PROM have suggested that when cerclage is .
removed on admission the ri~ of adverse per4latal
outcomes is just the same as those without
pretenn PROM without cerclage. The role for
short-term certlage retention while att~mpting to
enhan.c e fetal maturation v.rith antenatal .ste.roids
in the previabte gestation has not been
determined.

CoNFIRM THE DIAGNOS IS

!. 3peculum exm~ination.
2 fernill8 .~ . J,'. . ; ., -,~l.: ' .

3. nitrazine papetllitmus .paper

4. .ultrasound
s. dydnst.aUation .
..:: :.
l
BASIC LABORATORY
PARAMETERS
CBC ( espej:ially.WB<; w/
Differential count)
ESR
C:::':~tiv~ prQiei~ .
Urinalysis
oramstain( lfnecessiuy)

GENERAL MANAGEMENt
Vital signs every 4 hours
Qianges in color/smell of
Amniotic fluid
Observe for signs/symptOms :, .
~ .

of choiioamniooitis
NST ( weekly )

> 34wccks
Tenn /Near Tam

Pelivery 34136wccks

Induction of Labor
Figure 44.1. Algorithm of PROM.

Scanned 8y: ~
 SECTION VI: OOMPUCAOONS IN PREGNANCY

POINTS TO REMEMBER

Diagnosis of PROM should be confirmed based.o~ the histol)' ~nd documentation of fluid passing
form the .cervix or from the .vaginal pool of fluid.

Should initial examination is negative. feming test. Nitrazine test be carried out "Ultrasound
evaluation may prove to be useful.ln .its confirmation.

The .onset of maternal and neon~tal complications due to PROM results in problems in
management.

r _.. PROM Js associated wi!h an increase in:preterm delivery, maternal and neonataiinfections, neonatal
. .. mpreidity ~nd mortality.

PROM atterm/ or those clos~ to term should ,beinduced in order to reduce the incidence .of
chonoamnionitis.

P-ROM before 32 \'leeks of gestation, 1n abSEtnce of chorioamnionitis' can be managed expeCtantly

till34" week of-gestation lf there are no matemat oor fetal contreir.dicat!ons. A 4a-:hour course of -..__
intravenous antibiolies followed by oral antibiotic intake for the next five d3ys be initiated .in this
expetant management.

Asin91e cour5e of antenatal corticosteroids should .be.given to .those with PROM tess-than 32
weeks ef gesta~cn .to reduce or mir.lrrt~Z.ettm Incidence oj Respiratory Distress Syndrome, lower
perinatal mo~lity as we!! a~ othar morbiditie$. ..
. .
~ . Repeat~ ceNicaLexamilic;tiOns .shoUld ~ avOided :or-minimized in cases of PROM; uniessthey
are ln.labor.

7. .Pasquiet J , et al. Effects of latency period after

1. Jazayeri A, Sulkin G. TQcolysis d!)e~ .not impr.ove
neori,atal outcome in. patients With pr..em~b,lre tup.t ute
of membranes. Am J Perinatol2003; 189-193.
~-. .Mercer 13M. Preterm premature rupture ohnembnmes:
Current !lpproac;hes to evaluation and -management.
.Obstet Gyuecol Clin N Am 2005; 3 2-33.
3. 'fried G, Sand A, et al. Endothelin 1 and macrophages
colony stim~lating fa<:tors. Mol Human Reprod' 2003;
9(p): 71~724 ..
4. Margarit L, et al. Amniotic fluid endothelin levels and
incidence ofPRQM. lnt J Gynecol Obstet 2006; 93: 18-
. 21.
5 . Mercer BM. Preterm premature rupture of membmnes.
Obstet Qynecol2003; 101: 178:--193 ~
6. Medina T, H!ll A. ~eterm pr-emature rupture of
membranes;"Diagnosis and management. JAm Acad
Fam Phys 73(4). . l74: 589-!)97.
ptelilature rupture of membtanes .on :! yean infant
mortality ( DOMINOS Study) E1,1r J Ob$tet Gynecol
2006.
8. Naef RW, Albert VR, Ross EL. Premature rupture (Jf
membranes at 34 to 37 weeks' gestatiQD:.aggressive
vers)ls conservative management..AmJ Obstet Gynecot
2005; ' 105: l2"17 .
9. l..ietnanJM, Bru:illeld CG, CarloW, Ram.seyPS. PROM:
Is.there an opt.i.m~ gestational <1-ge for.delivqy? Obstet
Gynecol2005; 105: 12-17.
10. Harding JE, Pang J, -L iggins GC. Do antenata l
corticosteroids help in the setting of preterm rupture
ofme mbranes? Am J Obste.t Gynecol200.1; 184.
11. Vidaeff AG, Doyle NM, Gilstrap LC. Antenatal
corticosteroids for fetal matUration in women at risk
for pretenn delivery. Clih Perinatol2003; 30: 825-840.
12. Egarter C, et al. Antibiotic treatment in preterm
premature rupture of membranes and neonatal
niorbiditj: a meta-arialyses. Am. J :Obstet Gynecoll996;

Scanned 8y: ~
 CHAPTER 44: PRELABOR RUPTURE OF MEMBRANES ., 675

13. The Cochrane Database of Systematic Reviews 2007
Issue 3, Copyright 2007.
14. Fontenot T, Lewis DF. Tocolytic therapy with preterm
premature rupture of membranes. Clin Perinato! 2001;
28: 787796. . 18. Carlan SJ, O'Brien WF, et al. Pretenn premature
15. Eh~nberg HM, Mercer BM. Antibiotics and the
manag~trteJttof preterm premature rupture cf
~cillb~e&. Clin Perinatol200l; 28: 807-818.
16. American College of Obstetricians and Gynecologists.
P:"emature ruptureoimembraues. 2005; 105-(lj.
_ ;~~~,-
17. Gopalani S, Krohn M, ct ai. Contemporary management
of preterm premature rupture of membranes:
determinants of latency and neonatal outcome. Obstet
Gynecol2005; 60: 16- 17.
rupture of membranes: A randomized study of home
ve111us hospital management. Obstet Gynecol 1993; 81 : .
61 6.4. . .
19. GuzickDS, Wlnn K. The association of chorioamnionitis
with preterm delivery. Obstet Gynecol 1985; 65: 11-
16. .

20. UQlde(llbergRL, Hauth JC.Andrews WW. IntJ'euteriue

inte.ction and pteterm birth. N .Engt J Med 2000; 342:
1500-1507.

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... ;. .

Scanned 8y: ~
 CONGENITAL M_ALFORMATIONS
AND INHERITED DISEASES
ANA MARiER. MADAMB~-:-BlJRGOS, MD

I. Screening fot Risk for Congenital Disease

a. History Taking for Risk Assessment for Birth Defects
b. Scre~ning Tests
i. Screening for Carrier Statu.$
ii. Routine Screening for Birth Defects in ,a low Risk Population
1. Maternal Serum Sreening
a. Screening for Neural Tube Defects
b . Down Syndrome Screening
c. Multiple Marker Screening.
d. First Trim~ster SCreening 'f or Down Syndrome
2. Combined Modalities Screening Test
3. Ultrasound Screening at 16--24 Weeks
4. Screening for Aneuploidy in the First Trimester

II. The Cat:Jse of Fetai~A.nornalies

a. ChromostnnarAbnoffiialifies
i. Trisomy 21
ii. Trisomy 18
iii. Trisomy 13
iv. Monosomy
V. TripiOidy
b. Teratogenically-lnduced Malformations
i. Mechanism cf Teratogenicity
ii. Drug/Chemical Teratogens
iii. Infectious Agents
iv. Radiation Exposure

Ill. Diagnosing Fetal Anomalies

a. Categories of Fetal_Defects
b. Structural Anomalies
i. Anomalies of the Central Nervous System
1. Neural Tube Defects
2. Hydrocephalus and Ventriculomegaly
3. Holoprose ncephaly

Scanned By: C
:~ ~=~ f~~ti}J<:J!v(j ~~~~i"al Mal~rmatioos
5. "Dandy-Walker Malfromatien/Cerebellar Hypoplasia
" : ~"t :.

ii. Faciai.Ciefts ; : .

iii. Cardi~c Abnormalities

1. Atrial Septal Deiects . :
2. Ventricular Septal Defects
.3. A.triov.entri~lar Septal. D~feets
4. Cardios.plenic;:. Sydromes .
. 5. Aortic Stenosis .
6. Hypqplastic l;.eft fie~rt Syndrom~ .
7. . Pulmonary stenosis and Pulmonary Atresia
a: Transposition of the Great Arteries
9. Tetralogy of F~llot

iv. Pulmonary Abn.ormalities

1. . Gysti~ f.\cJenomatoid Malformation
2. ConJeh1tal Diaphragmatic::Hemia
. .
v. Anterior Abdominal W31l Def~$
1. Omphalqcele
2. Gastr~~~l~is !',: . ~
3. Body Shill< Anomaly_

vi. Gastreintestinal Tract..Ahoin~nes

1. Esophageal -Atresia and Tracheoesophageal Fistula
2. Duodenal Atresia
3. Intestinal Obstruction
4. Abdominal Cysts

vii. Kidneys and the Urinary Tract

1. Renal Agenesis
2. Infantile Polycystic Kidneys
3. Multicystic Dysplastic Kiqney .
4. Adult Polycystic Kidney Oisease (Potter 'fype 3)
5. Obstructive Uropathy

viii. Skeletal Abnormalities G

1. Thanatrophic Dysplasia
2~ Achondrogenesis
3. Osteogenesis Imperfects
4. Achondroplasia

Scanned 8y: C
 CHAPTER 45: CONGENITAL MALFOmAATrONS AND INHERITED DISEASES 679

INTRODUCTION physician systematically l09k for risk factors for

congenital disease. The following mo_dalities are
Most pregnancies give rise to healthy used to screen for this risk.
newborns. Unfortunately about 2~3 percent of
n~wboms will have a major anomaly. 1 1n 2006, at Hist-or; taking for maternal conditions that
the Philippine General Hospital alone; llbout 1. 7 can give rise to birth defects
percent of babies w~re bOrn with a congenital Biochemical s creening tests
defect, ~(l more thM 20 percent cf these cases Fetal ultrasound
had . multiple anoma..lies. 2 Apart from creating M3.gnetic resonance imaging
emotional pain to the children and to the families Amniocentesis
caring for them, these. anomalies. also cause a Katyotyping
s.ignificant portion of neonatal deaths a.nd
a.dn:Ussions to pediatric intensive care units.
History-taking for Risk ?actor Assessmentfor Birth
\V;hat are congenital anomalies? Defects.

These are defects that may be detected for the
first tiute while still in utero, or seen i!nlnediately
at birth.. ordefeets that willmw.ifest ~ytime, even
-., lat~r on in life but had their .origins -quring fetal
]if~. Because {)( ~e technological 9;dvances in
ultras:q.u:nd a-nd molecular biology, newer
$Creenln~-techn:iques have evdlved towards earlier
detection of these .defects ih. t!.tero.
Early- dete~tion .-of fetal cQngenital anomalies is
importaht-ror the Joll?wing reaS.ons:
1. It b'Qpes to offer M increasing number of
therapeutic options in utero, if they are
a'lailable, whethetn1ediCat 9r S)l~~~ to ~ter
-the.."Severityofthe:congeriita1_disea~e:
During history:-taking, a patie~t is at risk of
havinJ? a bii-th defect if any <Of. the following
conditions are elicited:
Age 35 years or older at the time of-deli~~.ty. , .
(see Taple 45.1) - ;>~ ~,.,.:
Family or personal history, of birth deiecti --
Previous baby with a birth d~fect .,~'--'" .
Used certain medications during or arouncf"the
time :o f Gonception
. J~abitUal- al,cohbl Us .and smoking . .--'
-Diabetes prior to pregriaricy _-.;_ ' . --
Table 45.1;Matqnahig~relatt:d midtrimester risk ofD<>.wn's
syntf.rolll~ 'Cl,mt~ ~~V.:.P-19.kli.~~. 4 .
-

~. -:'f<rptuvid<n::lo~--gurveiltanceof tlie-_progressfon Mi<itrimc;sta:irlcid~ee Term Liveborn hriience

of the fetal conditioi1 caused _by the anomaly Maternal Down All Aneuploidies Down All Aru:uploidies
th~t ~ows for planning for appropriate timing
age
of delivery and .optL~al neonatal support. 33 1/417 1/208 1/625 l/345
3. Cost..benefit analysis for Down's ~yndrome 34 l/333 1/152 . . 1/500 1/2_78
.screening relies on the premise that many. 35 li250 1/132 1/3~4 1/204 .
wo~en .v,.i_U chc.o se to terminate an affected 36 1/i92 1/lOS- 1/303 1/157
pregnancy. 3 In our setting however, pregnancy
37 1/149 1/83 it227 1/130 .
38 1/115 "1/65 1/175 1/103"
termination is not an option, rather, -detection 39 1/89 1/53 1/137 1/81
of congenital anomalies will help prepar .the 40 1/69 1/-4 0. 1/106 1/63
par.e nts for the care of a baby with problems 41 1/53 1/31 1/81 -1/50
42- 1/41 1/25 1/64 1/39
and"" help them connect with support groups. 43 1/31 . 1/30
1/19 1/50
4. It helps provide counseling in all cases, 44 1/25 1/15 1/38 1/24
particularly to prepare the parents for the 45 1/19 1/12 1/30 1/19-
eventual less of their child.
From Hook and colleagues , 1983 {Williams)
SCREENiNG FOR RISK FOR CONGENITAL ~-
DIS;EASE - From the prenatal -history, conditiotrs that
suggest the possibility of birth-defects that are
_ Since not all anomalies are easy to detect, genetic in origin can be furtller 'elicited using the
different strategies have been designed to help the Ust in Table 45.2.

Scanned By: ~
 680 SECTION VI~ .COMPLICATIONS IN PREGNANCY
Table 45.2. Risk factors for genetic disorder.s :5
Matez:nal age 35 and ~bolie
Pattrnalage SO and above
'Medi~ean or Asian descent .at risk for tpalassemfu
Family history .o f neural tube defect
Family history,of -=ongenital heart defect
Family history of Down syndrome
"' EaStern EUropean, Jewish. French C anadian de1>e~nt.for
Tay$achs Disease
Mrican~American fer a f~ily hlst<>xy of siclde c;:U anemia
F~ bistozyofhettlophilia
F~bistocy of muscular dystrophy
Faiftilybiati:lry ofcystic fibro$is
Family h~totyafHuntington's disease
F.emily history of mental retardation
~us congenital anomaly, Chtc.moso1llal anomaly,
'. ~.uiy~t'llembet
DiabeieJ me1litus
Phen~to~utia ',
Hu.St()ifl5(p~o~.~g~$.:~rstiJ.lt>it;tlJ. '
. ~
SCreening T:e,sts
~.~e~.~t~~~~ce~pq~itiy~,his~cy. .. _ . fetoprotein-levels :P~ak, a.,t ,.-:1~ ,-w-~~ ~4.:
for :~,:geneti~ di~ iS.-,,eUcl.td,.,.~r.ee$g., tests.. . . . . .gx:adtia,U,y,:decline::.~er . ~3.-weeks. AbnQrnially
are::pe.rlotpt~. on~.both~ p.~e~ts::. to,{check-;i.Ltheyi., .
canjr the ~efe.ve ;gell.e. Th.e~ :inelude t~s.ts . for -
cy.$i!c li\n'Qs1s, :thalasSenlia that is.ill>Ottimt in
tlie . Asiiin popul:auon:.;:slc~le :c~Ir anemi&,
neiii'ot>1iilia; Tay~sae-lis ars~-a:s-e~ :arahetes iind
otl;le..~. Appropriate refe~ for pt~nat,i:ii :genetic
cotinseling canJ)rovide turther irifori:nation and
evaluation of the true risk of.the fetus.
\ a con-firmatory uhra.sound shuulq be
HoweveJi, .m 9st congenital anourcJjes ocelolr
<Wen Vihen there~ .uo histotj of problems fu the
ff;Uiilly~ Ro~fu1e scyeeiting tests des'i~d for ~l)e
low risk popul~tion of pregnant women are then
recommended~
. . '
Routine .screening tests for b.ir'ih defects in the low
~kpopuJation:
. Thes.~ tests involve a com}}ination of
biochemical and ultrasound modalities. s creening
i:s .done .for the most common anomalies, which
are ~e\iral tubedefects;Down- syndrome.a nd other
aneuploidies. By design; th~~e.tests do not provide
a dia,gnosis but help ::us o,nly to tdentify those
pregritmcies at risk~ Screenjng, how~v'er should.
be voluntary and the patient should be informed
. Scanned 8y:
of the limitations and benefits of the tesi They
should also be made aware that a negative result
does not .guarant.e.e that the child will be
completely free of a fetal defect. A positive test
how~ver is notyet d,i~gnostic of a defeet buhather
indicates that the risk is sufficient to warrant
further testing to q:mfltm the defect.6
Maternal Serum Screening
This is a non-it1vasive test perfortneq 14-22at
weeks of pregnancy. ~lso called the tiipie J
quadruple marker scr~ning t~st, it tries to id~
fetuses at risk of having a neural-tube defect,
abdoli14ta,l wall defect, D.oWil syndrome, orTrisomy
18. Mate.mal .serutn .l evels of alpha-fetQprotein,
estriol, free beta-human chorionic goila~tropin,
and in:hihin~A are th~n compared to a noiip;al
population curve of pr.egn~n.t wo~:en or a
predetermined Cl,lt-off.
1. .. Screehillg, Jor neurai. tub,e . :defecta.. using.
matex:naL . ser,.um.;.~lp:ha..Jetoprotein"..was::;
histod.caUy. .the ..fi:r,$.tAest. u t.il4ed.: 'this..
glycQprotPJ, is ..synthesized by the fetaJ yolk
. sac~ liver..QJ1~.::gas.t;rQint~stina~ tra.ct..A.l.Pha- .
elev.ated:lveJs.- .il~ve ,.an.1;1pper !it;..~i:. off,
of ~Mtor 2,s .rn:tilt,iple.of.tile. :,ti.J.~ ,fM9MJ at .
14 w~s ~riward~.. ~.e s~~piq9u$ .for~
ni&ecrere<:ts:nnnnr-:rta.nt:to..em~~ileie
tlia:t~~ee~g-~~~~--~-:;;rt-~~ee~ti9nai
~ge. Since this .sen:tm test has a positive
ptediti've val~e of~nly 2 ~r.ceptto 6 pertent,
sensiti"'J'ity.(>f90 peteceht proper .counscling and
rf~rme4. lil~~u~d .ca..t1:now di8gnosc tlose
to 10'0 percent of neur~J tube defeCts. 8
Neve:tthf!l~~s; if :tne:re is no evidence &f an
abnortnaljty bh ultrasound, a persistently
elevated alpha-fetoptotein .is ass'ociated with
other ;poot pregr.aricy .outcomes .such as low
birth .weights, placental .abn,Ip.t ion,
oligohydtanu1ios, andfetal .death. FortUnately
fo.lic acid supplementation has been .shovi.n to
red);J.ce t)le recurr~n(;f; of neural tube d.efects
by 72 percent and it should be given before
another pregnancy is attempted at a dose of
at leastAQOnig per cday;9: Its use :h a.s also '
reduced the risk of oral clefts by 64 peCcent. 10
2. Down Syndrome :screening: Down Syndrome
or trisomy 21 is associated with low levels of
C
 CHAPTER 45: CONGENITAL MALFORMATIONS AND INHE~ITEO DISEASES
--------'--~---------....-..-.----'--------~---,....
alpha-fetoprotein. This expanded the
indications .for screening .of maternal serum
for alpha-fetoprotein. Dow n syndrome
detec.tion rates increased further when
maternal age~i-elited ti:sk (>3.5 years) was
inctlrporat"!d because it is one of the most
powerful predictors of aneuploidy . .
Coilfu-matory testing with amniocentesi~ for
amniotic fluid lcaryotyp~ is usu~y offered. 6
Unlike neural tube defects which.a retreatable,
effective .screening and defection ra:tes for
Down syndrome and other aneuploidies. will
_..:;
not improve their .condi?cns sinec the~ are
uritreatable. The rnain t ean for screening
then is to offer the patient the option of .
terminating these "Undesirable pregnancies.
3. Mulqple Marker Screenirig fC?r aneuploidies: .
Se.nun screening nas ~n foeused on .Down
syndrome although it had f ue potential fot
det~tting other non- D.Own eht'omosomal
-a,."lo~aHes .l ike Trisomy 18. Other biochemical
m~rkeTS like sertJ.in human cho.r ion.jc
gonadotropin were :iiJ;trod~ced and sho'WP. to
be higher and u.nconjugatet}.e stri()l.lower than
' npnuafin a.rteuploid -babies. After c6mblning
the~'.Yalues of serum analytes, hCG,
uii(:Oiijugated estriol, With alpha,.fetoprotein
serWI:l-l ev.e ls, this con:tbinafron ap~ed to be
better at distinguishing a'll al;le\.tploid
P.&n~ncy hem~ euplojqone th$ll~mg any .
.onh...patamet~.alone . .A. compo.s1i:e~.likeJThOod
ratio .was-determined..by<a -'C()mbmation-. ot all
three a,na;lytes.and tilrthenxiultiplied with the
matermU age.:related risk hoping to improve
detection iates. Results ate co~oar1=d to a
detennined~reerung. threshold ri~k or ~~t 'off
which are ~ithet based on the niidt:iim.ester
rlSk.of.a 35 Y~old:woma,n Qr lt'-t hreshold that
is se1ected based 'on a combination of a high
detection rate with a low .screen positiV'e test
and has been determined to be at 1:200. At
thi~ level, a woman yb.unger than $5 year$ who
tests pOsitive Will"have a 60% detection rate
of Down syndr:ome. For women older than 35
years; this screening test ..cut off picks up 75
percent of Dovin Syndrome and 25 percent of
other ane'u ploidies. 6 These women usually
have confirmatory anfnio~e'ntes*s for
kary~typing after appropriate counseling.
4 . First Trimester Screening forDown Syndrome:
rhe need to detect aneuploidies earlier became
more pressirtg, terminations done in the first
Scanned By:
,.
trilllester were less more cost effective and
associated With less maternal morbidity. This
served as the impetus f~r earlier Screening and
detection in the frrstt,rimester. Maternal serum
free beta~hCG and P.r egnancy Associated
PlasQl.a Protein-A (PAPP-A) performed a,t the
. lQih to .14th week and. have been shown to be .
as eff~ctive as second trimester seru~
screening. 11
Combined Modalities Screening Tests
l. Currently, many centers abroad use a
combination .of maternai age.. ultrasound
measurement <?f .fetal nuchJrl translucency (a
thickerJng at t.h~ ~lc of t..'l.e neck of ~e fetus),
and Jests for maternal sei'UOl fr~ .beta--hCG
and Pregnancy". Associated Piasin~ Prot~i,rl-A
.(PAP.P -Ai as screening tes ts for Down
SYJ~~mxne, Trisomy 18 and heart defects. This
integrated .test c-omp.r ising the ultrasound
. . flridings and bi9cbeinical :tests c~rpoteiltially
.. '.i dentify 88 peicep.~~~m percent of .~trlsain)'' 21
.c ases w.alh.a false positive
. .
rate of2-31>emerit.11.12
..
2 . .Wapner, etaL~00~ , u~d suGllaCQmQlnation .
13
of:m~tunal age, riia~roaJ.serum' 6iocheisti}.r
a.n(i ultrasound 'para~eters iike-""iit\~hal
transiUcency. They used .a Do~ sYD,~e
cut off of 1::270 arid d~tected 85 peh~~ht of
cases with a 9 :4 petcent false PositiVe rate .
Measurement..of-nuch~.:.ttanslucency~however
posed a problem,sinceiHs su bjeet-to operator
variability and requires. a high resolution
1dttasound machine that n,ot all -centersmay
have.
3. Malone and colleagues 2003 14 further
expanded this. testing scheine by putting
together the first a,nd second trimester
screening methods to improve detection rate,
called the First . and Second Trim e s ter
Screening Evaluation of Risk (FASTER) Trial.
It is a two s taged test starting in the first
trimester with nuchal translucency (NT),
serum free beta-hCG, Pregnancy Associ.a ted
Plasma Protein A. The patient then retu'm s at
15 to 18 weeks for a quadruple ~creen of
serum alpha-fetoprotein, tota.l hCG,
unconju_gated estri~l. .and , i~bin -A.
Karyotypmg for any pos1t1ve result ei,ther first
or secQnd trimester was offerbct.. They
compared detection rates based on
karyotyping during the first trimester, the
~
~
 692 s5~TION;'!1:. CO~PLICAtiO~S IN PREGNANCY
n

~con.d.trimester an~ after integration of tl)e Neck

two grou,ps of tesw. They found that the best Cystic hygroma
-detection rates C{UI).e .from tl:le integrated test Terato~a:
:at a risk cut off l~v~l of 1:'3 00 for Down . .
syndrOme. -MoreT.ec.ent .evidence shows that Spine .. . . ..
<tm Use of.the Down syndrom.l'! c:ut off 'in the . Mye.olo!llening~ele
first triinester ~Y pi~s up 'majoritY o fnon- Sacrococcyf?ea.l t eratorn a
. DoWJ1animpl9idies: the
'C,!..ddition of-a trisomy
lB .. sp~c~f.iC- risk' a,lgQ~rithm ln -thO ~econd C~e$t . .
trimester pidi:s up
another 46 per.c~nt. 15 ;16 ' .Djap:tfrS,im.aliC. hernia
Pleural 'eff\isipn.

.Cardiac
9,ongenit:ii1. -a:p.~matie.s m.aY be found 4-.charnber ~cml.c abnortnaliti~s{requires fetal
. . mciden:tallJ .U:l~und ~g.-of a low risk . 2;..D :echocard.iogr:aphy) .
. i.f.oPp.; .f.pr ,b~~r ~:ndl<ia:tiorts .. A. .thorough
...ul~5G~'d...ev,~u~tiq-n:theti may feveal.tbat .that A~_omen
::x;rg~Iiit:al -.e.h9tnruy..nmybe ~.iso-late<hfmdin.g or Dubdenal atrezia
'it Js one' .' tJf :a.Jl:,.~r ,~f .Bnotn~ .corrt.:pdsi:ng a O~pJi;:iloq!le ~' .
$~d.rOitrt'i:ih.t't~~gtnefiG or.:)Jlulti-.fac;t~.rial ca~se. Gastr.o$Chisis . .......

~-;~~n,~~~~~~ted;:.~t~~~'~rp~tLne~u~~so~nd. ..:.'.Bnn~~ct:
:Sct-~:rr:tew.l'lrom't.l;i.~es~in'l:owrl~k~~patien:t$ . ... R~'ha,getiesis ~ ... ~ . . . . ..
...:r.~=!X>~:trove~.i:~~~v~::th:e -'d~~t;lo~:'rate. of .. . PolycystiC ki~ey
m~jor ~?m&..Ii~~ ,4!'~-~- ~n;,t.appar to l;)e ll~gh . . . M;ult;i.Y.stic 1tidnqs.
.. -~n~u6h;O#.!V~-~)._ .:J:7~s?.~rce~t-~~l'J!iideal ... ,. .. ,:Hyro~pp:t:o.si~. ,
:,cirmu~s~;.tl:J.e;~gi@.~:,;~g;,~!4~~~,~entP : :. . ,
, !fic;nv~er-:h1:~k:~~~un~s,~Japan, :$~~~r,J.:.. <- ...
i\ll,ti.C~s6'und ..~te~~m~ '!P:t .an9'itl?-1ie,$:--is -d~ne. Acq.,~ioqropli.tsia . .
roU:~~Iy:-.:m~::. ~ ;~~tei?,(ion . tat~ betwe.eu .6 1-100 -A~e:p.esis or l?o'ile'l'lJ.P<>J?~asia . ., .
per~nt.:~ ;R'~.~ , dpn~;:_d\?.~g the :Qtid '!'tiMester ~$.'er. :qqp~ ~ysp~sias eausihg dwarfisnf"
:~d-h:e~~ehek':~'-Or-fu~4'6U(;>Win15-:f~t;~i:h:<m.i;Utions . .. .._... ---.... -.. .. " --- .. -: .. <.. -- ~-

~we)k ... -: -.- .... - -.. .. u -me:~cr~erung fi.ttra.soun<Cfuills . oiit ..to

be
~u~picious., adetai!~d. :ulp-asound s~ (2D, 3D-
-Cor.r~:fet<!l age -of the ietu~ :b ased on biom~tric 4D). br magri.etic ri;s6rtan~-:i:magingto cOnfirm th<!
.~etets pre:s.~ri.c:e_ ,o f co~g~_nital anp_ni.,i:lie.s m~y be
.:FeW .nU;m~r: perfqr.tn.ed. if the .'fincUhgs ar e s:ugge;>tiv~ of a
Ad~~cy:--of. f~ gr.ew:tl} c~f~m.o.:~ofual ;:tno~~ly, fetal karyoty;ping is
.Pta~t411~tio~ sugge:$te-d. S9,m~ 9:dfect$ .a:reame:rp.ble to wrgicil
:Ret~l.wi;1J.::~itt.g ~d :oh :.fetal ~ear:t ~tc, activity or ~~dic~l- tn;atrnei).t, unfort~nate,ly a .great
artd:amount.,of aniniotic fluid
I, ' '
.m~oiity are not.
E~tilm oHern..I.otgan:sand structures l ike a
physiGill'ex~ in utero . Certru.i'l soft s.t ructunu fetal -markers :ieen in
1
.. . . .
.
..
.
the ,f1r..s:t :trimester -b.ave .been sho\vn to be
High -~~~lutiqn \llt:rasound is used to screen .asso~iated with eh romosomal anomalies like'
for th:e foU'(}wing commonly encountered m,. lchal. tr~nsluce~cy thickness and pr~sence of
anomalies: the nasal bone l;>etwec:m 10 to 14 weeks..

. .Head T~e- n:.u~hal translucency appears to .be the

Anencephaly b~~t ultrasou~d marker the3.t discriminates a
~Hy~~c~phaly. normal vs an. a:ffe.c ted pregnancy . 19 It is a
.Eiit~phalocele _ ~nolucency oan the feW n~ck.. The -NT .is believed
Intracranial sttu~tura:l :defects: cerebellum to
repres.en~ one of the en~ or' th'e 'spectrum of

Scanned 8y: ~
 CHAPTER 45: CONGENlTA'l MALFORMATIONS AND 1NHERITED DISEASES
lymphatic obstruction sequen.ce~'!i:fhe normal
measurement is between 0-Srtun depending.on the
fetal age. The prevalence .o f chromosomal
anomalies varies from 30 percent to 86 percent in
fetuses with measurements above L'lis value. It is
now incorporated into the screening parameters
for Dov.rn syndrome. 20 Unfo:rtunately.; its
measurement requires precise . measurement.
Possible sources of error for its measurement
include measurement of amniotic membrane, poor
visibility I hyper~xtanded fetal neck, nuchal COJ1d
and intet- and intra-operator variability. For this
reason, It is recommei;ded that it shmdd b.e
performed only by th()se -W'lth sufficient training
ind with hjgh resolution machines. , chromosome (monosomy) or inheriting an extra
Those fetuses ~itli .increased nuchal
translucency but normal kruyocype are still at
increased risk of e;ardiac defects. Thelymplledema
seen may be cardiogeniciP. natw:e. 21 .22
'fhe_"Jetall'lasa.l. bone at l0-14 was found to
be absent.:iri 73 perce~t df women .carrying Oown
syndtm:ne babies but absent in only 0.5 p.e rcent
ofnonnaHetuses;23. ijowever, the.'FAsTER trial that
$Creel1.edl::;w ri.s k women,the-absen-ce o f thena~
bone c!i~ not identify -the t::-a:s~s with Down
~cko'i:ttcl,4~s
A great number of major anonialies have b een
correctly identified using the tn:od:alities already
mentioned_ The. vacying.--causes of :congeni-tal
defects-:ar-e . the ..following chromosomal,
teratogenic. infectious, or. ma.temaJ disease. If a
-chron:&osomal - problem b SUSpected,
atn:niocentesis .o r umbilica4 cord . blood sampling
may be performed to obtain specimen~ tor
karyotypitlg. Unfortunately, in a large major:lt) of
fueCii$es, the ca11se 'c annot .l;>e found.
THE CAUSE OF FETAL ANOMALlES
Based on certain general principles the
underiy-i'ng pa tho'genesis .o f ce'r tain -congenital
anomalie~ can be classified according to the
Jollowing "causes: .
Genetic/ 'Chromosoma~ . pr~sence of a major abnormality, frequently leads
Multi-factorial
Exposure to Teratogens
Structural
Scanned By:
'683
Chromosomal AbnormaliU~s ' 1fi,
Chromosome abnormalities are important
causes of fetal abnormalities. They account for 50
percent of exnbr,roriic d~aths, 5-7 perrent of fetal
losses, 6-11 percent of stillbirths and neonatal
deaths and . 0.9 percent of abnormalities in
newborns. ln the United Sta tes, 13 percent oi
causes o:f c:o ngenital anomalies are due to
chromosomal de'fects:27
Aneuplodies are abnormalities in the number
of chromosomes that <nsist in the inheritance of
an extra chromosome (trisomy} , oi' tcissing one
set of chromosome {polyploidy). The .resulting
chroxno:s omal abnormality produce a typical
pattern of physical and functional abno~~es
c.ompl)Slng a syndro:rn.e.. The common
aneuploidies have well known a:nd well
documented clinical characteristics but manv
other~romoso:rruil abnormalities pt~~entOOtri'Pl~
probl~ti}'S Lit<liagnosis an:a prognosis>' - ~ :~:-~:::,,
Most aneuploidies . result in s~/ere
malform.ation3 that they usually do .nQt .sur-6ve
. beyort~ .the finif trimester excepf~for :a'i:tt~inal
trisriniies 13~ 18 and 21. > -;;. i ':~;,\f:..
:-=- ..
Trisomy 21 or.Dot.Vn SJ;ndrome
:,.. .-. - :"': ", .
THso'mY~l r esults'ffom haV:fug' tliieecopies
o.r . a :ffip1icate of'alr or impodan:t ~parts' of
chromosome 21. Maternal disjunction of
chro.moso.me21 is the c ause in 95 perdmt o(cases
while the rest ~dse from tr3.n:slocation or
m.osaiciSQ1~28
The newborn..shows marked hypotonia, tongue
protrusion, small head with a flattened occiput,
fla t nasal bridge, an.d an up-slanting palpebr~l
fis sure with thick epicantha l folqs. Loo~e skin
aro:Urid t}1e nape, snort fingers, single palmar
crease .and absent or hypoplastic middle phalanx
of the little finger and "saridaltoe" .gap are typical
findi'ngs. Some of these findings can be detected
by ultraso'Jp.d scanning. Unfortunately , the
to th.e diagnosis of Down syndrome. Hea.r-ttdefects !
o.c cur in 4'0 percent, particularly en~Qcardial i
cushion defects, and gas~rointestinal atx:~;:;ias like
. e~ophag~aJ,-the~e .patients
:i
. ha v a.n' irlcreased
. . also .
1
.,
C 1
684
"!; ,~.

risk for childhood leukemias and thyroid dise9;se. Trlploidy., implies that there -i$ an extra set of
The IQ of these children-do not go beyond 50. They chromosome th:!=tt i.s derived from eitper the
.are however very sociable and are ahead by 3-4 patetnal or maternal sie. P1:1-tern.a1. triploidy is
yeats of their mental ~ge. If the condition is due e.s~ted .with mol'a t -pr~gnancies :that rarely go
to non-disjunction, the recurrence-.r.i.sk in tmother beyond 2'0 weeks. .C ases of triploidy may survi-ve
pregnancy is about i_.~rcent until the age-r:elz.t~ up to the 3r<1 trimester but there is sev.ere
-risk predotninates. asymmetric .growth restriction, cardiac
abnormalities,
:,-...
myelomenin.gocele, .a nd -syndactyly.
U,ltc1s~und detecti!Jr.. for Down synqrome .has ...
been proposed using a co01bination of .differ-ent tp.e .p:resence therefor~ of an.y ou:e :major
-s onqgraphic s;ereening criteria. (Table 45.3) .antrtnaly should pr-Q!llpt the search' for other
ano:m.alies that :n:iay comp.ris.e a part of a
Chn:>.mosom:al S)'n~_?me.
-fi.b~e -45.3. Vl.trasoundscotbg for Down -s~dro:m~
. .
seore Once a ;group of -anotJ?.alie~ i~ observed.,
karyoty.ping :rn?,:y be advis~d . H-owever, if the
M~R.f ~mA!Y . 2 . :fin~g~ o-n. ~t:ra.:s,9UP<i. su;ggest thattbe condition
Nuch:al fbld:i!'-6mm .2 is leth.hl, the:~Y may be -counseled and th.eii
:siiort-:ra.nt~r . 1 -w isheS ~peeted. .
.s~rt hument!3 .. .. . -... . ... . . 1
.Pyeiectatiia > 4 tnin 1
Ec!i~SG-Net . 1 Tct:atdgen:ically induced. M alfo:pn.ations:
~~~~(fcki,i:fi:t _ ...... .. -r ~

-:--..;.;
,_:.._,...~,..:;
.._;.;. :..-.,..:..;..,:;~....,_~........._...,..._..,._,..,...:.....-...,;---::'-~~----:-:--- .-..- . A "t~r:P:t:9gen':~can:. be:.a.p;y.: :~fug, <ih~mical',
:infeijel,l.S:O.r;p1ly~ .agent C::." rp.af:eriiahlisease
:Other feqtiti;-es-thc:tt: qu.J. :pe detected mutero o!". alt~r'e.d. ineta~:li~ ~t-ate :.:wh~.ch affect.th'e
-:~rit~o no~.;:ft>i-zn.;patt''Of .th~' ind~ ~~ 'C)i.n:Oifu~ly : ,_&evJQF.i::ig.1hmfl~. :etp:pi:j.o ,.-or:'JetU:~ .-cau:si~g
.'.or ::~y.popta~.'9f.:mi9,dJ.-P.h~ :-of'the .s~~dit?;it. . .-..-sti:U~.:malfo~ti.ons-~or.d'w.iGtiona}:i:iisability .
saxidlli .gap tc>e.- after.~birth> :The :::Qiehanism:.:by...which these
te~t.Qg~$ .can: iff fue.f~s w ill depend :orr i:he
Tt-i.$orny 1'8 is as59ciateo: ;with a stl:aw.P:ercy- foll9~~ CQ~~
~s-EJle'fid; .c hor.oids ~~:srs~t -~bsent:9f2.~ . .... .......... ..- .-
~ -

-~lo~_DandJ.:;.Wa:llf_er__ Q...i~p.l~~...m~~ti.QP,,
fai.ai .:lefts, 'm icrognathia, n~chal.edeJn.a, heQ.I:t &p~- mu:st .o ccur dr;Itin:g a~le - $ge,S
defects, '~~~tic C.e.I:nia,. ~spphagealJi:tr~.si.a,, ofiJ;evekJp'-mimt
~tllpliilbctle; r~:Pai defect:;;, iny't!low.eirln;gqcele;
gto~ re.~tio~ ang. -short?nizt~ _of th~ . . ~hs. l. T..qe pr~imp(~atio,n.peri94, (two weeks _-pos~
ra~'apla~la, typ1cal.overlappmg finger~, club.feet. fe~tior..and. 'b efor,e -~plantaticm) is a1so
or reeker bOttom: feet. These fetuses 'd6 n6t survive cill.e4 t he '~all:or .r}p~e'" pziod.: This is th~ .t ime
b.eyopdt,n.e infancy_.s tage. 29 ' f.zygpte:dhiision 'into .fue.inil'er $l,d out~r cell
\" . .. . ..
'
t'ilass. Dainage-toa la:tge ,~ount-of c~lis can
Triso.m y -13 is associ f1t eP, W.ilh cau~ eQibry.o nic G.eath. If the damage t o .the
holQpro.seirc.~phaly arid r.e'La:ted fa<;:i~l cells ~s mil').i.n;lal, compen~atio,n is u~ually
a bptitmalities 'that iiui:nifest as. midline :fusion p,os.sibfe . ~rr<t fi'r,) anofll,a~eS: -are. opse.rved.
;d~t~&ts, ::l)l~n5ro'cbplialy ... C:ardia-G"and u~~r HiiW.ev:et; jf' the .ins lilt :l:pvo h:,e s'''a:signilk9.'il:t
abnormalities, omphalo~e'le. a:rn.o.~nt of the inne-r cell mass, .;,_ .q:ose.:.
d,e pendent redu c;tion in body.size,may-be seen.
, Mono~qmy or . 'fumer syn.dr.ome. There are two
types- o.t' Turner .syndr.om.e: the letha). tyPf! ?Jld 2. The einbryonic_p.e riod('2nd .to the Sthweek after
no~kthaJtype. Th.elethal type pr-eS;ents 'Witb'huge conception~ is the crucia1 time of
cyst lc : n.yiroin.a., generalized ed:eina, pleural organogenesis. An insult at this' time may
effu.s ion and ascites . or hj-Mops;and ciirdiac cause structural -malfo~ations.
abnot!ll~Htles. :rtie P:ci.n--le:f haf .type' . m,ay ~go
undete.cted but may manifest wi~h a. short neck. . 3. The feta'l p~riod .( from 9th week .up to terin) This
j

c
They are .females and a re usually. infertile. is the :time of c ontin1.;-oUs fetal growth to

Scanned 8y:
 CHAPTER 45: CONGENITAL MALFORMATIONS AN.D INHERITED DISEASES
~:~ achieve maturity .and functional development.
Certain :Organs remain vulnerabl.e to
teratogenic insults thrqughout fetal life
like
the brain,
Placental transfer -and dose-response relationship
in ~era!ogenic effects
The agent must cross the placenta in
suffici~nf amounts to affect fetal development
or alter maternal and placental function. It must
also consider the presence 6f placental enzymes,
molecular s~e. fat solubility, protein binding,
etc.
Teratogenic effects show distinc;tiue patterns .of
m:alfonnations
Since . there. are many genetic and
e~!Uiteli~' f~ekors Ul.~t can .cause .a . si.m~:-:r
anom.al.Yt~.r phenocopies, t:t may be d'ifficu1t to
determine the precise cause of lhe d efect.
However,i.U:.the defect is relatively severe and there
.a re three or more cases with the same rare
exposure then it is easier to identify the cause.
An ~j>le:is isctretino:iii whiCh js an infrequent
expos~~-~d a genesis of the ears have a ca'l.4se
andeffecf:trelationship. .
The ~ teratogen shbuld cause a defect in
animals.
It appears that :ifthe agent can -aifectniari.y
different species 1 the lik!?lihood of affecting the
human embryo increases. However, not all human
teratogens can cause ddects in .a nimals an
example being thalidomide .t hat causes
phocotn()lia iri humans but not in mice.
Corticosteroids on the other hand cause cleft
palate in mice but not in humans ... . -.
There must be a b~ologically plausible association..
EJ:Ifde~iolo'git;;J.:l.fi.i!:dirrgs m:ust be c dnsisterit
Mechanisms of Teratogenicity
1. Affects physiological processes:
Multiple defects cari . be seen with. a single
teratogen because abnormal phys~ological
processes can be induced in many different
cells al the same time. The most common
processes tha t are dis rupted .are: a) folic acid
Scanned By:
685
metabolism to form methionine n~ed in
methylation action for protein, lipids and
myelin production. It is also needed in normal .
meiosis and mitosis, and b) Fetal epoxide
hydrolase activity is weak and can be
overwhelmed by an abnormal aocumulation
of o:xidative intermediates or free oxide
radlcais, which ~.re m:Y.tagenic and
carcin()genic. An example of these tera togens
are the anticonvillsants.
2. - Maternal and fetal genetic composition
~: determine drug effects. An example is
inadequate maternal iritiike of folic acid in a
setting of homozygous/heterozygous MTHFR
deficiency . predisposes.t6 neural tube defects.
3. Homeobox ge}Jes are genes that are found in
all humans and confer .e qual susceptibility to
the sarile ag~nt. These are highly conseryed
genes t hat share a region of homol9gy. They
are r~gulatory ge.n es that ar~. ixppor;tilnt jn
"positioningvarlous body struc~~~r4~4g :the
body axis. Agents like retinoids acti:vat.-some
of these genes prematurely causing a :.c haotic
gene expression and abnorm~U'ties i-n 'the
. limbs and hindbrain. . -::~;~:..,,.>,.!~:.;.: ..~
4. Paternat exposure to drugs or, e~Viro~ental
influences may induce gene mutation in the
sperm ;or the drugs in s em inal fluid,can.teach
the-"fetus-;"" paternal- ge~ cell exposure to- a
teratogenic -agent-can alter gene expression.
Infectious Agents
Various infectious agents can potentially harm
the growing fetus via trans placental transfer.
(Table 45.4)
The I:Ubella virus in the first trimester can
cause cataracts and congential glaucoma, heart
disease iikeFDA and pulmonary artery stenosis,
deafness, m~crocephaly, developmental delay,
mental retardation, pigmentary retinopathy. Later
in pregna.ncy growth restriction is more evident.
Toxoplasmosis is a protozoal disease that can
affect the fetus any time in pregnancy. It is
transmitted through cat litter or ingesti~.Wof ~oorly
cooked meat. The affected fetus ~mfests
neurological a:nomalies like in t~kcranial
calcification,_hydrocephaly or micro.cephaly and
chorioretinitis.
~
~
 686 SEC-nON VI.: QOMPLICATIONS IN PREGNANCY
:~:':'.
~-------------------------
.t-

l'able 45.-4. Known .teratogen.s: Drugs or substance
sus~ted o.i proven to be human teratogens.)l
Alcohol car&ac defects, iomt defects,
craniofad..al ab~rnuilities like $h9rt
nose, m.icroph~ failUre to thrive
arm per~ist~nt irritability. ~er
dev~opmental delay, growth
deficier-.cy, poor coordination, mental
retatdatio~ Ab:rm, l~g
imp3jtm~t, cerebral palsy rd
ep~p~y-become man.ifes t.
.AnticonvUlsants Craniofacial d::fe<:ts, fmgernail
hypoplasia. spina bifida, neural tube
defectS;, car.diac and rer..al. antm~alies
GYtomegalovirus infection can affect th~ fetus
causing severe low birth weight, mlcrocephaly.
intracranial calcification; chorioretinitis. mental
and motor retardation. Fortunately. only'6 percent
'of w_feded fetuses manifest these fmdings_ .
The Parv0virus B19 is the :rnost cbmmon cause
of non-immune fetal hydrops. ft.c ause:s severe fetal
anemia due to fetal red blood-"'cell preGurs.o r
destruction. ~orne. cases have receive,d ~ utero
transfusion to correct the anemi~ that has led to
cardiat: ..fa,i.lure .and .fetal hydrops. 6utc.OI!le after
transfusion is usually .good.

r Vari~ella -zcster infection between 13 arid 20

.Nlisai.anifid ft;ce nYhoplasUi, .
stippled vertebraland femoral
epiJlhY:s.is. l~fetm i4'~~94<:y
. heinn~e;6f.lri.ve,lved o~s
. ~1-i'Sbgc~iliatil:i:o.riii:: b"cwt4 -imd
tkfonhii.tions'e:g, b"~dyNl~er
conipJc~; ,J;#idline. ~be!Jar:.at:rophy, ..
. . ....... ;_ .
~ \ . m.ici:Qp_~~:<Ip~a~~Y>:
weeks. can ca use congenita.l -anomalies iike
choriDretinitis , cerebral cortical atrophy,
hydrooephrC:sis, cut~neous and bone 'd(:f~cts.
Varicel1a .ffifectlon prior to. or during la.J?or a:nct
P.elive:ry. p~se~.~ ~~ri?..us. threat -of.djsse;mih~~ted
viseeral and, CNS irifect!qt:rs. Varic11a.))J:!.eum~mia
~ ,befatal .
. .

M~hSin~ Renalpl.pillary-aridwbuliu:'at:rop}ly, . Rcidi~n Expo sri~ .

Cbnverti:ri.g . . lo~ or:urin.Bry.~"Oncentl:at:qig:fl.bility.
. .En..--jm~
.. . Expqsure. to. .les~ -1jhan 5 =?.d.s has . negligible
inN!!~ .
.. . risk .of. . majo~ m .a Jfortn,a:t iqns. .. Ho~e':'er,
Retinoids ..: Ear defoririitie:J,.c left palii.te;. chiractedsiic. advers-e ..eff~ct';3. re;potted .are . .
. maldev~q.ptnent.qfthe .facial pones
r::iit:r:.o cephaly ~nd mental. retardation, growth.
, ;
..~=~~~%r~~cal restriction aJJ.d som:e ha,.ve mentioned. c~pod
leu:l<e.thias. -7'
.AndrQgs~n.of..:afemal~
.Je.tu~}es:ilisterone:arid. ~l;>Plic
steroHls.- Virilizaqon of'femali
p1A<iNesiNG i:ffi~ ~.o.~iRS
An.tll).eop}a~c Missingo~ hypoplastic..qigit.-;, 'cleft This part of t,ti~ chapt<!.r v.ill .give ex.a..ttJ;ple;:; ..of
(cycloph~hrun.ide .palate failureof:closiJre <if c;alvarium, the different type:S :of cong.e n.i tal _a.I}.omalies ,
methotrexate) craniesyn0S~sis, micro~thia, ~evere
l.inlb abnormalifie~
preventa~le stra.tegl.es-if any, tesfing, 'dia!7l9sis,
.~d tieapnent .if a.v..illlab~~- This .cl;l;;tpter can by ~o .
~bi<ds means be e~ha:4st'jve . a:.nd tli:e reader is
-r:c~e Yellow-. brown teeth.discoloration ~ecommended to lo9k ~p the following web sites.
~tifun~3 . fbr x:bore detailed inforriiation:
. {01'1$e9fuMn) Anomalies cfCNS :a nd skeleton
Fetus (http; / /ww:w.thefetus.net)
TobaCco FetaJ .g:oW:th restlicti:on
Online. Men.9;~~~ il;lh~D.bms:e. il'l;, .Man..
'COaine Va scular disr-uption lcadinf;:to skUll (httP: I /www.ncbi.nlm.n:ih.gov/Omim)
defects,.porencephaly, pefiveotiicular GeneClinics (http: r/ww:vf..geneclinics.com)
andsu bepe ndym~ cysts,cardiac Diagnostic rro:aging o( F.e~ Anomalies
anom alie~ ileal-in:farcts
(http:/ /www.fetalanomalies.or g)
Thalidomide Upper or lowedirnb phocomelia,
gallbiadder a.p lasia, duoqen~ atresia Categ~ries of. Fetal Defects
Methyl Mereury . Disturbed neuronaLcell division
causing .de;el.orm~ntal :d~y,: mild Mor.e than 3,0(}{) :d,iiferent qmg.enital
neurologkal ~age;mjQ:oeephaly or an~malies have b eeil identified. Mo.; t ' defects 1
_wo'ts e sev~re bram damage . ho;,.,ev~r. can b e explained ~n the ~asis p[ a ~ingle

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 CHAPTER 45: CONGENITALMALFORMAT10N.S AND INHERITED DISEASES

morphogentic problem that leads to a cascad of
:s ubsequent defects referred to as a sequence.
Ba-sed on .t his approach, most defects arise from
three different mechanisms.26
A malfomation seqtience involves a single
localized anomalous tissue formation that was
"progra!l\tnecr- :or detertnined to develop. This will
then -initiates a ohlaiil of subsequent defects fuat
.c an zn.anifest in different degrees. One-third of
fetuses wiU1 malfuTruations will have. multiple
defect disord.er.s that may be caused .. bY
ch:romos'Qrilal abettations. gene mutations or
teratogens, They have a :patt\ernof an:omalie:!ii that
comprise a malfoTmation syndrome.
A deformation sequence, on the other hand..
inv.olves ertemal mechanical forces tb.at restrict
the .:growth of a n9rm~ fe.ti.il sttuct::ut.:e: These m
u~~ due to:la,te utf!rine epnstr~m.ts on the fetus
and afe.,ofthe "itiolding" type 'because of f~tal
-ctowding; ;1'his is s een in mult.iple :gestation,
-oligohyd.t 8Jllilios or -f etal :malpresentatiprt like
dark sonolucent area. By 9 weeks, COU"(Oiiltions
of the three primary cerebral ventricles can be
appreciated. By 11 weeks, the brain is finally
divideci into the two lateral ventricles with bright
echogenic choroid plexus filling them and
intrac-r aniai structures and vessels become
prominent. The second trimester is characterized
by the enlargement of th~ brain mass as it
compares to the hi.teral ventricles and chorbids
plextis. ('fable 45.5)
The fetal spine has a typical d~mble raihvay
appearance on ultrasound. Sach vertebrae is
noted to have three ossification centers forming
an ar-ch. This tapers down to the sacrum. The
tissue. layers coveripg the spine can also be
inspected for .any defects. 32
.
t~le 45.~. Anomali~s .cftp..e centnti nervous ~~tem:-32
MalMte,~ie
. . . .

breech o t tra:n~e~ lie. Neurt.tl Tube Defects sri600'-~-~-~ --

~encq)baly and Spina hifida .95~{-(jf'"~:i r
Encepb,alocele 5% of cases
A dis~ptiqn $equence re_eu tts from a tn.o:re
scirete aeStr-uctioi;l of previou~>lY 'f().nned normal Hy~halus
feW tislh;l~~ It i~ u&ua.lly ..an .acddental external VentricUlo.megaly 2bbdoJ.:;,~~;,
destrtictivbffoil:e. like a ,va:~ulat or mechameal . .. . , . :.. .. :,:.1 :::.~-- \....,
force that prevents fUrther normal growth. Holoprosencephaly 1/10000. . .
E~aD,\-pl.es are v~~Cl,llat ac.cid~nb.. lUce. 5/1000_ __ ..
Agtnesis of Corpus Callosum
,b}:~JR.<ur.hage.s:_Jlt . o_c.clu.sions,..Ir.eqtiently.,s~en .in --- . .. ,. .":'

. fetuses ..oLmothets~ahusing: coci.ine, .or--a rare rtaoooo:

mechanical force seen in amnion rupture
.s equence. Microcephaly 1/_1000.
Destructive Cerebral V!sions i/10000'
SOmetime.s there-are abnormalities that~ppear Hydianencephaly .
identicarbut b~ve .different etiol0gies. Thse. are Pcre.ncep}laly
called phenoeopies. Sch.i.unceJ)haiy 0
...
Multiple defects that o ccur together and Choroid .PleJCUs Cyst 2%
develop as a result of a single cause is called a
Vein of Galen Aneurysm rare
syndrome. However, mu~tiple defects that occur
together frequently but:do. not appear -to -b e ' dtie
to a -common etiology is called an qssociation.

Struetunl Auoma_
l1es
Neural Tube D.e fects
Anomalies of t-he Central Nervous System
This conditi.9n includes a . raWge of
r he fetal brain changes . and develops anom~lies.The prevalence rate is slii'i)'ect to
throughout pregnancy. 'these are visible on temporal and regional variations. In :the1UK and
ultrasound. As early -as 7 weel~s gestational age, USA, it is about 5/1000 births, the majqrity being
the rhombencepha lon can already be seen as a a nencephaly and spina bifida. 32

Scanned By: ~
 .sECTION vr: GOMPUCATlONS IN :PR~NANcY

Anencephaly is a conditio.I:l :where there is .t he What causes neural tube defects?

:partial or co_mplete absence of the cranial vault
{aq::acia.} and second_a ry d~genei-ation of the .fetal There a:re a variety' of c~uses na.m ely
brain so that .no cereb.t al hemispheres are seen chromosomal abnormalities, single xp.utant-genes,
(anwcephaly:), However, the facial ~nes, thebt;rin maternal diabetes :mellitus, intake of teratogens
~tem. and l)Ortions .of the mid,-brain. an~. QCC'ipit:z.l like anti-epil~ptic drugs. These etiologic factors
boces .c~ be seen. Di~gnosis may be dif:ficult , can explain only 10 percent of .cases while the
during the firs~ trim:ester until the 11\h w.eekwhen . rest re.m ai:n .la-r gely unknown, 1_'hf! risk of
. . o~Sifi:(;a.tiol+ !}f the -cranial vault 'is expected. It is recuiTenC.I! is about 5-1 o pereent. rile .intake of
easier to diagnose. in the sec;o.nd. 't:rin'ie~ter' w.Q.ex:~ folic add has Qeen ~hewn ~o decr.ea:se this risk. by
the fen,ts take~ <JU a 1<frog.:.like~ appearance on SO :percent imp~Jing a .r ole -of :fqlic at;id <,iefi<;:iency
:ultrasoupd becaus.e -of the pr0Iilfuence of.th.e :Orbits ..fu the d~velopment of n~p;ral tube ue!ects. Neural
because ofthe a.'\ilsent crantup:1. This.-c.ondiijon is tu'b.e defects may . therefore .be p revented by
. usuauy fatal at ~.r...fu or withln hours. or. :days :fctter preconceptic.n folic .acid supp1e~eP.tation .i"Q. a
but~ . . significant nuniber of cases. 9.

En:cephaloceles ru:e .&;fects in th.e ~that

alio';'l the fluid..:filled meninges or- cerebral tissue
to herniate .outward .formir.g cy~t-l,ike :sU"l!.ctt,rres }Jyqro.ce;p'fi.<;zt~ is e:lii i. ,:a cter tzed by the
proi:hl.P..ing-out qf fu.e f.etall);ea<l. They cart" pe{ound a:tm.c:mhal inc:r:ea~e 1n the siz~ .Of t.he cerebral
most common.w .m thi! oecipitru .itgi~n ws%
ot. ventricl~s wbi!.~ veri.trictlLomegwy hdlia1ion.ofthc
. ca$es}~and~less :f reql;l:enwi n :the Irpntl)ethmt;~li1~ lateral :~...re~tal yentricles :Of .l()ttri;n en: ~ore. ~his
~rid.:::P~rt'~ta.:r ::l:e.Mons.. Tlie :.:i>_ro.gnos~~:... -iP. . de'velo,ps;~~:a;l:esu;!t::.o: ~~-cfum,. W''the"flp:w :<;if
encep~~ie. depends :en ..the- ~~~t,~f~:tmi41 the cerebt()$9~ fiuid c:a.vsll)g .ex:pj'i.ilsion:of the
tissue that has :,hern.ia:te::t-o:ci.t.The::: associatea veptrides and calvari:urn_ Qn ~ uJ:~und,. this is
ne~ri~t~_..morti.lity. is abonfi4.0_pei;~~nt:mui.. ~t~n~transv:erse.,~' P..f:;tP.e..f4U h~-at the
intelie~tual:'and ne'ur?ld~c?J: han,di~ i~:-seen: . ~- .level.oi ih.e.~cav:um .Qf.th~ . -~..P.~ ;P.!ll~<:id~ as
.more:;~-~-:s~_-:Per:cent :af:$urv:i\tq~::' .: :. . . : .... -<lila:~ }.ateral.~e~tt:i~~:gr~a;ta. :IP'~ :10-:l:nni. The
.ChoroiQ:s,PleXU.s;whlhjlotmani'~:UJ.~veptri<,;Ie,
. s;,_\nir.iJ;Jifidq:-are:d:efects_futi}!;: P.ural'':ar
.:.:AA, is :se.n to be pushed aViay ttbm 'the ihidline and
::-:
usually::located 'J
in tlie .l:umblr~~ ~ .:,tll'~t;
n._.. -an.
.o. . . r:.._.,..
:,.n.._.t:Ji> _ ..........
~ .--, . -~
"".......... ...
:. . d...:e d'. b:,.J~.. .a>,l~_r<'i:
._:!.e..":'.:_._.:-<.,...~_ ::ro::_Wl
~-6 ~ .
.:__-.t.-9.~f.--u.
: ;,_.U: . . 1_;d.
a~tesult_-e_;c:posefue-meni~ge~ :atr!f--:p:e.rve-s-: 'tO" tn ca~sassocia't:ea~mi:J:l~ .:tglaa:;:tr.-ii11he.
secontiJdam~ge:~ The-~ ~d:eftc~ ~r '~~all se:c0Iia1nfii:~tf~ ili~T{~d:_cir~0:itiference-:-m:~y- :Oat
and ea~ily missed but associated dei:ects ifl .the be l~ge rather 'it way be Sl'.n2.11er.
$kuU. :and brain .hav~ epha:nced th~i.r de~on,
Ass6ated .abno:rrna+ities d~tected .on ul~()ll;nc;i This condition is-seen-in abo\lt 2/1000 births.
inc1\ld~ -front?-1 bqne scalloping ;p.r-odutiiP.g the Ventriculomegaly may be seei?:.:in l 'percerit of
. ~le:rpon sigrt" or obj.itera tion of the:cist~.rP:al:Ii~~ pregftancies ~t .the 18'-2~ w~k -qJtraspund scan
withan ~absent.cerebellu:m:... .a:briortnat or
. , . . .anteiior a s an inciderital f"li"\.dirig and::q6 n ot develop
curvatu;e of th~ c-ereheH~r :he~i~phe~es . or cliniqJ.lly impbrtant.hydroc~phalus~
ban:i;l'xfa .~ign" due to h :ern-iation of these-
st..ru:ctur~s -in -~o the cister:n.a m~gna. Abo1;1f 70 A number of causes have ~en im:plica:ted in
perc:~nt:pf eas~s a l so h~:~.;~e. -~n_: as s qcl-at.e q . hydrQ\:ephalus sddi as chtOmo;:;omai and genetic
ven t~iiu:lomega:ly. 33 Su_rviv9 r s are Often abnormttllti:Gs,. c.<m;gen.i.W ,ini:e,ctigns.;. inb;auterine.
handicapped with low~r liii)."!:J :p~ralysis, h emox::rhages but .the rest ha.ve no known eti~logy.
incontinence of the bladder and rectum.
Fortunately, if the hyd:roGephalm~ is mild, The progrtosis de_pends on th..e presence of
intelligence may s.till be. normal. Some centers other malforma tions and chromosomal defects.
have attempted in utero Closure ofthe !:;pina'l;>ifida Although. mild v~ntricu1ome galy { O~lS . mm
to reduce the handicap risk. .Tills is because .the dilation) is associated with a good.prognosis, most
third trimester fluid is though~ to be. neurote5tdc. of them are 'highly associa ted with chro.i:nosomal
The pr9C~dil.re ~~~ai.J;ts to he ~ri-Jn.en;tal. . a bnopnalities i.ike Trisomy 2 l. About- ~0 per:G'e nt

..
0

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 CHAPTER 4o: CONGENITAL tAALFORMAl>IONS AND INHERITED DISEASES '689

of cases have some mild to mOderate developmental hydranencephaly, porencephaly and schizence-
de~y if"there are no associated abnormalities, 32 phaly.

In the 19SOs, attempts were made to insert In h,ydmnencephaly, the cerebral hemispheres
vent.-iculo-amrJot:ic shunts in utero in fetuses with are absent but the midbrain and cerebellum are
severe hydrocephalus. Unfortunately, the r~sults . prese~ed. This res\,llts b an ultrasound flnding
were poor :a nd did not improve fetal outcomes as of complete absence of echoes in the anterior and
compared to those that were delivered ai'ld middle fossa. It can be differentiated from severe
underWent surgery at bitth,'34 hydrqcephalus where a thin rim of cerebral cortex
. and a mid-line echo is always seen, lt results frotn
Ho.lo,p rosencephaly a widesp.r ead vas.cular o.c clusion along the
distribution ofthe intemal carotid arteries, or an
This is a malformation s equence that involv.es overwhe!m.ing :infection such as toxoplasmosis or
the brai.."'l .and face. 1t is characteri~!d by CMV,. or pJ;Olonged severe hydroc~phalus. This
incomplete cleavage of the . forebr~in or conditionis.incompatible with survival beyo~d the
prosencephaion into the olfactory and. opti.c bulbs flrst YeaT of life.32
horizontally, sagitally into . the cerepral
hemisphetel;l, ~11d transverse~y into the Potenrephal.y is Charactetized by cystic C{lvities
telenc:ephalo!l .and.:diencephalons. T}lree types withiri the brain tha~ CQmmunicate within the
are n;;>.ted. according to the degret."((f c!eav~e. The ventriculas system, the subarachnoid space or
~alobaT!~W-J>e is themostsev:ere tYPe and()rtly one
both. One Qr more cystic .a reas ~!!JO,.lfl}4~:~ '.the
sing.le .;y~~J:itricular cavity .is s.e en with. a Jus~d cerebral cor.t~x: that ccrnmuni<;:i;it~~' }\r.iJl.).;qthe
thaJarili.;:~Jn.:Jhe semUobar type, there lS partial
separatiOri ofthe_cerebralventrides. and cereb~ cerebral ventricle as s:en
on ultrasound. i~~.P.~9.ft.t~e
arte.r;1es an!! hemorrhages .!Jlt<? th>!;;Qr.aL<
heJDispheres p<jsteriri:rly with incomplete th.alan:u parenchyffia are poss}bte causes. 6.ther cys.t s in
,fusibl:L:~;tpe lobar type, n.o~al s~pa..ratign o f the
tbe:,brain that may looklike. pore~~PP3.Ji9~cyst~
thalaml~a ~ere'Qral vent:ricl~i; are seen, The .
are,arachnoiQ .cyStS.:Or:gl~Oependyn:i,~;.(o/~~~ ~at
cavU:rn:~t:,:ttu~ septum j)ellucidum 'however is
are usually fcund within the cortex/ ijf iif:t\i~ :Jnid:.:
absertt:.'The.se findings in the brain are typically line causing compression of ~e}, bdliii~'~'the
acc6rnpanied by facial malformation and
ou~me VViJI depend -op. the s~ ~9. t~pon of
microcephruy. The alobar and semi lo~ trPe may the cjst. Most fetuses develop normally .bufthere
. ~.ac::com})allied"l:ly:cyclo.pia...or--hypo~elorl.sm,faeial reii:iims ~n-"rnc~rease-a........
r:Is"k -o-r~im:ii~Tr=ea
. clefta-llke~nasai -hy:poplasia-or- proboscis -and neur~develo;Pmerit."" - "" - --- .. - -...... -..
usUally midline cleft p9late, occasionally bilateral
cleft pal;;tte. .
Schizencephaly is a condition where clefts .a re
. . noted in the fetal brain that connect the lateral
The i?cidenq~ is about 1 per 1000. 0 .~~s. ventricle to the subarachnoid space. It may arise .
Forty to SIXty percept of.<;~ses ~e.as~Clat~ Wlth as a primary developmental disorder, ot may be
.clm>mosomal abnorm~ties, p&rtioW.arly 'Iliso.rp.y . . , due tO. bifuteral occlusion of the middle cereb.r al
13 .(7S% ofcasesl, or wtth monogenic ~yn:dromes arteries. On ultrasaurid, bl.lateral clefts are noted o
like Meckel syndr~me, autosomal dommant or a on the brain connecting the ventricles to the
recessive gene dtsorder~, Other cases have no subarachnoid space. The cavum of the septum
known _c aus e. Sporadtc~ non-c~ro:m?soi_Ual pellucidum is also usually absent. The out~ome
holoprosenc.ephaly however, carnes With lt a of babies with schizencephaly includes severe
recurrence nsk of 12 percent,33 ~eurologic and develo'p mental" delay and
The alobar and semilobar types are uniformly seiZures. 32
fatal. The lobar type i~ associated With significant
mental retardation. Dandy- Walker Malformation/ Cerebellar
..... ' ~ .......
Hypoplasia
Destructive Cerebral Malformations . :-~
a
. . This is cotnplex spectntm of m.alfoh:natioris
This is a range of disorders that result from that affect the cerebelh.iin, vermis and cisterna
vascular occlusion in the b!"ain. This includes magna and has three variants:

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690 St:CTJON V1: COMPLICATtONS IN PREGNANCY

1. Dartdy-Walker malformation, the most severe
form, includes complete or panial agenesis of
the vermis and an enlarged posterior fossa or
posterior fossa cyst {> lOmm). 'fh~re is
associated hydrocephalus and defects outside
the - brain~ more than 50 percent of eases.
2. Dandy -Wal}cer varja:t>,t or partial -a genesis of
the cer.e bellai vehnis without any enlargement
of the j)ostetior fcs~
3. Mega-cisterna magna with a notm_a l ven:nis
and fourth ventricle.
.
This condition iS seen in 1/30000 births. It" i~
seen in-a n~ber Of elu.'Otnosomal anomalies the
. .
inajoril Me Trisomy 18~ or l3 and triplQi(J.y, .and is
associated with more than :SO g~.tic syn'drotnes,
congenital infections orteratogens like warfarin. Less
frequently, it is an isolated Jlnding. The mortality
-tate is greater than ;2~.&.. while ihtel!ecititJ:l and
neurologi::ai. impaimient i~ above -$00/o.~
:r-.~iii "CbJts
TW~ m~Iud~;;~-. ~- wide-.. S:p.e,~tr:Um. -P.f. tl~ftill_g .
-defects-that may. be linilliter:at.-~Uateraroi' midline
:dtectipg the up~r llp; plilitte; or bOth;_ Th~.seve;icy .
van~s~w~which~l:llaY. :D
. e'lUilfui:i~ -~i~lii;xear
~~ ~dentation_ o~ ~~-'up~r)l?.:br: ~d~~t ~(!)r:.the .. .:pement~wben:;two:m,t;>~g$-~atecte~t-1Hhe:father
,50~ :palateo~y)o ~~siV~ -4~!et$-. ~f_, fueSaclal-. , _is~~e;#.,;the.-risk.-q! :~Uf'renGe i::~ 2, perc~ntbut
boris:~d tissus. A' :l~ftUp ~i~y '$tilrt t(s a
-~ - in ,th~- ~pper lip atl~- ~d$_~to 'e l)o~tiil
CJe1t~ti:sjii3_y~iiivolV.cHhc~$0f~.~~J.iat"d.~pcilirte_;
The prognosis depends of the extent of the
defect and -associated anomalies. Problems with
swallowing, t'es~piration and of cou;rse cosmetic
issues have been addressed by advancements in
surgical t.ecluliques. However, the .prognosis really
depends on tbe pr.esence of other associated
anomalies that ClaU$C greatl!r morbidity.3;
Caritkc AbnonnalitleS .
Heart abnormalities are one of the rn:ost
common congenital defects s~eri in a newbom yet
they may be the -most ditfi<;:u)t to pick up by
ultrasound while ~ .utet'Q. They are seen in 5-10
per 1000 livebirtbs and in about 30/1000
stillliutbs. Multiple ~uses an give rise to cardiac
an()malie$ in tbe fetus. These include
environm-ental and ~e-netic factors, maternal
cli.abe~s mellitus, tQlh!.gen disease, viral frJ!eetions
like tubeUa M4 drug e.~sut~. Ninety :}:>ercent of
-r~::u~s with Tris()tn,Y ~8 -and i3 have cardiac
abno~~ti:e$.;- SO. ~nt in 'Trisoi;Oy 21 -an<l 40
percent :m:Tumer:$,Yri_
drt:m?.e ,---: -
. Ill 'the-~ce of-a gene.tic--sy_pdro~e. a ,history
of~ ~ibling'With a heart de.fetin:crea,s~ the risk of
- ree~e:':tjy.-~ ;~~~~-8nd-ulls jh~~~-.to .10
ir the !noth~r is affe.ted, the risk tjses to 10
percen-t.-1B __
. ~ ...

.tlie a1veol3.r- ridg~l. .-sometline~ -teahmg--th~~noor 1'he ifnp()~ee-~.f~nuig iUid delectio'ri: in

of the nore and orbit. Utlilate,::al :i{l.,volve'ent is this. high rlsk .ftro~p-is ti> allow ~e fqr teferral to
J;Dore romm:on, usually :the left side. The inci<lence speCialiZed center$. All risk .factors ;men:tioned
__.i$_abopt 1 in-.800. hi about 50 .per.cetit of cases . above -~ indications for screenirig that includes
both lip .futd palate are involyed~36 a to'Utin 4-chilplber viW during the. 20 week
ulfraso~d scan. tb.at I:Q.ay detet .3 0 percent of
. : :Facial cle!t:s. are .cau-sed by a failure- .o f th .Jm~.j6r ~ac ~~riiaii~s. Also -at risk .a,re those
. . fu~ion -_of the four
me~etithymhl '.:QUtgrowths, th~ fe.tu~s ~~-lrl~~d nuch~ trcmslucency:in the.
frcai't!Hiasal, the mandibular :and the pa,it:ed l0-14 week _scan th~t s~ould be referred to a
maxiuruj swellings. A-cleft lip a~ :an i~olated sp~dalist for ech,ocardiogi-aphy.
'c ondition i:s seen ao percent ofthe.time. 1Wel'):ty
p.etcent however are associated with genetic Abo.ut 50 :percent of:ventr;i.cplar septal d efects
syndromes. Ari 'isQl~ted cleft palate on the.other are isolated, wniie the other 50 per-cent .form part
hand is m<>re commonly as.sodated with about of a complex of hel;lrt -defects. Depending on the
200 genetic syndromes. Associa ted anonuilies .!U'~ . locatfo.p of the; defect it can _e ither be
seen in more than ~Opercent of ~ses -Wi$ isolated penmembranous, irilet trabecular p r outlet.
cleft palate than with cleft lip and palate :( 1~%)
All kinds of pattern of. inheritance. have been Atrial Se_pta..l Defects
d e scribed. Chromo~om:al anomalies are m~nly
trisomies 16 and 13 ln 1.:.2 . p~rcent .of t::ases. This involves either-a defect above th,e fotdmen
Recurrence_'is type specUic'.ij.Ild Will be_similar -t~ . cwale .($eptum s~etindum) or below th-e foramen
the index case. ouale (septum primum). Defect~ in the atrial septum

Scanned 8y: ~
 CHAPTER 4S: CONGENITAL MALFORMA110NS AND INHERITED DISEASES
secundum is the most common type of anomaly,
It is usually isolated but may be associated with
other heart defects and occasionally some
syndromes. .(Table 45.6) Ultrasound differentiation
from the foramen o...al~ maybe difficult unless the
defect is big. Most babies in utero thrive well as
well as in the postnatal period.
'fable 45,6. PrevAlence of congenital heart defects.38
Incidence
ASD l/3000
VSD 2/1000
AVSP 1/3000
Cill'dlosple~ Synckome 1/10000
Univent;Iincular.fleart rare .
. Aortic.Stenosis 1j7000
Hypqp~ Left-Heart 1/1'0000
~n.acySteilosis 1/2000 '
Ntr~ 1/10000
Co.tnmcatM~onnations
~~sitipl:l of Great.Arteries 20-30%.of CHD
Doul>'ieco~tlet Right Ven~cle 1/5000
Te~ogyQfFallot . 1/10000
Tr.mcis Arteriosu:~ Comniunis 1j30o0
Eb~tclit Mortialy/ 'rr!cuspid Valve
~~ 1/1.0000
~' .. J
VentricUlar .s eptal Defects
They ru:e not associated . .rith -hemodynamic
pro.'bkxn.sc.:Nb.ile.in .u tero .because the right.and-1eft
\tentrlculo.r. ..pressures .are...equal, More than90
percent .of small defects close spontaneously
within the fu'st year of life, Large defects present
with congestive heart failure and are tre-ated
medically: Sutgical closure may be undertaken
and has been~'shown .t o have a survival rate 'o f more
than 90 percent with a normal life e?Cpectancy.
Atrioventricular Septal Defect (Endocardial Cushion
Defect, Atrio.v~ntrieular Canal)
Th is .is .an anomaly :of the central core
structuresoft heheart.IUuisesfromtheabnormal
development .Qf .the apical -portion of the atrium,
. the ba~ :potion of the interventricular septum
. and the atrioventricular valw!s. The defect results
in the fusion of the mitral and tricuspid valves
forming a single valve that bridges the ' two
ventricles which at dmes . is .incompetent. This
incompetent single valv.e allqws regurgitation of .
blood from the ventricle to 't he atria during systole
giving rise to congestive heart failure. It represents
Scanned 8y:
' 691
'. ~- ..
7 percent of all congenital heart d~fects .aitct found
in 1~3000 births. On fetal 2Dechocardiography
and Color Doppler the diagnosis can be made
easily when the regurgitant jet of blood is
.. visualized if the single valve is insufficient. The
diagnosis is more. difficult with a competent valve.
Atrioventricular septal defects seen in utero are
usually atcompanied by heart failure and cany a
poor prognosis. Fifty percent of them die on the
. first year of life because of heart failure if. not
corrected surgically. If sur.gical correction is done
before Ei.~en.mengerization sets in, survival is 90
p\!rcent and long term .:Prognosis is usually good.
However, the ultimate prognosis depends on the
presence ofother anomalies since t.~ey are usually
seen in fetuses with chromosomal abnormalities,
50 percent of them have aneuploidy .
C.ardiosplenic Syndrorn.es.
... "...
This- refers to ari. anomaly wherein the fetus is
composed of either two left sides.or. two righf'Sides
also referr~d .to as right o r left iStlmeriSriir -ij' the
left side is absent then two right miri'or;jmages
are present, no spleen is seen. If the 'rightSide is
absent and two !eft sides are Sf!en, ;the;efP~t.be
more than,one spleen .. Other:u:npau-ed org~s:hke
the liver, stomach and spleen .may b:e:~~erit;
midline or duplicated. In.ldt isomerisnt/tht';:tight
atrium might be absent which is the Sea:t 'of tpe
pacemaker and fetus c?xi,pres~p.t with AVb1ocks.
T-his -abnormality-jsassociate'd Wifutli'"e -~bntifftra;l
disposition of the-- atrdomtnal otgaiis a:na:.is dtiP.
to Ute diagnosis. Prognosis for the fetus is usually
poor.
Aortic Stenosis
Stenosis of t he aorta can present in three
fortns: a) the supravalvar type that involves a
membrana over the sinus ofvalsc:rlva, ora localized
narrowing of the ascending aorta or diffuse
n a rrowing of the aortic arc~; b) the valvar form
have thickened, dysplastic or fused aortic cusps;
c) the subaortic type has afibr.o us or
fibtomuscular obstr:uction or a . thickened
ventricular. septum obstructing the outflow tract.
Mild cases are difficult to diagnose in utero but
the severe type have a hypertrophic leftY.entricle
that can be occasionally diagnosed ;-'i'i.lr utero.
Lesions usually remain stable in utero. /.itenatal
transventricular balloon . valvuloplasty hc;~.s been
attempted in the . valvar type since these cause
heart failure in the fetus and newborn. The results
~
 ~92 sECTION VI: COMPLICATIONS IN PREGNANCY

~e remaln uncertain as -of this tim;e. Balloon
valvuloplasty carried out.-in. neonatal period is
need~ in &0 percent of ca~s while surgery is
usually peiiormed in the JU'St 10 year:s of life.33
Jiyp~f.cistic [;eft Heart SyndroTT}-e
A spectrum ,uf. ~omalies characterized by a
vecy small left ventricle With .mitr"a.l-J3ne/or aorti,c_
atresia or- hypoplasia. The bloQd .flow {a the head,
neek ~d- co:r:ouaries is -~upplied, in- .a retrograde
manner-via t.lie .d uctus artetios\:ls. This conditjon
is.~w~11 tolerated frrutero' b.ut .the p!"'ogntrsis i~ pYOr
shown r1ot to cross but arise parallel to each other
as -they -arise from the base of-the h~ While .in
uter:o, the fetal circ\l.lation allow~ normal
oxygenation. After i:!irth, the- outcome will depend
on the amount of--mixing of the two citculatio~s
and , this depends on the other concomitant
defects. Surgery to cor:r~ct the a.rl8:to.:.:aic and
physiological connections is usually perfonned
within th~ first.tw9 weeks of life. This i.s associated
with a 10% mortalitY rate and a -good 10-year
follow up. .
Tetralogy cf FaUot .--
.~

at''Qlrth':and/25 percent dit in~e :f~t'weekfrrfe

'Un!es:s treated.. 0ptio-ns for f:t?tinent a,re.qu--d:iac This. anomaly has following features: a) mal-:
.tftil:splant :or No'rw.<>Od.-~pmr in sev~ stc::ges. alignment V.sb with anterior dis_placement of the
Recently; the pa:1;holo;t~ic ch~_n__ges ':le~ding to infun9-.ib;uiar' septum with subpulm'onary
hjpopUtstic ldt heart pathology -Q.as ~n s.t'..Hlieci- narrow.ing and overriding of the aorti~ io:ot-,
~Y hiihd.e!inition Ultraso:Und: .it -apgears that :ln. b) demonstra"ble con.qnu!ty be&:~en. :fi~e n.gb:t .
some-tasds -pjogr~s:siort .to HLHS is:Q:ue to critical outflow tr:ad .and t..'1.e pul.G:lonary tn.mk arid .if
.~ol$c:~t6os~s.-a..'ld may be -~enable to in..:utero co~ection la~kt,"lg/ pulmonary atresia .d!;;v:clops.
'bhll(?bn:idil~rloiii~t:dtiru..iao.itic:steh.o.Sis;;using:-a: . It' cart b:~ -a~s<>"ciate<:f'w:ith ~ V~D. ab'sent
.:perCi.rt:arloiis:-.a.J'rpr.OaK!3 ? :: .' puhnona:tr;'Y.a1ve .. J.'Ii~rtro}>hy~o.r-:ogE_t:vwbicle
. : : . ._ is seen ill posfu_ci:tallffe/ Thi.s cottditionisa..rti.~ble
.Puirrwnafil::Steno$~- CzndFi;tl~ ~1\.ti~a to.st.lrger)_r V1-t1pt. 90 .perce:nt,stiiyiy~ :rit;e.lf surgery
.: :: . :.J~. .... . ._. .- . . .. , . is.perf6tii].ed!m .-t he 3lil.fu.-ortth.;b{iife.~
. :'~Ji~:;:t:lno-mlrl.yr.inL~~QIY~e-$;J,th:e:~~-u:S:iO~~~~oJ:!?th_ef'. ... . . . ~
-~O:~.,Y- ~t"S~gl.~:g,_ns~ht~~~: incr~as~A: . ~onatf-.~.n?rinallties
.w.o'f-kl(iad: ii:n: ~:~the..::i}.rg:P.t-. ::V.entt-i,de c~~sing; ...
.;a~.dtQ~PY :Of ~~ v*n~cm.a.r .w~~. -If mjld,.i Coin~on co:t;tgenital al.mormalitie~ -affeclmg
k'~entloq. j~ not :n~eii. 'Seye~ .s~~osis with the'hritgs and their.prevalerice40 ' . .-
.-.!i.~t:,.Ye~Ci.t!lar~~~~r!~<Gh~~~~s~~~c.;Qui~~.!I~i :..~::~~~.-~:. :~=:~.~~.--:- - . . ..:-:-- . ,. .
J;~ firllu);:~ an:d b a11Qbn valvtilo.p~asty -tP,a_y be Cysti,c Ad~omatoid
n~ed.,ir:Cape.diatd:y ~h;th;e. ne.:mate wit.h.e):CcelleJ:!t - M-alformatiDn (CAM) l :-4'0 00
lcn,_g 4erm .ou~rnes. .Dia..p'l:UitgJ;Oatic .-Hern.J.a . 1:1-0oQ
PleurM ~liusions a'Ssocia~ with
Pulmonary -atresia With 1;1.n 'enlarge.d right ascites, hydiups
V.e:q.triCle hav~ high ifttrau~~tine and p~rinatal Seques.tratious ~f the .Lung rate
mp$litj.. Qn.. ~~ -e.ther .han!i~)f.th.e right.ventride
is ;4y.popJast'!;c, bive.n:t#ca!ar t~\ir:giG:a\1 :r:ep~ni?:Y Cy~c ~denpm.atoid MalfQnn;icn (C.AM)
:deqea~e moii:itlicy :t0' 4.0 ,j:)ercent: . . .
This ts .!5e~n as a-hypet:echogeniC-cystic, miXed
-T~positipn ,ot the llieit A:rt~il~s or solid pulmonary tum~Yr seen on ultrasound. This
is (lue. to a develqpmenW anomaly .ari.sing from
This is an :abn.o rma.lity ,whec-e the aorta ari~es . an over-growth. of the t.rminal respiratory
tp.tally, or-':in part, fromthe:ri~tyenmcle'while the bron.chiol~s forming cysts~ lt -is predominantly a
pulmonary ar:tety :~ses 1'r:om.-tlie1e.ft ver;ttricle. unila~eral lung or S.in:gle Jo be involvement, with
There -are other..associated c.ar~a~ ahnor;malities equ~Lptedprnina:nce- of left~or right lung, altho\lgh
like VSD, pu:l'm9rracy - st~p.o s-is, -mitral valye involvem~nt of all lung tissues have been -~ The
?Uo-malies 'and unbalanced. size of the
ventride.s: lesion~ are:.either- macro cysts CAMtype 1 ~ 5mm
_Th~e -~ compiex:anom.cili.e s d.ifri~Itto dfagn~se in.diame.ter},. ot mixed :(CAM:. type 2f~r micr()cyst~
.in ..1,1teto .sirrce.. mo'st CftS.e ~ h~~~, a riQrmaJ tha t.appear solid (<'5 mm.in. dlame,tef) CAM. cy-pe:
4.-cham~r .v iew W:i.th normal sized ventrlde;s.' The .3~ A m~dias'tinal shif~: corr).pression of the heart
. diagnos~s i s .made when the two great .vessels are and ~omp:ression of the rp.aj or vessel~ in the

Snanned 8y: C .
 CHAPTE.R 45: CONGENITAL MALfORMATIONS AND INHERITED DISEASES
thorax, and pulmonary hypoplasia can lead to fetal
hydrops. Mortality is high in
bilateral disease. In
stable unilateral le.s ions without hydrops. the
outcome is generally good after s urgical resection
postna:t~. If the neonate is asymptomatic, surgery
may not be necessary.40 .
'COngf7nital Diaphragmatic He.rr..ia
Since the diaphragm .is completely fanned by
the gu. week of age; a defective diaphragm will allow
he~ation of v isceraf contents into the chest as
early as the lOthl2th week of age when the
intestitles return to the abdotninal cavity and pent:Qnelln;l. p.nd amnion herniated 'into. the 'base
when t he physiologic mid ~t herniatiQn resalves.
The .stomacharid intesth-les or liver may be seen
in the thorax pu$hing the mediastmum and its
<:ontQlts to_the ,o pposite side. Polyhydtamnios
dev~ops jn 75 pet<;:~U.t t>f :(&.se:;_ , a;s ..a J:e$Uitof
'it:n~ed fetal swt:~~\oW:ing beca.'llse of.cotnpression
<if the;,~phagu$ hy the her.niated viscera. The
greate~t.--pr()bletn is. p'liln:toruuy hypopW:sia t:hat
carrie.Si~dugh mortality rn.te. The bronchial tree is
fullydevelop,..-d by the 16th week of age but further
growth in size and number of t1le alveoli and the
blOod~ssel$ t}mtac~Dipany tham continue until
adu}fl?()Q<i. The-dW.p~gmat,ic lle_rrtia.restricts the
thota~;.~pace and this limit$ alveolar gt()Wth
lead,in:g' .to purn.onacy hypoplasia and ptilmon.ary
hypertenSion. the most feared.complic~.:tions. .Poor
pro~stic si[ms ~ the foU9wing assQdated
chtP.mQ..sotnill.1mO.rnaliea:(pjitti~ 'Tti$-omy :lB,
.13, ::tetrasomy.~l2 .p ..in. 5 0% ,of-.cases)y-henri.ation
before 20 weeks when irr.eve~ible damage to the
bronchial ttee ~d vasculature would be jnevi~ble.
seve-re . mediastinal compression, and
polyhydramnios. This simple qefect carries with it
a 50 percent mortality rate .Atte'i:npts at fetal
therapy by endoscqpic occlusion oft.~e .fetal trachea
with a l>all~n to .a llow retepticn of -pul.tn~tiary
secretions h~ve been perfonned in. hu:n!ian fewses
with dia:phramuatic hernia l:>~t the nun:lber of.cases
. are too few to draw conclusions.
.JU1tenor Abdominal Wall Defects
The normal fusion of th:e four ectomesodermic
fold is expected by the 12th week. At 8-lOweeks
gestation, all fetuses demonstrate a physiologic
mid-gut hemiation at the base of the unib'Uical
cord 'that contains the fetal intestines: this
normally retraCts into the :abdotninal caVity .at 11
weeks and 5 days and leaves the abdonimal wall
in~act.
Scanned By:
693
Congenital Abdominal Wall Defects:
.Omphalocele 1:4,000
Gastroschisis 1:4,000
Body stalk anomaly 1:10,000
Bladder and cloacal extrophy 1:200,000
Omphalocele
An ornphalocele ;esults from the failur.e of the
mid-.g ut herniation to regress into the abdominal
cavity. The abdominal .contents including the
jnt~stines, liver and spleen covered by the
of the umbilicai cord. Sometimes, the
~phalic
portion o.fthe ectodermic fold.fails to !us~ resulting
m . the Pentalogy of Cantrell prod:ttcing an upper
tmdline om.phalocele, ante.ricr diaphra_gtll.atic
hernia, ectopia cordis, sternal cleft .and
intracardiac defect. The caudal portion ofthe fold
can . also be defectfv.e in w-Mh -_:c ase 'the
?Il).phalt>celeis associated With:blaqd~~ '~Qphy,
1mperforate anus, colo.n ic afresii{1J:!tt~~acral
vertebr.al arionialies. OmphalOc:eles '8.ri~s~e;:aliy
corr-ectable but the prognosis depend:!C9fa the
presence of assoCiated atiomaliee. Unfortunaiely,
50 percent percent of c~ses are asSociated with
chromoscimal abnormalities .like :m~~;:.~s~and
13 or with Beckwith-Wiedemarin-syndrcifue:42;' -
-- ~ ., ~ .... ,,.h~ .. ~
. . . .. ...... . :.; ;!,; - .
. . ! ...-~ ...
. , _.!.._ ~ :
.In.Jl:!fi ~~P.:tii.Y:~ili~ .J?~_.6Qdi:rilld__S.::anct
the umbiliGal.cord and ring form no~, howeVer
a .small defect located just lateral and usuaily to
the rigbt of an intact umbilic;U cord allows tlie
herniation, o~ the intestines. The intestinal loops
. no~t freely .m the'' amniotic fluid ~d usually
thicken beco~e edematous and get matted
tog~~er. Fortunately.; th,is a.b.nQI"Illality is spor.adic
and 1s rarely associated with chromosomal
anomalies. Other associated problems are
atre.sias
of certain potions of the. gut due to strangulation
and infarcti.o n. This condition is amenable to
. surgical correction usually with a .good outcome
ul)l:ss complicatiohs.of the "short gut syndrome
become }Jroblerna.tic.
BOdy stalk Anomaly
This defect is characterized b~ lllajor
abdomin~ wall defect, severe .kyphoscol!osis, and
a rudimentary umbilical cord. The possible causes -
are: anabnormal folding of the trilaminar embryo,
or an early amnion. rupture with amniotic band
r-.
~
 SECTION Yl: COMPLICATIONS lN PR~GNANCY

syndrome anci{ or an early g~nerelized compromise intestine. In atr'esia, the. intestines may be just
of embryonic Jlow. In the .first trimester; the fetal wnnected .b yafibrous cord. Instenosis,thelum~
. body can be. found partly in the amniotic cavity of .the intestin~ may be narrowed ~use of a
find partly in the eelonlic ~v:ity most'like~y d\le to septum.
:e arly .amni<m rupture. T his condition is lethal.
'Bxtrinsk obstructions .are caused. .by
Gastrointestinal Tract Anomalies malrotatiGn of.t..'le colon with volvulus, peritoneal
bands, meconium ileus .and aganglicsis .. Intestitial
,,esoj)'kage.,r;tl atre.siCl. and tra;eheoesophagea: obstruction usually occurs late in pregnancy,
:fistu1:a re:slift from the. failure of the foregut to usu?:Uyrnote than'25 'weel<:s ~ince the dila?on of .
dh-ide ir.lto-.t,l,le. anterior trii.'!Zhea and posterior the intestines occtix slowly and progressive}y.
esophagus. Theseare ~p<)tadlc abnotinalitie~ but Jej\tnal and ileal o bstructions can be seen as
;chro:tn:osb-mal a,bnorroalities are al~o found ill ..multiple<lilated fiuid..:filled lbOps in the abdomen
a.:.oo~t-20 per~t of<f~tus.t!S ml3t.J.yt:rkomyl8 er .a:n'd the :Presence o:r peristalsis can he1p
'2i..The~istent a~ence.oftpe stomach ,p1Jbble diff:erentia!te . it. from tlle ~t'her a bdominal
:on u1ti;;su1,1nd . s.c~ .arid p.olyhydr:ar4ni"C!.s op. strUctm'e~ .. Differential dia gnosis t ndudes o1)ler
tilti1iSQund:s~gge$~ :es<>ph'a,geal-atresia:However, mtra..abdomin~ cys~ .such as 'm.es'riteric cys ts,
o:tf tb.~.'ls~a.. t:raclreOe:sO~.eaUistU1a, S0Jile IP..xiP oV:~ cySctS .and .:r enal t:r;ac;t &bi\or1Dalities: .The
can-dilate't ne .:.. st(>rhaclian'd 'tnake ltlo'ok normal. ptqguO~~ :<;iepetl:US 'OQ. ~e ~ge b.f gestati~n; fue
. Trac~phB,.,.~ fl;tula Pl~Y al~ iomt Part of .si,~C>.fo~huctionap:doth~rasSoci~teitanomaii~s.
fu~N:A:"f.ER {vhrtebtal. venp-l.cular septal 'a~fect, .Sumva:I.ls 11.suhlly mo:re. than. 95 . J>efCnt.if the
. ~ax:a1:~~esia.:. ~h~~sP:ph:a,.geaJ ;.f;ist:U~,. renal . qabyis born..beypttd 32weeks ,. an(i:invdves only
=1~::~~:=~~~~e~~;;:;:~~.:~.~:~o~:~ea1;~f~bow.6~., . ; ... -~'-, .
to.,sci:gzy-bti'tthb~i;li;ll;o'Q.'t~me.depend~onotlier:.. Abilorrdiw!Cysts
.a~~ anom,tili:es.~~.:~. .... .. : : ... ..
. ~~de f:rotn\dilated :'mtes:tines;': cyst~:; 1n~.'the .
. Duc?d~~~; ::. : ::: .. :.: . alX,l0t:nn:fuayongir*t'Hr:ti,t!bi:lre~l;ln;e}'s:::Ilciwever .
..
.~:: . }: .- .:..~ -~ ::-.:~.;:.~ .. . ( : .., . :. -. ., ::o.tne.r.~bys~i.s nlay.ati~~rrom ~ the~:ct>i:iunoA~ b~e:dll;ct
:purixig-..~J,1lbeypniq life, "tt.t:e .d-:uo.l:len'um is.. ~ ~~1~6c~ ~::;tor ov~~~h .w;~~ : or
.b~~'}jy,pro1if~!ive endometriU:i,'IiilrlP.lfu.e .111h om.~ 'cy~t:$. live'r cysts, Uiiest,ilial. 'dup)lgd:io.n
week>wb.<e:i'i.,.:vatuoHzatiort-:b egins an:d-piaten:gris evstsfia.Da1fhrioTiilalities :o'ftlieumb'ilical v~Tile
;e~ti;'b'Usii~-d~ :.F~ur~-~bf~t;hik;_p.to~s~ Teids.'to . erlM~gi..9c:fb'e. 9'st':c~nb;..sttg,gested bj. lli~
'stei>.Qsis)~r~~ia.'Extetnal .eoip:pr:!ssiohfro~ the position of the :cyst and its rela,tiof.lsliipwith .'t he
.~ pi~fl'ctr~s .Ot pe'titoo:eal.Ij.bri:>us :b~'d~?:cim other <>~gans a:nd the n0iin1~nes:;. of ~ tp.~ oth.er
,causeobstiu~oll.'':it.is .See::h in l per:5009 births. organs.
Aboill<S'O ,per-qmt of .Ba;st!s b~ve .a.ssod;3-ted
.~bbqrzp.~tl~s,;parfi:~arly :tnsO'.p:ty.'2l;~.d s'\teleW. Kidcnt-ys :a :ld 'the. Vr~7 T:rac~ .
.defe.ct~, GI ~prri:a.1ie:;s :like tracheo~ioph~teal
.=t:-~:1 ~ 'd'' :'+'.~,:; .....;..,.,.:.::...;:..,-:-:-tatiO"n
~L~~~ ..~~I:.J.ll~~!W'
.and:.tardiac:a..-.d
: . ,. , : . .....~ The kidneys ta..'1: be :se.eri as early 'as rue 9~
.renat.defci;ts: lt:give~dhe. ty:pi~ ..<J.o'l,ible b ubble" wd:~ by \iltci$6i.1n'd: Th ey ate :loeated below i):le
s ign.on ultt!ls61:md scatinin;g because of ~he level-ofthe stomach .and a re fou,nd .on .boi:h sides
:<;:Hiat'~d ~tq.:rna.ch -and pr.o~rrial -duodentl:':m~ of the spiiie appe:aP.ng like toun:d. .si:nictures' on
<:ii.~qstic :.atr ~~.. ,i eeks, .A;l.though it may .az:ise tra hsv.erse .view an<;!, e,llipt1cal structu;res on
a~ a ~radic abnormaJ.ity, it J;Iiay be 'inheri~ed in longitudjnal views. Theratio of renalto abO.orn.inal
an aut&sorri!'rl recessive pattern. the condition is circumference t emains at about 30 percent
~ena~~e to sur:gery with a 95 Pi!i;cent surviv~ t.hr'()ughou.t gestation.
rate bl,lt the ultimate prognosis depends on the
other assoei~ted anomalies. 'l:p:e fetal ureters, .ifthey are, normal, are rarely
vi'$iQle' op. ultrasound but the fluld-f'liled fetal.
..lT:l,~
. Obstnlction.
. .bladder Can. be visualized as :eatly as the.flrs
.trimester .. The oladder changes in. siZe helping to
intrlnsic
. Th.e ca~ses intestlnhl :0 bstrUction distinguish :it from other cystic structure$ ln. the
of
. r~sult from absent .or partial recanalization of the fetal aixlom'.!n.

Scanned 8y: C
 CHAPTER 45: CONGENITAL .MALFORMATIONS AND INHERili:o DISEASES - 695
,,.,, .

The following are the frequentiy encountered chronic renal disease, hepatic fibrosis and~portal
renal anomalies.3 . hypertension. They usually require a renal
transplant to survive usually up to their teens.
Renal Agenesis Unilateral 1 per 2,000
Bilateral l per 5,000 Multi.cystic Dysplct-stic Kidney (Potter Type 2)
Infantile Polycystic
Kidney (Potter I) 1 per 30,000 This is usually a spor:adic abnormality but has
Multicystic I)ysplastic been associated with Trisomy 18 and other genetic
J(idney ( Potter II) 1 per 1,000 syndromes and defects . involVing the heart. The
Adult Polycystic collecting tubules fonn cy:sts of varying-sizes that
Kidh~y (Potter IIl) 1 per- J;OOO detenn.ine the si,ze oft he kidney, big or small. This
ObstrUctive disorder can be UI),ilateral, bilateral qr segmental.
U.to~thlcs Sporadic . ln some cates. the renal artery or vein may be
absent. pr tlle.-ure.ter i$a-bsent suggestjng that it
could bepart of the -..pectrutn of te~ agenesi-s.
Reri.al Agenesis In abo:Ut 15 percent of cases of unilateral
dys_plasi~. the other kidney is
~bsent . Whi_l~
Tbe f~w:e of the the metaJlephric blastema b1latend inv:olvement is fatal, .unilater~l
to diffetentiat~ during the 25th to ~au: 4ay of i.-,volvernent -h.a s a normal prognosis
-embryonic development results in the absence of
both -ureter~. kidneys and renal arteries. It is
. . '
. . . .
Adult Polycystic.Kidney Disea:se {Pottet;:'l)JP? -3)-.
us.ually sporadic but ta,rely it may be caused by a . . ' ~::.i;C:.~~~ .:o~: .;.-;i.u:;~.:
chromosomal abnormality ,o r part of a genetic .This i$--characterized _by m~ke:i;Uy>_~~(!d
syn-dronie like Fraser syndrome, or a irregular k;idneys with numetou$ v~ri~~~ts
deve!onmental defect lik-e VACT~RL a"$SQciation. admixed with normal or compressed renal tissue.
ln 9.oo"ut 15 .percent <>f cases., .OJ'le of the pa,rent Both.kidileys .are generally equa1ly enlarged. but
ha~ Unilateral renal a,geriesi$ which )ncreases the not as w..rge, as the infantile type~ -a.n~.,very_,,mrely
-l isk or "r~P.,iJ;!;te:tice: Bllatenil i,rivolvemelu is lethal : .is. the'iiiyplvement:unilater~it It isas:Soclated~
because of..; the failure of. -;the fetal lungs to grow cysts in the lli-er, pa,ncrea;s," spl~en .otlungs.i:P:'9;ne-
due to p uhnoriary hypoplasia. be~use of the third of~ and cerebrill anetizysm.s . in .on~~fifth
a. b $ence .()f .runnlQo+.O-.
H flUl'd ""h'~ l~,.m.~~-
. .._.,..;-r; ~t s .as _or~ ~ ~ d~~- t~_ oo t\v.tom~_d<;>~t
~g~!YO.~._.a.:g~.J;!Q!: . 9.f Jlltill~..fiJ.l~~LbJMd..er gene.Jn~tiP.n ,a.nd..is.. ~en..with.,oth~r-MendeUan
. ru:t_q. i:t.e.__r_e_na.l. _a_rte.rle.&._c_anno.Lhe..:.Jri~~d- on . diso~ders-llke-Stur..ge~Webc"t--6yndrome.,--Moon-
Doppler scan. Unilateral rena! agenesis however . Biedl syndrome .anP., Meckel-Gruber syq.drome. It
is ccmpatil:i1e with a ncrmaloutco.nie andis difficult only becomes symptotruitic towards the 3n1 or 4th
to (iiagnose antenatally. decade 'OfUfe ~~d ~ly in infancy or adulthood.

lnja.tttiie Polycystic Kidney.(Potter.Typel) Ob;Stntctive Uropathy

This i~ an a~ to somal recesSive condition and This incltid_.es ,a group of :disorders

the . responsible gene is in the short arm of characterized by dilatation of a part or all of the
cr..rotno~Iile 6. This condition is-characterized by organs of the 'Urinary tract due to obstruction at
a _spectrum of renil involvement. The kidneys are different levels of .t he urinary tract. wh~n the
markedly enlarged bec~se of ,the numerous obstruction o~curs early in fetal life and is
cortical cysts filli.ri.g it and .the collecting ducts are complete, .d struction of renal tissue resulting in
dilated as .well .. The disease is divid-ed into agenesisor .dysplasia m.a y occur. However, if the
perinatal, neonatal, infantil-e and juvenile types obstructjop is inter.rilittent , allowing &ome growth
depending on the time ofonset and degree of renal of normal rena.l tis~ue, and it o~clirs later in
involvement. The perinatal type is usually lethal pregn~ncy, hydronephrosis or dilation of the
~ince the severe oligdhydramni<:is restricts the pelvocalyceal area due to accumulation.:9,~urine
growth of the lungs lea-din-g to' pulmonary in the kidney, -sets ih. ~
. Bi;.
hypoplasia. ,The rteonatat. -type develops . ren.al : ~~-

.:faUute wlthin the first year of life and dies ea rly, Hydronephx.-osis, or x:noderate hydroneph~os"is
while th~ juvenile e.nd infantile types will have i s characterized by an anteroposterior

Scanned 8y: ~.
 69-6 .~ sEc'noN"VJ:.cGMPUCATIONs
. .
tN PREGNI.\NCY
. .

p.e lvic.alyceal' diameter of 'QlOre than 1 Omm~ AQnormalities -of the skeleton are called
PelvocalyCeal. ~ta:tion, is u~ually progressive an,d skeletal eysplasias_ This is found in 1 per 4000
in no m~e than S{) pe~nt of case.s sur~ry is births_ 'f:4e common. skeletal dysplasias have the
necessary quring the first two years of life. The following prevalence:
folloWing are the most comma~ causes of .urinary
. obstruction ca.).l.sing hyd=:onephi-osis.
'Tabl~ -4 5;7. Pre~ence- of C<>o:Jtil:on skdetal dysplasia3..
UreW.opelvicj~ctidn 9bst~udion
Ureterovesical. obstruction :"'"
vesi~ethral reflUx Lethal dysplasia
Urethnil 'obst;ru:ctibn Thana:ttbphicdysp~ 1 in 10000
A:clw~aiesis 1 in 40 000
Severe :hyq.r.onePhro~s leads to r~al d~ge Osteogenesi3 .impetf-ecta, cype II 1 'in 60000
and oligohy~os w.hkh resttlt:rin p\i.lln.o~ ~hypophospb:atasia.. 1 in 100 o60
hyt>cpl.asi.a. The poss~bmty .of in \lt~o treatment Cb:ondrodyspla:sia punctat.a lin 110000
:by d~~presSion of :th.t bladder or kidney may Non-iethcl dysplasia
r .e s.u lt in }PJ..:P.rvv~p. k.idn~y a nd p ulm'o naty He~l!s;achanodi-oplasia l.in ~0 00:0
function~ Potential candi-dates .for ' inqaut-erine Os~~-iri;ipeifecta. .i)i>e I 1 in .30 000
~urgery ..ar:~ '{e~~e~:. ~t;h 'J;j.ilatera.l mbd:~~1y A$ph~~~~d~~ 1 in 7.9000
5ev~ J>;e~eea!Qilatation-and no~ cor..ical ..'
echqgehl~ty. or .S;ever~y ~g~ blad4er with
9-Piohyi:L~$ b~~-Wi'u.l:uorilial ~eyeis;pfurinary
- ~:iu.~ .tialcl'tWl:and~-~~'IPlei?f9...o?ll;lln:,..~ ... ......
. .
The patholpgical caus-es; :9f..s'k.el~tal . dyspl.asias
.Skel~~ :M>.~o~tl~s have .~ .classified :uftotnree: .
. .
.SlcCJ.~titl ..fl:bn:O.t;JAatiti~s:'inv:oiv.e.. ~ ,ta,p.ge.:' of... a). .O~~on~y~la,si.a~ or abnon:i:).a)iti.es. of.
~O~!~t:~n;~o1Ve,th~Jto!J:g:bo:b:~Athe .~~Cis .. ..:,~.and,/'6-r='Pone ~$d4evel<>pment..
~d- :fe-et; ji@.ine/rul.d :.bOnyr:thorix~~ ~T.heyu:;:nay.. b) .~Di~-dev.~l~pm~t;ci!~fue'ca.-1ilageand,
ptes~n't:: :a.$. .' 9ha~:g~~. : in ~ Je.q gth, . . ~b.aP,. .fibrou.s Coln.tlltmt:Qt.~e ~le~ ,
-~l. It\i9~~J?21i~ .'d~tfuclio~ :or oste.OiY.~:

~~~:=!~===
, - ;:--- -- ----.;-.- : - '" - -~- - ____ ,.,. _ .... ........... ~ .. -w "''- w r . ... .. . ,~.

.fuc.entire limb (nnero:mll.aJ ~-~~:.in .dwaifi:~m.

O,r Ule :differe!t;t ..~egm~iit= .9 f the ll'Pr~s may be
,@vplvctL J:;im~~ ~y.beideticlertt 4u:eto c.on.genit';hl
runp~t?-t~ons p"i:' .isol{l.ted. limb lbs~ :as .jn
:phOCQmeli.a Fe.t al fii.igers ru,id: :toes . ~ .:'be :s~n,
th~ir IlUJlil;X:r, :tx>.sit;iop, prt>~ftion @d shape din
b.e -ev'al\):ated, ~. nU:~~t :of .d~g'its ~lkd
~lyda~'iy 'or fu'Sioil. of ~fi:hgefs Mned ~~d'ato/ly
can alsO. be .~en. .Abti:o~at . P.Qstures notd like
Clubft=;H~t. ~H):d.' <ilub}ia,:p:~ arc~ ~ssbd;3.:ted .Wtth
cfuOin')SOttra.! .iibn<?nn~tiesr ge~etic syndfoJhes
with ear,diac defects and l)em~to:h:'rgical .
ab~on:mtl;ty lil<:e .Fanconi's pant:Y.~operiia. F~~l
~o:v.eme~ts are -~e~s ,pex:.e eptlbte. in
fttuse$ with.
skeletal abnormalities ~irlce there :may -be some
limita~6n of'.lun:b ..moy~iil.ents. S~ll bOn~s may
be-a:ffect.ed and defonned because of:d~fective.oone ..
min~ralization. A small thorax qau#ng chest
l>estrictions. are also seen in .certain s keletal
abrib~ties. and ~e. .more :o'ften 'iefuaJ.l)ecause
..bf pulm~n~ hYP.oplas~a. {Ta~l~ ~S-.7). . .
t/u;ztl.rophic dyspl~a. :is ~ .co-:rnmon -lethal
dysp~sia thar:act~riZedby ,severe shortening -of
the)lnibs, r..atrow ~0~ :normal t;tu:p.k leflgth and
1arg ;q~ wifu prriil:iinenf for:e~~d:
AhoTUP'..<.1g~ is '<!JliJthr leth<>,l .dy~lasia
withsevere .s1).orten.i:ng:o'rt;he.li.rnbs, ~.i::horax.
s hort t.rU.nk ?Jld lar;ge rr~d: :R ib fratures. poor
miner,ilizatio.n of the ,skull and verteb:r:ae are
typicaJ: ofTypei :Whlh is autosOmal reces$ive. Type .
ti on the. pther hand, is. .sporadic; wi~ only the
verteb~~bodJes .showing hyp:Oriliri.~ralization while
the ribs and limbs show .n:o fracture .
Osteog,enesi:siniperjecta.. is characterized. by
.bone ..fragility~
ma.riife~ted .'as-ll).ultiple .fractures,.
b1ue stlerae, :lQbie joints artd growth deficiency:.
.There.is :a doniir).aht. --n~gative. mutation. affecting
.i he collagen gene that-alter the fon:O.ation of type
I c6.1lagen important for normal ..skin and bOne

Scanned 8y: ~
 CHAPTER 45: CONGENITAL MALFORMATIONS AND INHERITED DISEASES 697

development. This results in the production of Achondroplasia

abnonnal quantity -and quality of collagen. It has
four clinical subtypes. Tyi>e I is compatible with a
normal life expectancy -despite fragile bones, blue
sclerae and progressive d~ess. Type II is the
only lethal type that is characterized by early
prenatal onset of severe bone shortening and
of
bowing due to multiple fractures the long bones,
ribs and pocr s'kull .b one mineraliiation. Types III
and lV are not lethal but short stature and
scoliosis ~nd deformities of long bones are
common.
This is the typi~ dwarfism we see that is an
autosomal dominant syndro:ne. This is due to a
specific mutation within the fibroblast growth
recepto~ type _3 gene. If both parents having
achondroplasia, the risk of the lethal homozygous
type is about 2~ percent. 'fhe heterozygous type .
has short limbs, lumbar lordosis, short hands and
fingers; macrocephaly wi.t h frontal bossing and
d~pressed nasal bridge. Intelligence and life
expectancy are normal.

POINTS TO REMEMBER

Two tq three percent of newborns will have a major anomaly.

Matern~! age..35 y~ars and above significantly increases 'the risk for Down syndrome -an~' Other
~n~~pia1dies. .

- From the maternal personal and family history, risk factcrs :for genetic disorders rnay:~ .:eJidit~~:::-
,: sc~eenil1g tests for a carrier status for a birth defect isoffered to the cOl!ple~ If the couple censent:S::a:n<F -
the .-esuits tum out positive, referral for prenatal geMtic counseling for further evaluc;Uor. oHetahis.k::-:..
is adVised.
: . ::.'
. .:: :.,. ;:;cre~ning -te.sts for.birth defects may be offered to the general ob~tetric .population qiaihlyi:for:'~e'r :-.
..: .;.:~E~"detectio:n of the most c6mnion fetal anomalies like neurallt.ibedefects; Down syndrome: add~othe'rf''
~--"--- retal aneuploidies. These tests include a combination of biochemical screening tests ln. the firnt~gri'Q>.~-:-'
seeond trimester that includes maternal ~erum alpha-f.etoproteiri, hCG, unconjugated estriOl, Pr~gnanCV" -
~~~ed Plasma Ptotein-Aand lnhibirrA at a determinedfisk eut.;().ff:lev~f. ~;;1te_iy( cfr\ 'ir:W!Qrat.~"tesf
-lhat- combine"S:'maternalage,-biochemical tests; andultrasound--rneasurertrent-'of-the-fetatnuchal
transluceney-performe<f1n-the-first:and-second-trimestei"S'was-founcttohaveihe-:hestdetect:ion.rates:
if the screening tests arc positive, detailed ultrasound scanning and fetal ka;yotyping is recommended.
Unfortunately, these tests screen for conditions that are not amenable to treatment and resuit in
elective pregn~ncy termination in most cases. In our setting however, appropriate support and
prepa~tion is :offer-e.d for the co1,1ple to ~repare them for the care of a ~hild with an abnormality.

Fetal anpmalies may also be detected durin9 routine ultraso.und scanning. This is performed during .
the second. tlimester with varying detection rates rar.ging from 17-35% in the. USA and from 65-tOO
percent in certain countries in Europe and Japan where ultrasound scree11ing is done routinely. A
detaile,d ultraso.uhd scan, 20, 3D or 40 if the. presence of an anomaly is suspected. Karyotyping is
r,ecominended if a chromosomal cause is suspected.

The ultrasound detection of a thickened nuchal translucency is considered by some groups to be the
a
best m~rl<er that discriminates normal versus ;3nd affected pregnancy.

Chromosomal abnormalities account for about 13 percent of. causes of congenital anomalies.
Aneuploidies, or abnormalities in the number of chromosomes, account for the most common
chromosomal anomalie~ that we enG<)unter since some charaCteristically reach term and others :may
survive beyond infancy. the most common are Trisomy 21 or Down s)'ndrome, irisomy 1.3, arid 18:
which are commonly assoCiated with major structural fetal anomalies. One major fetal arlOriraly should
prompt the search for other anomalies that may comprise a part of a chromosomal syndrome.

Snanned By: ~
698 SECTION VI: COMPUCATIONS 1N PREGNANCY

Teratogens canbe any drl,lg, chemical; infectious or physieal.agent, maternal disease, or altered
metabolic 'State that can affect the developing embi)'O. These can affect physiological processes,
or activate a genetic predisposition to .an abnormality. Paternal germ cell exposure to teratogens
canalter ~en~ expression. Alcohol i~ one of the most common teratogEms.

Infectious agents such as Rubella .can affect the fetu~ in the fifst .trirn~ster While , .toxoplasma and
cytomegalovirus can cause .anomalies any time during the p'regn_~ncy.

Radiation -exposure to less 'than 5 rads carrie.s a negligible risk of major malformations.

1. EliROCAT Working Group. Appendix 7 apd Appendix
8 inReJJOrtB: Sll.tVeiUance oreori'&.enita:l Anomalies in
Europe 1980-1999. UniversJ:!Y of Ulster: 2002.
2, : univer~ity : o! the Philippl ne~~J?hilippine., 'G eneral
'fto:i~i~; :il>~ent:~l\:Otist~~~s:::~~ ''QyR~colow,~: .. .'1 3.F.erccn o.- .Auer M; ..Oemvassili :A,: ~t:.e.l: .Ser.eening for '
'SeclionotMiiietrial and' FetahMedic:ine>2006 Mnual
~rlnsia:i.StatistitS":'
4. 1Wyldes .'M and .Hod.gkiss S .Sereening::for fetal
~nonn.tJ.lri JaiJles.D.~:-~iihQed le~-Sto~e P~ et al
11. Wiicox AJ, Ue RT, SolvoU K,. et.a l. Folic acid supplement
~ risk of facial clefts: NatiolU!l Population Based Case-
Control Study{.l'.bst:act). BMJ 2007; 334: 464~
12. American College <>f ObstetriCians and Gynecoli>gists.
First trimester screening for fetal ' aneuploidy.
Committee opinion N6.296, July .2 004 . .
trisomy 21.\)y 'ret~ tri~uspid tegurgitation, .nuchal .
tt$s!u~eney and,ina ternru serum fr~e ~beta~hCG and
J>.-..PP-A at 11 +0 to 1~+6 wee.k s. Ultrasund Obstet
Gynecot2006; 27(2)':151.
. . . .

.. (~~l;~ic:len:ec: B.;~ed~:'Qb$t~tries; ;:2'!'1-:_:dc.. Lori4.on;:. 14. W~pner: ~fhe. E.-.S~P.so;t ~.n..-, et,al.;Firsttrimester
~~Pinlted :~(}Q"l: 43:..4:5 . . . . Sree~g fer ttisotnies"2'1 and~ts.l't Etigl J 'Med 2003;
349: 1405. . .
5. - ~ Fa; Lev~no K.J, Bleom.SL, eta!. (~d~):
~~~s~d.~tJ'i~ra_w._ ~(!-~J,l,ij~_s '0bstetriq.S, }5. Mtildie,m , W.ald NJ. CAAickJA; et al. First and .sond
22"'.4a..::He.W.::Yorl4"McGtaw.liiiJ.:!2Q05i'31-& - - ttim~~r-eve.!ttEttiti'tF6r-h"slt--w~S1E::Rf~ci'j)ai
.... . .,... -" ,. ..... ....
~. - ""' ' o-own:s-sfiiaiOme
-res):ilts-of"the-NICSHf>m'!-iltirc-e'hi:~r
.(). A)nerjcan 'CoUege of 0bstetfics and Oy,rte~ology so:eening ~tudy {abstract). Am J 'Obstet Gynec()l !87:
.Edu~tioh.Pam:>Wet.AP146~Bif.th P.efe~ts. 2005 http: I . S56,2003b .
W'Ww..ato~or:g . .
16. erea:thnach FM, Malon.e F D, Lainbert-lo4esserlian GL,
't. AnieriClm:College of Obs~etridanl! ~4 :Gj'necol~gi.sts: et al. Fi:fst and second-trimester 8cn:ening: Detection
tdate~al serum.Sc.r~eQ.ing. E:<iucational Bulletin of dleuploldis.other ;:haf1 !>own's syndrome (abstt:act).
No:228, Sept~ber 1996. . Obstet Gynecol2C01; U(): 651-.

17. Filkins J(. Koos ij.J. Ul~~uqd:an~.f~ ~osili.Curr

8 .. Burtoti s~:Etev:a'ttdmatemhl. ~r.uitialpl\_a-fetoprotein ..
(M$AFP); Interpretation Md {ollow~up.. Clin 6bstet
Gyne011998; .3 1 :-2'94.
9 . Sepulyeda W, Donaldson A, JohnsonRD, et al. Are
routine alph'a-!etoprotein and acetylcholine_sterase
determination still nece ssary .a t .s econd trimester
.am'niocentetois? \mpact or . high r esolution
. ultrasonography. Obstet Gynecoll99S; 85: 1'07.
10. Lumt,ey.J.:waison L, Watson M, ~U.l. -Periconceptio.nal
suppien;tentation with folate and/or multivitamins for
p~t!.ne neural tu.b c defects.Jn .C~hrfine Database
o f Sy~tematic Reviews, issue .1. Oxford: U.pdate.
SonWare.200Q.
Q.pin Obs~et Gynecol2005; 17(2): 18S"l9S.
18. Van Dorsten JP, H~lsey TC, 1-fewman RB:, et al. Fetal
anomaly qetection by Second ~ester uftraso~ography
in a tertiary center. Am J Ohstet Gynecol1998; 178:
742.
19. Royal College o,i Obstetricians -and Gynecologists
Guidelines and Working Party Report Ultrasound
screening: 1!>Upplemi:ht to ultrasound screening for fetal
abnormalities. July 2000 ..
20. Nicolrudes KH. Nuchal translucency arid other fJrSt
trimester $onog:-aphic -m arkers of chr,on;tosomal
. abnqrmalities; Am J Obst~.t G)'l'lecol2004; .191:45-6 7.

Seanne4 IJy: ~
 CHAPTER 45: CONGENITAL MALFORMAT.IONS AND INHERITED DISEASES
21. Malone FD, D'Alton ME, First Trimester sonographic
screenin~ for Down's syndrome. Obstet Gynecol2003;
102(5 Pt 1):1066-1019.
22. Atezi A, Gajewska K, Huggon IC, et al. Relationship
between nudlaltran~lucenr.-J thickness and prevalence
of major cardiac ~eJects in fetuses with normal
karyotype. Ultrasound Obstet Gyn~col2005; 26: 154
157.
23. Makrydimas G, Sotiriadis A, Joannidis JP. Screening
perform&nce of first trimester nuchal translucency for
m!ljor cardiac defects: a meta-analysis. Am J Obstet
Gynecol2003; 189: 1330-1335.
24. Clc~. s. Sonek JD, McKennti:Ds, et e!. Nasal bone
hypoplasia in trisomy 21 at 15-22 weeks gestation.
Ultrasound Obstet Gynecol2003; 21: !5-1.8.
2 5. Malone FD, Ball .RH, Nyberg DA. et al. First trimester
nasal bone e-v:aluati()b .far aneuploidy L"l an :unselected
generalpopulatlbn: Te.s ults fro.tn the FASTER tri:U. Am
J Obstet 'Oyneco12003; 189: S79.
26. ~rolll!>tein.,M, Blazer S, Zimmer EZ. Transv:lginal
$6nographic. e~1ation vf the fetal nasal bone is
liiUili~~o:;Ptedict Dovm's ~yndrome at 14-16 weeks
g;;stat.ioti. (letter) Ultrasou:td Obstet Gynecol2005; 25:
625-628..
27. C\lnnib~~ FG, Leveno KJ, Bloom SL, et ru. '(eds):
... GmetiC$dn.Williams Obstetrics, -22..s ed. New York:
MdJtaW:ffill ~005; .286. . . Obstet Gynecol 2005; 26: 481-486.
.2 8. CUnningham FG, Leveno KJ, Bloom SL, et al. (eds):
Gen.eties in WillW.ms Obstetrics, 22..s ed. New York,
McGtaw.Hill200$; 286.
29. ~naeerrafBR; Ultrasourrdevaluatiort of cfulimosainal
abnormalities. In Callen PW (ed}: Ultra sonography in
Obstetrics and Gynecology 4tb ed. Philapelphia: WB
saunders Company 2ooo; 3.8 .
30. ~icolaldes KH, Snijers R. Features of chromosomal
q~ects. In Pilu 0 and Nicolaides KH (eds): Diagnosis .
of Fetal Abnotmatities: the 18-23 ~ve.:k Scat:t. Diploma
in Fetal Medicine Series. New York: The Parthenon
PublishingGroUp 1999.
31. Cunningham FG, Leve110 KJ, Bloom SL, et al. (eds):
Teratology,- drugs and other medica tions in: Williatns
Obstetrics, 2.21i4 ed. New York: McGraw Hill2005; .342-
346.
32. Cunningham FG, J.,eveno KJ, Bloom SL, et al. (eds):
Infections. In Williams Obstetrics, 22"" ed. New York,
McGrawHill2005; 1276-1284 ..
33~ Pilu G arid Nicolaides KH (eds): Central Nervous System
in the Diagnosis of Fetal Abnormalities: the 18-23- week
Scan; Diploma in Fet~ Medicine Series. New York: The
Parthenon Pub.l ishing Group 1999; 5 .
Scanned 8y:
699
34. McGahan JP, Pilu G, Nyberg DA. Neural tub~1tffects.
In Nyberg DA, McGahanJP, Pretorius DH, et aJ, ieds):
Diagnostic Imaging of Fetal Anomalies. Philadelphia:
Lippincott Williams & Wilkins 2003; 291.
35. ScottAdzickN, Hedrl:ickMH. Other. surgical conditions .
.In Fisk NM, Moise Jr KJ(eds): Fetal therapy: lnv~sive
and Transplacental. Cambridge: Cambridge Uni,.ersity
Press 1997; 311-312.
36. Rutherford J, Dandy-Walke:- malformation. 1n James
DK, Mahomed K, Stone P, et al. {eds):Evidence Based
Obstetrics, 2Dd ed. London: Elsiever Limited 2004; 97.
37. Face. In Pilu G and Nicolaides KH (eus): Diagnosis of
Fetal Abnornialities: the 18-23- week Scan. Diploma
in Fetal Medicine Series. New York: The Parthenon
Publishing Group 1999; 21.
38. Benacerraf BR, Nyberg DA. The face and neck. In
Nyberg DA, McGahan JP, Pretorius DH, et al. (eds):
Diagnostic lma,ging of Fetal AnO'malies. Philadelphia:
Lippincott Wi1Uams~7;, Wilkins 1003; 345-355.
39. Jeancy t>, Pilu G. Cardiovascular syste~.l1l. Pi'.u G.and.
Nicolcides KH.Diagnosis of.Fetal ~nonnali!l~:;the:l8-:
23- week Scan. Diploma in Fetal Medicine:~nUiN.ew
York: The Parthenon Publishing Group t99i;'2g~;/ :
40. Wilkins-Haug.LE, Benson .CB, Tworer.zlcy W, et al. In
uterQ interve.n tion for hypoplastic left'l~c;tUt,.:Syn<h:pme
- a perinatologistp<;rspective (editorial); {;JI~und .
~"' ; :!.'< '
41. Pilu G and Nicolaides KH (eds): Pulmonary
Abnonn$lities in the .Diagnosis of FetalAbnonnalities:
.!11:~ . .8.:~~: ..W~!:k SJ;.tm, .D.iploma ..in. Fetal.:Medicine
.S~fi:!:s._New York: Tl)~ Pru:then.on .Publishing Group
1999; 53.
42. Pilu G and Nicolaides KH (eds): Anterior Abdominal Wall
in Diagnosis of Fetal Abnorma lities: thel8-23- week
Scail: Diploma in Fetal Medicine Series. NeW York The
Parthenon Publishing Group 1999; 61. ..
43. ~yberg DA, Neilsen JR. Abdomen and gastrointeStinal
tract._ln Nyberg DA, McGahan JP, Pretorius DH, et al.
(eds): Diagnostic imaging of fe!al anomalies.
Philadelphia: Lippincott Williams & Wilkins 2003; 547-
560.
44. Pilu G and Nicolaides KH (eds): Kidneys and Urinary
Tract in the Diagnosis of Fetal Abnormalities: the 18-
23- week Scan. Diploma in Fetal Medicine Series. New
York: The Parthenon Publishing Group 1999; 77 -84 .
45. Pilu G, Romero R. Skeleton. In Pilu G and Nicolaides
KH (eds): Dia?Dosis ?f Fetal .Abn~r;nali~s: t.h,~S-23-
week Scan. D1ploma~ Fetal Med1cme Series.lfQY,;York:
The Parthenon Publishing Group 1999: a1-9~;
.
~
~
 l .

.,

Saanned 8y: C
 46

DISEASES AND INJURIES OF THE

FETUS AND NEWBORN
VIRGINIA R. "DE-JESUS, .MD~ MHPEd

Diseases of the Pre.teilTI Fetus and Newborn

Respiratory Distress Syr.drorna
Retinopathy of Prematurity
lntraven~ricular Hemorrhage
N~crotizing Eritercc01itis
Brain Disorders
Anemia
Isoimmunization
Hyperbilirubinemia
Non-Immune Hydrops Fei.alis .
Fetal Cardiac Arrythmias

Diseases of the Term Fetus and Neonate

Re.~piratotY ,Oi$tress Syndrome
......Meoor.aiumAspiration-Syndt:ome
--Hemorrhagic-6isease--of-the NeWborn
Thrombocytop~nia
Polycythemia and Hyperviscosity

Fetal Death _
Definition of t=etal Mortality
Causes of Fetal Dea:th
Evaluation of the Stillborn Infant

Injuries of the Fetus and Newborn

Spontaneous Intracranial Hemorrhage
lntraventicular Hemorrhage from Mechanical Injury
Cephalhematoma
Nerve Injuries
Skeletal and Muscle Injuries
Congenital Injuries

Scanned By: ~
 SECIION VI: COMPLICATIONS IN PREGNANCY ...;,
,::
.. , .
. ,. . .
D.lSEASES OF THE PRETERM FETUS AND to 39 percent. Kari a n d associates in -19.94 . .
. NEWBORN confirmed that the addition of surfactant. 'to .
an~natal..cortico.steroids s howed ru:t even g:rea:~
r eduction is ovetall death ra:te and death secoit~
. ,F~splratory Distress Syndro:ne to RDS.
.-". . .. .. "
-: At birth, the infants' lungs must rapidly be Th~ frequent complications of persisten~
.. ' Jill~g with air and be clear~ of fluid and tne hyperplasia are bronchopulmonary dyspJ.a:sia:or .
.. ~<;>l~e of blood that perfus e the lUI!g ~~st ~sp oxygen hmg d.i:sea~e. pulmonary hypertensi~arld
: ;.incr~se remarkably. Puring vaginal delivery, rdropathy of prematurity.
:.. 5Qme.>of..th:e flui!i :from. the lup.gs. ;ar~ 'leared dt;:.e . . .
.. 't ? ~he,si: ~ori:tpres:sjph. 'rh;e ,~~d~d al'v~li : Jn ~s w.hej'e-d~ijve.i-y: <>f.:a.ix>SSJ.o~ prc:t:ei:ni :
.... .
;.~r~ sJa~i~i~ii ."by ,s\tfffci~nt . suif~ctal).t.,: T)ic infantis,iii~~,Jetallung.pi?-nt:Jr,ean~~ted
:.,~1l~~~Jl.f~f<;>w~.ts .: :t;p:e :~:U.!fa~~ :fe_,h~ioil. !J?'U.~ . . hr. i>everru .~~fr.~Q<:ls: l~~tlfu?.:--s1-.in~omy($n }.,iS .,
:p~.tr~~ting ~tcig. erilla:pse du.ri:D.g :~ti.On. ;T.b:ts tatio, -phoSJ)ha.~dylgy'cerol; surfactant .to illb~ .
, .~ ~~#.:ctant is synthe sized by type li pneu:tn~ytes. ratio in uncelitrifuged amnionic fl~d [IDx;"f;LMJ
.. :~ ~9rfactant is inadequate, respinttory distress .and foam. stability te;st. . '
. ; :4~~qps and hy~e .iuem_brane is .forme.d in tJ:le
1

: .~~:Brpnohioles. and alveoli. Respira.to.r y distress Retinopai.@ ofPrem.ai;y.rity . .:, .

. '. .. _:i.n~~.~ new \X'~ is <Uso called hyaline membrane
. . :~'diS::ase. Tw.~ conditio.ri foh;nerly .knoWn. as retrolenhU
.. fibr<?plasia ;~ sci::Qndary to prol~Iy.ged aposure :fu
;". :..:.. . :.J~e~pir~tocy. ,cii~tr:ess .sy.n drome .. (R;DSi .is high oxygen:;conc~ntr.atipn,;...:thlS.f.is .due :to $the:
: . :,ge~lj. a .disea.se of .pr~.term.nebJ.Jate~:. It.ca,u .. .endotheii.aldrun.age anq.~ves:s.cl 'oolitcmtion...fu the
.. Q(:didnterm. Wants :Wh(ib.~ve sepSis;oqneco!lium retil\a. . ': .
~.'' ~P:~tion. J;y_piC3J.iy, .P.PS ID:anifesta . as ...
: . :.~eawithc~eSt:will r:etraction,.,g r.unting ~d Intravent.r:ii:;u.lp :ReriJ.orrhag~., ' .,
:. , . . 'fl~g~of nost:fi...la during .. CJqi~Ottr 'With .t he :
~ .-:~lltlJ'it::i:Ag of: b~0:0\1 through the r10n~v:enated lung. T-here are 4.;inajo.~. ~~t~g~rles or n-een:iw. :: .
. : ~ .~e:re~ls- l_ly.po;xemia~.which 1s followed :by
. . .:~~i:it .~---. ,.... and ree.pU:ato . .acidoSis
_ .. .rJ .. . ... .. . leadhi
.'-~'ltenu-&cu.latio;r~.nd-systemi:c-h}'Pdtensioh.
.~~=Jt~~hftli~/h~~~~~t~:=t::
...... . g +o
~ .poeI'
rrem9:~~~g~-:a-.n-~-~ti{~v.~n~~W~f~nano~e:
.-:, :!~ib:~.:: ~ c~st i ambgrapfi snoW:s <liiftise Prognosis-:;a;ft~ro:-.nem:o:-rrlia,g~.~p-enas - Q.li-'tfie...
I
. ;:.: ~h~lcli.logtc:nular infiltr.a tes with .air filled iocation : ti:na -~en.t bf bleerupg.. , I
. . tt,ilclieobronchial tree. I
Pc~riventricular . ancl .in:t'r avcntrit.)J.lar . .
...:.. . Th<; mos t ~portant -factor .effecting survival .i s hemorrhage is commoi). among pret~pn miari:ts . I
. . :;.4.~i9n to a n eonatal jnten$ive q;u:e unit where specially those tx>m "1?low 3.~ w:eek~ .. Most d~p : . I
!Xi'ntihuous posit:.v~ .aii-way. pressure (GPAP) and within 12hours oflhirth ana~ late as 72 li6ui-s. I
. .. .ci.tii~ recently, :pjgh keq\lt<ncy . .oscillator-y This can also~~ pre~bor. ~~19~g term~. I
verifitation whiCh reduces the .risk of barotrauma. of ~t:z:a.vef1tri~I.ar- periV."enttiQularhcmo~
;b~. fu.oidence ofbro~~hopulmo~ary dysplasia is is periven tricui~leukomalaci..3... . I
. :~~}~uced. The adl;lliillst:n:J:uonDf:;n.lrfa~ctant can I
,grefeht hyaline membrane dis~se. It has been Administration "of coit.icostetoid at least 24
.. "9.~ fpr propyla'Cis of preter:m infants at risk. of 'hours bCforedeli1~ry appears to p~ent or"red.uce..
_Tc~iratory distress a s w ell as rescue of those wiili the inciderite an~l: s ever.ir/-of intraventrictllar .
: est:alilished clisease. hemorrh.ag~ . Bet~methaso,ne is preferr~ #>.
'. dexameth:;sone since it is .found 'to exert its dfect.s
.: . ':-:;]obe ( 1993) i.n a meta ana~ysis of 35 for long~r quriition apd. deq:~ the ~ .
.. . .modomized COn trolled Studies.of.sllifactant either of leukomalaci~..apd rcspira,t,ory ,distress; SI.ngie: .
. . . .~~ ~scue and prophylaxis a gain;>t-RDS showed couqe of; betamethasone is gi~en as 2~ pig .7 '
. . ~that there is a reduction in both incidence of intramuscular fer 2 .doses, 24 ~o:urs apart. Op~:. . :
,:. ~pi?-e~othora'C and dea th at 28 day.s of life .by 31 .b enefits begin 24 hours after initiation. :

...

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 CHAPTER 46: DISEASES AND INJURIES OF THE FETUS AND NEWBORN
Necrotizing Enterocolitis
this eonditlon manifests as abdominal
distention, ileus ~d bloody stools. Radiologically,
there is pneumatosis intestinalis or gas in the
bowel wans. 'l'his gas is formed by invading gas
fonning bacteria. Some investigations believ-e that
some corona viruses cause this condition.
Brain disorder or dama~e which includes
cerebf.al palsy are a eomple~ and .Jimltifactorial
,p rocess caused by a combination of genetic,
physjological, environmental and obsteti:ical .
f~I'$. The sentinel event that ca1,1sed the br:ain
damage can o6cu.r duiing the prenatal period, prior
to the onset of labor and intrapartum. This
conditioi'i includes bt't is not limited to birth
~sphyxia which indicates neurblo.giCal injury
(,luring birth. . palsy.but are not u.supllyassociated Wi~perinatal
....Th~ American College of Obstetricians G..rtd
(fjri~logistS (ACO.G) .fu:2003 defined the et:iteria
i'or:birth asphyXia. These are:
1. ~<ProfoUnd metabolic and mixed acidosis .(plHess
.. . 'than ,7::0) determL11ed onan umbilical cord
, -:arterial :blood-saiilple.
2. 'Persi$ten:t Apgar score of 0 to 3 . from longer
than 5 II1inutes."
.3 . . in8a.en6.e <if rieurologieal . segnelae such as
: - ~iZUres, .coma orl1ypo"Tom<>r (lysnmcHOii-ol .. a:I?~~s:~~~~r.~tic-.ftii~s:'~Th~i:a~~Qp:~~~~2
Qn e or m:or-e-aclli.e -roTiowrtig..s-y.-s.fems: weeks to 104 days after birth.
cardiovascular, gastto intestinal, hematolo-
. gical, pulmonary .o r renal.
When all 3 conditions are present, perinatal
hypoxic ischemic encephruo~thy has develope!i.
-A lso; -the Task Force convene(i QY the American
COU~ge of Pediatrics and ACOG in 2003 developed
a set of criteria which occurring together1 suggest
that the supp<>sed insult occurred within 0 to 48
hours of injury. .
1. . A.sentinel hypoxic event occurring immediately
before or-during labor.
2. Sudden anQ. sustained bradycardia or the
absence of .fetal heart rate variability in the
presence of persistent late, or varial;lle
decelerations, usua:lly after a hypoxic .s entinel
event when the fetal heart rate pattem are
previouslynonnal.
3. Apgar score of 0 to 2 beyond 5 min.u tes.
Snanned 8y:
703
:' . .
4. Onset of multi system dysfunction witb.in 72
hours of birth.
5. Early imaging study showing evidence oh.cute,
non~focal cerebral abnormality.
Clinically, the infants present with neonatal
encephalopathy which is defined as .some
combination of abnorm-al consciousriess, tone,
reflexes, feeding, respiration1 or seizures in the
term or near term infants. There are many dlfferent
causes which may or may not result in peimaneot
sequelae -including cerebral palsy.
Cerebral .Palsy
Thi.s refers to a group of conditions that are
characterized by chronic movement or posture
abnorto~ties w4ich are cerebral in o qgm. anS<!
early in life and are non-progressive..~ and
merit~ retardation frequently accompatiy cerebral
asphyxia i n_Jhe .a bsence of cetebtal ~sy._ :.'
. -~t~~-:~~- !:i.S~.. -~ :
Cerebral palsy is commonly cla$siJjed. JjJ.~:the
type of neurological dysfunction and/ tlie :nuhlber
and distribution of the . involved linibS. Only the
spastic qti.adrlplegic type ,canresulUtoni an~te
intetniption ..of-b laod supply: intrapartll~> ::~: 1:-
.. ~ ~
. . . .....;. Jt;~ }- ~~ ~.:f..'\ : ;
The 'pathology that develops -deep..ittithe-;Htain
wh~te ~atter aJt~r hemorrhagic @.~ j~D)i
infraction is petiventrlcular lel;l:komatacia: which .
Periventricular !eukomalacia is rnore strongly
. . linked to infection and inflammation than to
intraventicular hemorrhage. Va~ularinsuflicicticy
before 22 #eeks would result to damage to
pyrainidal tracts causings pastic diplegia After ~2
weeks, vascular injury will primarily be jn the
cortical region.
In pretenn infants, corticosteroid therapy may
reduce the incidence of intraven:tricu't"ar
hemorrhage. Aggressive treatment of -i nfection
may also protect the infant"s froru ne.uroJogkal
injury . Magnesium sulfate is currently being
investigated as another neuroprotective agent.
-, 1 ...
Computed. to.mogr-aphy (Ct), Magnetic
Reson~ce Imaging {MRl) for older .children and
cranial ultrasound specially if do.n e serially
provi<ied useful information. Ideally, cra~ial
~
 7:04 SECTION VI: COMPLICATIONS IN PREl3NAN~Y .
ultrasound .~hould be done o.n bay l in ~~e of
suspected cranial damage. Serial examination can
detect .the-.develqpmeil.t of cystic s.paces ..deep in
the . white matter.
Tl:)..e hemoglobin valu~ during the first few
hqurs of "life Ii:lay ris'! by as -much as 20 perc~nt
due to del~yed .~rd -clamp~ng . .This precautiorl
resul~ in .an .appreciable volupJ.e of. blood being
expressed fl'uni .the placenta th,I]':iUgh, the ,cord to
the infant. :":
During '!ill pregnancies, vety small volume of
blood. c~n e~J?es rrom. th~ :fe.taJ. mtrav~scular
s~ tmd ;.enter the m.aterpal ip.ter:Wl!>.u8. .$pace.
.~- fetii' cells .Ca_'fTyit .IeaS,t due :antigirdilheriteG.
fr.om .t:h~. ,father
. .., . ... b.u t i~ ..ladtiq:g
. . 'ln.:
.
the.
-rcr..oth~r. If
enol!gti ;fe~ '~rJ.1!hr;pcyte,s.;ep:ter th~..mat~rl1al monitoring-?ffetal growth; am.n:ionic fluiP, volume,
c..r.cirlatic~::i$q~Uilliatirin: ..!n~.y..:.otc\rr...-. ~~ .. .
. . ::: . . . . . .
The . -tWo . m;o ~r. ~omtp.:on . types of
.iS9it:nl:p.~t;iq~iP,.Y:<:>t~.~'llie i\i?O.:blqq<f~':lP. an_d .
the;.~o~. i{Rhesu:s.):: l>1Q9.d:--~g:f.ou:P::~ ~Y:steil:rs.
.l.tlcorhpa!:ib$tJ)i5 :in'ajpJ:i -~ioo<t~gl-i?rip :ililtigen \4.;.&
-B :is ,e;m~(<;ami:4Pn~~~~e o(peip:ol):!i~;,~.sea.Sc ..
b:l then~bPP:i;;Dn~:~s~ting;an,eDi4l.i~ :i olld: 'ABo
~ii:ntn~tion:do.es not :become "inore.sev:ere:f u
-f\t~;.~iriicie~.~&~~ug4~ru{thtat~-ri16cit:<>rin~
~s-~a.~:n~.~~~~~ ..:n.e.(}~te~mu~t-becarclHllY
o~rtecl'oi' P.regres~i~e hypeibilitubinemia -which .
will r~ti.ire piiotot:p.erapy.
~n the CDE (R4:e~usj blopd .gzou_p, '.'J:il."os t
-~Ptp.Irion .ttnti~.ief; th~t..ai:.e ;rpun_d ar~ anti:D,
follow~- ):iy ait~~~l ::.a;1:l'ti~.and. .,-ap.ti c. A'nti."kell
a.n:til:>Qdi!!sfare al~o fouiJ.:.d l~p ~ t).q-li.emolysi's .occw:s
.b:ecati:se:~Wi~ antigens are.d'evelqPed orily after a
few weeks after birth.
'The n;lOs.~ ~v.~re: se.que.l~ . of i~oi.m.~."?.tiizatio~
is liyd..~ps.fet.alis. The;t~ is aii.:~bnormal collection
,of fluid'm m.ore than one (1) ~ea.: of the fetal pody,
_likeasci~. and. plural ~[fusion. _With. e:xces~ive t;md
pr-Olonged }1efuo1ysis,. anemia develops. "This will
stinlwate m arked.. ex_tram~duUary :hem,.atopoeisis
in the spleen and liv.er. with eventual. hepatic .
dysfunctio'n :(Nic6linian<l associa:te~. '199-1) . .T.h ere
maybe cardiac enla,rgeroc.nt, p'J.lti+onary
. .hemoi:"T-hag~. hyfuotho$;-ascites :artdgeheralized
-~dema T~e placenta is _also .m8!kedlyectematous
Scanned 8y:
enlarged a,nd boggy with la,r.ge promiheq.t
cotyledons and edematous Villi. These hydrqpic
cha"t:lge~ are visual~::?ted by .ultra.sonogra.phy.
Fetuses with severe hydrops may die in utero due
to cir.cutatory failure. Less severely affected fet;tj.ses .
maY: devel~p ma.r:ked. hjperbilir<.lbinemia which can
cause .k ernicterus; a centra.! nervous system
domage.
The fust step in identifying the woman at risk
.ofRh.isoimmunization is by the indirect Coomb's
test. Jr' the ~t;eenh :pOsitive, the iromV.noglobulin
subt:ypP., Ig~G c r Ig..:M is determined because only
lg-0 antib:odies caJ:l. cr9ss the placenta or cause
fet;3..l hemolysis. The Ig G level must also be
deten:ni'ned since .the results will affect the
subseqUei).t management. The test for fe~us or
neOnate, on t he other hand, is the cili:ect Coo;mb's
test.
.
Man.agement is inaivi4ualized. s _:eria1
..fetaLhemo:gl;;tl:5ir.i.; .b,)~~-,c~I:dio.centesiS. . .mayb e.
~rformeai 'E'etal ;blo.Qd~transflision. depending on
.t he fetal'hemoglobin leve!s.may9e given. Vaginal
delivery'atorn~term:is :i?~:ioal of n:i~~e~ent.
. ,, . : : . . ~ :
' ;T-:0. prevent ..ocurrence"'- :~d ~recurrence in
s.ub:::eq~ent ptegnp.nde.s,. :one rdo.se..~f..anti-D
imnninogloi:nili!lis .given .to all-D.- negative women
a.t about 28 .w eeks a :nd a Secbnd dose .is givep. at
del~v~ey-.:l(~~e-infant-:is ~Fj~~~tive: ~'b.,.n(i@:five
woll,le:U:m1J"stalso :be'.. givenim:tnMUog1obulirr:after
each .mi~ge.
..
. ..,
HyYerbiliriubinemia I
I
\J:n~onj.pgated -or fr. e e bilirubin cro?s the I
placenta fromJ:?.ot her to-Ietu~ or :Vice verS;t ifthe
matemat p~sm:a-.levei of .ttnt9njugatecl .bilirubin
I
is .J:Ugh.. .Uncohjugated. bi.li:it+bin.is noteX:cr.e ted into I
the bile or urine of the neonat~. The most .c ommon I
fo~ of \ll)conjugat~d non-hemolytic jaundice is I
physicl.ogicjaundlce. In :mature infapts, ::he serum
bilirubin "increases for 3 to "4 d ays to .serum levels I
)
up to 10 mg/.dl .a nd this falls -~pidly. In preterm I
infants, the rise is ~9re. prolonged and maybe more
intense.
I
. Elevated bilirubin or .h:yperbilirubinemia
sped<$y in' preterni can result to kernicterus.
.Kernieterus .is :the staining of the .b asal garigU.a: and
hip'pocamp\).s With resultant degeneration o.f.the-Fe
regio n.s . Sur'l!'iving infants show spasticity,
C
 CHAPTER 46: OISEASI;S ANO.INJURlES OF THE FETUS AND NEWBORN
muscular incoordination ahd vary.Uig degrees .of
mental retardation.
. Phptothetapy is u sed to treat hJ.perbiliru-
binelllia since liW.t~~mote$ hepatic excretion of
unconjugated bilirubin and oxidation of bilirubin.
..A.lso, light penetrates the skin which increases
periphetai b!ood flow there"Qy enhancing photo
oxidatic>n. If this .modality 1aU$, exchapge
transfusion may be done.
No.n-Imttlune Fetal Hydr<>pa Fetalls
A variety of pathogenic mechanisms can lead
to hydrops. Can:fu!,c abnon:iialities
present in
30. to 45 percent of cases, a third of hydtops eaS"es
result fro~ . inultiple .m alformatione or
chr<;lmo8omal ancmalies, Abdut lO percent are
associated with twin to twin ttan'$fulrion syndrome . the feta l lungs by norn;1al physiologic m~'li~
and tat'ely fu.>D.l the inborn etron; of !Jletabolism or
a.qomalpus:Jymph system. Prognosis of hydrops
cau~q :l?i.
!hese conditions is .poor and treatment
can provide~oi'ily temp<>rru:y r.e'Jief. . xpecon.ium, cord compression or u~1!f:6J>Ja;~.ia.I
.O~,}:~~gue complication of fetal hydro})-~ is. meconium t .a n lead to pulmonary hypertension
the JDAtetri:al-i riitrot syn.(}pjmewhere a mother With
.s evere:~eclampsia ..-dev.clops.~vere . e,<;lema.
' I .,;;: . .. . ; .. . .
Feta} <ianfiac Anythn1ias
Feta). cardiac . atryt~mias can rapg~ !rom
ci.....;,~;_.n+
b :ra.'J~'-UQ.\.U ..chyn~,:.,..:..ia:s
~: .. ~-;,~ . These. 'art usuaUy
as-spc~ted :'With-'n:U:iterfm1-~utimmun:e: otsoroets
and fet~J cat:_diac structural abnormalities.
Treatment is ~ted towardstheunderlying.eause
of th~ condition. Prognosis is dependent on the
underlying cause:
DISEASES OF'l'HE TERMFETUS AND NEONATE
Resp~toty Distress Syndr.o me
The common caus es of res piratory distress
syndrome inthose infants include sepsis specially
group B streptococcal disease and intrauterine
pneumonia, persistent puhnonacy hypertension of
the newborn, meconium aspiration syndrome and
pulmopary hemorrhage.
. Advances in neonatal-cure have improved the
survivl:!l rate and decreased the morbidity of these
conditibns. High frequency oscillatory_ventilation
which improves oxygenation without hi gh
ventilatory pressure and the nitric acid which is a
705
specific pulmonary vasolidator .h as reduced the
mortality as well as the need for extracorporeal
membrane oxygenat ion (Finer and Barrington,
2000) .
Meconium Aspiration Syndrome
The amnionic fluid is contam1nated by
meconium in about 20 percent .o f pregnancies at
term. In ' the majority of cases, this meconium
passage indicates a norma}Jy maturing
gastrointestinal tract or as a result of stimulatidn
from umbilical cord compression {Nathan:~ co-
workers,lQ94). Passageofmeconiumintoanorn:ial
-are
amnionic fluid volume results in light meconium
staining, and its aspiration before labor is a
relatively common occurrence. In healthy, well-
oxygenated fetuses, this mecor:Jutn is el~ l:>y
When this is riot cleared, meconi~. aspiration
syndtotne occurs. rusk factor-s .are ..diminished
amnionic rtu.id volume which i~.:l.Els to "th'ick
insuffiency. Prolonged and cons~f~~su(~.. to
which is character-ized by abn9r.mal
mascularization of 'the interacinar attenes.;Jfu~,.
Bowe s (1992) concluded ..that onlr~;2fi'rori't&i,!y
'.
asphyxiated fetuses develop meconi~ 1isP~~~n
syndrome.
In pati"ents With thick mecoruwrrsUun:m:g---'t ;r
the amnionic fluia. oropharyngeal sucfion1rig
before the delivery of the trunk and suctiorun-g"
under direct laryngoga scopic visuali,zation can
}ower the incidence of meconium aspiration
syndrome to 2 . 1 .percent. Amnioinfusion maybe
beneficial only if tlw meconium is thick and there
are recurrent variable decelera tions.
Hemorrhagic Disease of the Newborn
This is charCl.cterized by spon~aneous intema l
and external bleeding beginning anytime after
birth. Most are due to abnormally low levels of
Vitamin K dependent factors ( V, VII, IX, and X ),
prothrombin and protein C & S. This becomes
apparent 2 to 5 days after birth. Late hemorrhage
occurs at 2 to 12 weeks in infants exclusively
bieastfeed because breast milk contain"'very low
levels of vitamin K. . :~
Hemo rrhagic disease is avoided : by
intramuscular injection of lmg of vitam.ln K at
Scanned By:
r-.
t:_::.l
706 SECnO~ VI: COMPLICA'tTONS IN PREGNAN~Y

del,.:Very. In~ actively -b leeding infant. Vitamin .K Alloimmune thrombocytopep.ia (Isoimmune

is injected intravenously. - thrombocytopenia) follows rp.aternal i.wimmuni-
zation, usually again-st platelet antigen -HPA-la
T.lu-ombocytope!lla which -is found in 98% of the :P9PUlation. This
au:i.igen ,i s.lacl<ing-iri -~sceptible mother-S ~ t.,liey .
Table 46 ..1 Sh9.WS sbm~ causee . of become il;n.mun~d. when. exp9sed to the fetal
thrombocytopenia. Tltr-O;m.bocy.t~penia ten-ds tp be platelet. antigen. Th:J,s coriditi-on becomes more
more ~vere in pret.erm fetU~:specif:!Jl.Y thQS with s evere ~nd dev.e lops e _arlier in S'QCC.ssive' :.
respkatory.. di~tress .and ..)l~xia .or $ep:sis. In -p regp.a:ncy. (Sily<:Fand AssQCiate; 2 000}. Treatment
irru:Iiune throrphOcytopenia, tht~penia is is -weekly maternal tv infusion of :immunoglobulin
mp; - -.fiound_ m
"'d .-an. d- ~~ ........ ...tnt-: - Wl"fu
as~on ....,-.4-
- - .~emru ' w.hich .cat+ sllow vagi.')al delivery.
autoimmune . dise_~se.- ,Cotticostert;>.!d:. ~creas~
maternal pla,tdet.lev:els b:ut.t, the ~etill platelets. :Poiycytheoilii. ,and:-Hype~cosity
Vagiru1,1 -de~ery maybe allowed ~en Without fetal
pl.~te~ets ~plfug. - This conditio.n oc~urs as _a -r esmt .o f chr:onic
l1YP9$ -iri-~ut-e~o. from acute ~sfer from the
pla(;eni:a of twins :at q eijveiy :and::rar~li .from '
. . Some.
T$le 46.1. . of.neoD.e.t.al ~opatia.
ca:uses . . Il.l$.temat-f~ta1 .hem 9qhage. ',rreatm~nt -i s -partial .
-... . ~

:~cha,nge_ .transmsioz:+.
r~~;"un<throm~.
(\cpv~: - au~<m:Iunune~IYllirob~tosbs"ftalis.. . ..
Intrauteriiie ci~S.e:6ff.et,'Tls-esis'more:~.i:Jllnon
Irtfectiohi' with earlier age ox :gestation. A:lthoqgh the
incld~pc;e -Qf -stili birth,.h~s :d.~~ed o:ver :the.:past _
c~~~ ~e:~ct indd~;P.ce.-~s-;sti~l:uril\JWll. -The
-~Wl. . - . . PhiUpp~e :Ql;>stefrieiil:;aii<:i: Gyheeolqgi~ ~ecy
.-llirO~~cijl.Absem.~.s,('t.AR)'$#rqine - -and .th~ M~t-eniaJ. a+id.'.'F.etai. 'Me~iC,ine- Uil.it of
~-~=1~13i~: - ... .. . .... -. P}lilippinef:;Gene'ral"Ho,spi_t_:;U..v~y,.ga$er., data.
regairfuig.;;till births wei~g .SoOgms :or-more.
}d~:~flYIX?Plasia ' ..
_I;.cilkciiiTh Hi~.ti~Qsis.
.9-St~~~.
. '
-. .:-:
ar~r~i~f~~i!.Z~~i:~~~~~~~
~Pe-H~ rmea~ oh:~aeerat?-oii in the _sti:lf.bom. s'-+gg~ts lfu.l.t .~etal
demiSe has' occurred for" more fuan.24hours.
Di8$emij\'atedinfuunascu1ar Coai;ulation . ' ' ' ~ " 4

Irihe#-~ The caps~s -of f~ta:l. def'l:th caJil- b gn:>:Qped ;Is

.'~V1Sk9tt -- _s~~hSyndrofue fetal, ,pla,ental.a.pP, matein,al causes. The very low
. ~y . -- }'J.e~.AAorrHilY a~~cn>.sy f;ate -i!il th~- l~hjlippin~s rl;l.akes 1;ht

J'lllile 4-6.~. -~irfu injuries (PGH, l -9.92).

. . . . -
Total N\l.lllber Spontaneous . Cesarean Section Foreeps- Breech
-of.~e~ Extraction

Hematoma ro 1 -o 4 s
Ab~~;; 2 0 0 2 0
Cephalh~atoma 6 2 1 3 0
InCfsion 2. 0 2 0 Q
Braclllal 1 o- 0 0 1
'Nerve
:Pirisy I
-F orceps 6 6 l
.. :

Snanned fy: C
 --"----~C_HA
_ P_T_ER_46_
. .. SeA~
: c:-oot...... _s_E_S_A_N_O_iNJ_U_R_lE_S~O_F_,_TH~
E_ F_ET
__ U_S_AN~O-
_N_EW_._BO_R_,N_--:---- .; 707

determination of feuu death causes difficult. Some Table 46.3. Protocol for e:JU!Jllination of stmbom iitfifuts.
type of fetal ~bnormality accounts for .25 to 40
Infant Description
percent of stillbirth (Fretts and Usher, 1997). Thes~ Malformation
include congenital anomalies, infection, Skin Staining
m~fuum)i.~; han-immune hydrops :and anti""D Degree vf Macer&.tion
isciitntnunizatioiL " At tb.e rhilipp.ine General Color-pale, Plethoric
Ho~pitalMatemal and Feuil.Unit, multijlle'CO.m:plex
anomaly b the leading ca1i'se df fetal demise UnbilkalCord
P&olapS'C
secondary to congenital m&lfonn.ation and neural Entanglement..-neck, e.rnls, legs
tube defects as a single congenital anomaly. Hematomas or Strictures
Nu.triber o.fVessels
Placental abruption is the most ccJlliQ.on single Length
identifiable qause offetal deatl,11eading p1a.cen:tal \Vhartonjelly, normal, abse:q,t
and membrane infection. placental infraction and Anmionic Fluid
fetal matei'fial hemo~e. Color-meconium, blood
<::on~istency .
Hypertensive <Usordets and. diabetes ar:e the Voimne
two ~pUnonly cited m.ate~~~s ~
.with 5 w 8. percent of stillbirth~ (Fr~tts ~.d U.$h.er, Placenta
Weight
'1991)~ the. pr~sen~ Qf lUpus ~ti~lani~d SWiling~meconiwn
~tiCaroiolipin antibodies ow.ybe aSsociated .With. Adhetent :C lots
fetal death 'SeGondaryto decidual ~lOpathy. .. ......._,.... . .....
... ~ ':' .;.:~ ~

.~ ... . ----~..-.:.... Str:uctural~normaliti~-Cittu.mvaUa~ or ~thbes,

Evaluation of the Stillborn .I ntant Vdamentous insettion .
Edema~bYPmpic Cha,rlges

Intt:a<Uterine .f etal de:mise e-: reates a ' Mel!:lb~es

. p$yCboi~~~pa~on.thewoJriana.ni:fherfmi:rliy. MConium stained or cioudy ., ':.-<" ! k:.:: . . .- .
Effeetivc;.'tb1lri$~li.n.g to.
ovetcmne ilie tO:;s ~d nuckenmg ~: . . i. ~-~~ -.'~~;i~: -.

prevenf itS' i>ccurrence iri su~uent pregnancy

necessitates identifying the cause .o f the fetal
demise. A detailed h!story taldrig S,Jld physical
.exainination-of-the-fetus,placenta;and-metQ:bnme--
if- properly perform-ed- c~ -yie-Id---'\Tal'Uabte
information~ Use Qf ~ ch~cklist, sitnU&..r to the
c hecklist of Lunningham & Halleo (1997.) .can
facilitate completeness of tile ex:ammation.
Autbpsy of the. Q.eaci .fe.tus shouid be
e ncoU11lged.as this can yield additional.infoima.tion
which can change the recurrence risk estimate.
(Faye-Peterson and colleagues; 1999)
. .Counselling to couples with .a prior fetal death
should start prio:r to the subsequent CQnception.
Knowledge of the cp.use Of fetal death resUlts in a
more accurate calculation of recurrence. Early and
more frequent prenatal visits can facilitate the
initia tion of diagnostic tests, procedures and
treatment.
In fetal dea th associated whh neunil tube
def~cts, folic acid given 400mcgmf <1ay given ..3
months prior to conception and up to 3 months
into the pregnancy has b.een fotJ,nd to decrease the
ineitltmc-e -or these ct:efe"cts iri stibs'eqU.en t
pregnancicfs;
SpontaneoUs llitiacranial Hemorrhage
Fetal and neonatal hemorrhage can OCCli~. in
-sev.eral sites. Isolated intraventricular hemorrhage
into the brain matter without associated
sub<h-achnoid or subdural bleeding .i's the most .
common type of intr~cranial he.n iorrhage; this
u sually occurs s pontan~ou sly as a result of
immaturity and not from traumatic delivery or
obstetrical factbrs. Ahtinatal steroid did not have
a signific'ant effect on the developme-nt of
hemorrhage. (Table 46.4)
Although the
Ukelihood of severe hemorrhage
increased as gestational age at .delivery d~eased,
spontaneous intracr~ial hemorrhage hlfs been
documented in .h ealthy term monster. This can
happen as the fetal head passes through the birth
canal. These hema tomas usually resolve in 4 weeks
time.

Scanned By: ~
708 SECTION Vl: COMPlJCATIONS lN ":P:REGNANCY

Intraventlcular Hemorrhage from Metlianical . ufthe skull_as well as determination of eoagulation

Injury . factors.

Birth trauma is no longer a -comm.Q~ ,cause of Nezye I~jurles

intracranial herno;:-rhage.. Subdur.all:lemvrrhage
from tentorial tears and massive i.nfr:atentorial
hemorrhage have neu:::ologkal 'abrtot.ij"Uiliti.es ~t the
~e of b irth. Subarachnoid hem.onha:.ge,. on the
other hand, initially mariifest ~s :seiZures.
The eJ.irnination ofdi.fficultfo~ps -4~ety and
a_ppropriate manage~ent of the breech l"~.A$led to
the reduction of birth-rela~ed :injuqes. These
injuri.es -a re "i_.rsually associated with infant$
wei.gl"l:irig 400-gms or more.
Cepll.a:lhemato:ma
A-c~p~ematoma is usucilly,cau~ byfu.juty
to tll~ .perio.st~u.m of tb,e s~ "during :ia:Ptir.:t:d
defu:~ty, .altliough }t :~y :Q.evclo:p -.in .tfl.e. ~ce
of~birth ttauma.wh.en-Jdiilhemost:a$13 :iS<d1'ecti~.
. TP!a - ~~hoi:!ld 'b~ diffel'~:ntiatoed .ft~": -~S:ptit'
su~<:;da:O:etim. T.a"ble 44,5 .shows the :&ifterence
:rx:tweei>._ the_se .:two OO.n:iitiori~- "ln~~ ~ Qf. .
hematoma --and : oi:he:t eVidence$ ":.of ate-6l:ve -.
ht:ho~~}iag~ at-e in.dic~ti:o,n~,:-r~r -~i_rd1ti.6n~l . . del~id $d :"irifi;aspin,atu.S :.mu-s de .aS> :wj$--a.S .the
mv~#isap~e;proeeduis like-ril,(lli)~p~~stu.di.es . . fiexor::ril~scle'of:t;hed"o~ca~smgtbe;entfre~n:n:. .
~
. . . . . . . . ... w -
Spinal injucy_ is )..lsually due to.. over-Stretehing
of tpe :Spinal Cord due to excessive traction d.uri.."""lg
. delivery. Hemorrhage into tl).e spinal cord and
.someti.tUes actual Jracture or dislcx;ation -of the
. . vertebta:may ~cut.
Inqeasing b irthweights and breech d~veri~s.
are "t}te mpst significant risk factoros of ."b$chial
pietu:s- injuries . .The i'Il.Jqry_usuaUy fonows .a
diffir;:u).t delivery, although not irifl"e<jueb.tly, it may
be ~n "afte:- an appcrreD4y easy on:e. The incidence
is :a.~ut l:S.PO ~rm .~L--:t-."1-J.s. There w.~s .only .o:ne
. ca~ .t:>Pm~;Ch.i. ::n<trY~ .I!~. ip. 4~~ :4~1J:vffi:s, ~t
th~ Ph.ilipp.U,le G~e(al Hospital WGH Statistics,
:l99.2). 1'hlli ~w):r.dde:nce o fnrit.e injuzy.may be
attribu.t.e d to the :prop~r. hahcUin,g :([J"f breech
w
d<;i,t;ef:ks, the "lOW~r bj.rtb. weigt.i.t,s tb.~ pop$tior..
studi~d .~d fhe trend- of deliverin,"g .all 'bree~h
babies -c~:il.-..section.
PU11-enP,.e:or:E~s p~isi~ -~~is of the
.. 1.. .. : . ' '

, .

.Causc.(s)

V~ous "t ean Tt;m:m:a.com.ttt~:n'lly

"PI:etcnn>.te:tm . Comm.on -I k;nign Tta\:ima-term "H:YPoxia"~pretenfi

'
Mu1 tifaclbrial

Intraventiqilar Thin-walled ves~ls '6(g~ matrix

Unc:O~_on Variable Mult:ita.Ctu~, bemon-ruwcin!Iaction,

coagulc;:>athy,~~ardefect,E9MO

Ta-Q1e 46.5. Differences between ()aptit ~uccedan.eum an~ ceph.a.l.hema~oina.

Cep~alhematoma

l;.c>Cation Above pQsioon. Below periosteum;-limited.by-periosteal edges

Size . Maximalatl;lirtb. Grows larger
I .
Re~ut;ion Groyr.ssm~cr ho.~ ,to rlars Weeks -t~ .mo!J.ths

Scanned 8y: ~
 CHAPTER 46: DISEASES AND INJURIES OF THE FETuS AND NEWBORN
to fall limply Close to the side ofthe body With the
forearm e:xt~nded ami internally rotated. The
frmction of the fmgers is usually retained. This type
of paralysis is due to the excessive latP.ral flexion
of L~e neck, Reported tisk feo.ctcre, include fetu~s
weighing 4000gm, prolo?ged labor, fo~eps delivery
~d shoulder dystocia.. ln breech 'pre~eritation,
injury may be limited to th.e lower r,erves of the
brachial ple.xUs re.s ulting in paralysh~ of the hand
(Klumpke paralysis).
Facial paralysis results frorn irJuty of the facial
nerve. Faci.al paralysis ftlay be apparent at birth
or SQOn ruter birth. Usually the injUJY is seen in
infants c;teUver.ed J;;y forceps extrilclion wpen the
head is seized obliquely and :pres~re is applied
on thestylotnastOid foramen where the facial nerve
emerges. One third of ctl~es io f facial palsy followed
spontaneou!J delivery, with s}l9ntaneous recovery
occutting within a few days.
. :. ; ... ~ --
.::..
. .:. . . .. . ~;
.--~..:;;. -... ..,: . . . . .
Fractrites. of the sk>.ill. an4 the long bones of
the body have been identified folloWing difficult
:delivef.J;s,,:F.racture pf the. clavicle, which is. the
- -~- --~~ . . .
.most co~t>"n fracture, has an. inciqence of ?..to 3
per- lQOQ~-AV.e.~''bfrths. HuriJ:etal fta~tures ar-e less
c<:>Jnliloti:"":fli~ are enco"untered following d~ifficult
deliveo' of the shoulders in cephalic presentation
~d m ~n.ded.. anns in l;>reet:b p~sep,ta.P.on. Most
<;~f!;!}e~~~~~ttrntme.nsiickiype..CO.mplete
imGtllrn.3., :witb..oY-e.niding._of.the bone~.may:.occur.
Presence of crepit~tions . and ~nusual
. ittegtilarity ;o f the bones wiu-ra:nt.p rol!lpt radiologic
exam-ination. Brachial . palsy may coexist with
upper e.memity fractures.
Fractures of the skull m~y"follc>w spontaneous
delivery, forcible attempts at delivery especially
with forceps, and even cesarean section. On
radiologic examinativn .of the skull,, a depressed
area..~ay be seen~ Surgical. decompression is
~sually Stlcctss(ul.
Muscle Injuries
The most .commonly injured muscle is the
sternodeidomastoid, partic\,.tlarly a,fter a bree-ch
delivery. The muscle or fascial sheath may tear,
with hematoma formation and c icatricial
contraction. As the infant grows, the damaged
muscle, which is less elastic; does not elongate at
Scanned 8y: ~
- 709
the same -rate as its counterpart, with resultant
development of torticollis.
Con.gen ital Injuries
These groups of injurie~ include focat ring
constriction ')f the extremities and actuatloss of
digits or a Umb: Localized ~erm plasma failure and
early rupture of the an;tnion leading oo.Jonnation
of adherent. tou.g h bands . that constrict or
amputate an extremity of the fetus .are two of the
proposed causes of this conditi')n..
Congerlitat Postural Defori:nltles
Mechanical factors caused by eht-onic
oligohyc:lramrtios and the inappropriate $iZe and
s hape of the uterine cavity tnay p roduce .from
growmgfems.defornlities $uch as talijles .{clUl;>foo~ ,
scoliosis, lUp dislocation, J.4nb reduction,bOdy Wall
defects .and even hypolastic iung} .
:'-r.':;.j.:~~~--:_,~;-~>-H:~.~-
- ~~A. :.. ... -,_._.
~,.A .:,:;; ~ . - .. __,.,:~~- ~.:-
1. Hanreyo, ParkinsonCE,cQmpbellRRii;}c~~
distress. syndronie;.Lancet 1975; 1:42, '
. :-:;:A~~~~t~;~ (' t~ - ~-~~1:. ~,\r~ : .:
2. Quif.c JG. Bleasd.alc JE. Fetallung~it~Jn; tlie
presrumcyc:omplicated~ydiabetea mellitUs. f=i't>)R~e
GC, Hawkiils.RR (is): P~ Mediaue U~.and
Controversi:es. New Yorlci COrtina llit~ 19~;
11.7. . ..
3. Clements JA, Platzker ACG, Tierney DF, .et &.1.
Assessment of the risk of respirntory disb:e$$ "S}'Ildrome
:by a rapid test (or surfactant in alnniotiC fluid. N Ems J
Med 1972; 286: 1:07-7.
4. HerbertWNP,ChampnaJ.E,'CefaloRC. ~ofthe
foam stability iz}dex test in assessing Jetal lung
mattira~on. P!-esc_nted ~t the meeting of the S9ciety .of.
Perinatal Obstetricians, SanAn~oniot FebrilarY, 1~84.
5. Ba,r.kay "G, .Mashlach S, Lanzer 0, Kayai:n z, Erish
Goldman B. Detennbation -o f fetal lung mat>..uity from
amniotic fluid microviscosity in hi&}l- mk pregnancy,
Obs tet Gynecoll977; SO: :273.
6. Sb~.aa A.J, Michelwitz H,Sclvaraj RJ, ctat Relation
between optical density at 650 nm .and L/Sratio. Obstet
Oynecoll977; SO: 273.
7. StienfieldJD,SamuelsP,BulleyMA,CobenA.Ooodman
DBP,"Seruor Mi3. The utility of the TO in the assessment
of the fetal lung maturity. Obs.tet Gynceoll992; 79: 460.
8. Uggins GC, Howie RN. The prevention of.RDs in latemal
steroid therapy. In Gluck L (adj.): Modem Perin~tal
Medicine. Chicago Year Book, 1974; 142.
~
 710 _,.,.---:-__,.--~----~....._ __
SECTION VI: COMPUCAT10NS
...._._...___,...._.. 1N "...,.-.
9 . Howie RN, Uggins GC. Clinical trial -of ~terpartum
. betamethasone therapy fo.r prevep.tion o~ respiratory
distress in pretetm infants. Proceedings of Fifth StUdy
Group, Royal College of Obstetrician& and Gynecologic
October 1977; 281.
10. MO.rley CJ.-.$ urfactant tre~ent for ptemat\lreb abies
rcvicvt
. oh;linical trails.
. . : 199-li 66: 144.
At:th. Dis Child
11. Arias ~. ,~er J..M, Seifer s.,.,~ lL Prolonged
. neoq.crt8l_unconjugated t;~binemla as~ted
With breast"feeding and :~tetoi4., p~ane- s 'mplla beta-
. dicti."l ';.lUitemahtlilk that "j.!'l.h\bits gfueor:ona t~rtnation
in vitro. J Clln Inve3t 1964; 43: 2037.
12. Fo;>liot.A, Plou$SGrd, .Hol,l~ S, Ch.-isW!oJ";)v B. Brea~t
milk jaundice: In \'i:rto i.Qb1biticn ofr at liver blliritbin-
\U'iditle di.spbQ~pbate gl';lcoron,yl .tnmf~e ~vityand
zpro~ brCinosW!onph~ bindiilg'by hu:inl.u" br~.st
lllillc..P.cdiatrRes 1976;_10: :594.
13~ -~VA;:~tp:Fp, lr.Qh\lgre'SJ\.. ~eo.t o!ir;e~
,:anti~y ~g. :An1 J :O bstet Gys\ect rgss: '159-
'428. .
14 ..JC.at;:-MA, .~to.WP Jt, Xototl<~ J}l. Rccui'Tence rate .
: ABQ:h~ol)'QoilliJease of.the:newbQ~0bstefGynec6L .
1982; 59-- 6.1 1.
15. ~cw~ ~.:CJR. ~l\l~~J.ls.'~ PW , .Fi,lly .
Jt4.... $niith J<;. inv.~ti~ 91-!l.~b.;DDi~c hY,dro,p s
. retah~ Am.Jobstct-. GJn~ :t9M.;;.l'S();.oos .
19. hulpd A.. Qray.,ts,:Sro.wn.T, CJeWiy_jl,:.Cohen. SJ.
H~:~ovin,ts~ectiQnUl.ip~~cy ilndhydtops
~N-tnglJM~ i.9S'7; '316: l:$3. . . .
11 .Santola~.J, Alley. D , J.a!ec _R, W.ar130f St.. Mtenatal
. ~cl;i.tion -ofhydrops fetalis. Obstet Oyntcoll99~i
79='2.
18. Morales WJ, Koerten .,J. Prevention .of inti'a~cpt;ricular
hem9r:thag;: in very low birth W8hta hf' ~atetna.lly
ad.mjni~tered ph~ol)arbit.lll. O~tet G~ecol ~986.~ .6 8:
.29$. . . . .
0 32.. Mip.o M. Clinical uses and abu-ses of vita.IPin .E in
19. ~ SM, 'Mitch~!! M.- Epste~ :F', J;.ouik,C , GiA~la GP,
'SbaoitO ~. Heparin use as risk factOr fodntmve~tiicular
hailorthage in low :b4thweight. infants.: N .E ng} J Med
t986;:3J"J! 1!56. . . New EJ1gl J Med 1984~ 310: 1093.
20. Donna SM, Roloff .DW, Goldstein OW.. Prevention of
futrav~ntricular hemorrhage in .pretehil infants by
pheni:fbai-bitone. Lancet 1981; 2: 21.5.
:a; Sinha S , Davices J, Toner N, .Bogle S . Vitamin E
supplementation reduces frequency or perlventricular
hcpiorrhage. in very pretenn babies. l,ancet 1987 ; 1:
- ~. . '
Saanned 8y:
__ _______
PREGNANCY ~---- ...
22. 'relani N, Verma U, Hameeed C, Chayen B. Methl)d and
route of delivery in the low birth wel.iht vertex
pre_sentation correlated with early periYCntriailarf
intraventricular hemorrhage. Obstet Gyneoc;~t9e7.; 69:
1.
23. Freeman JM, Nelson KB. Intrapartum a$pllyxi;l.and
cerebral palsy. PecUatrics 1988; 82: 240.
24. Rosen MO. Di~~on .JC. The .inci~en~ of ccte'bml
palsy. Pediatr:Gjrnecol1992; t67-4l7.
25. Nel$0il KB, Ellenbe~:g JH. ~tC(;ed~ts nfCQtbral palsy.
. Multivariate an;;.lysis or riSk. N Engl J Med 1926; -3 15:
81. .
l
26. Nelson~. Ellenberg JH. ,Antecedents ofct:ranJ ~
. Vnivaoate aniUysis of risk. AmJ o is Child 19~; 139;
1031. . .
27. '!o~s CP, van d~ Ser~_.B, Oes:chsli FW, Cummins S.
. PrenauJ and perinatal f~ra mthe etiolOgy f:i( ~;:al
.palsy. J Pediatr 1990; 115: 615.
28. Luthy DA, Shy KK, Strit1dand D, et al. Stab.!s ofiQ!aQ.ts
at.birth .a nd-ri$k for. adv.erse n'ir~tat:'~..lttld iong, .
tt~seque~: -A .Study'ih low. birthw~iQtt'~ Am
J Qbstet Gyhecol1987; 157: .676.
29 .Dijxhoom- MJ, :.V~ . GW.. Fidler VJ, T~ a9L.
. it.sjes&:tApga,r. SCQte, liJ.~rii\,un 6Jl(l ~ia at
bi11hin n:leiiot:~.Jo n~natal~gical~ m
terni m.r&nta._-a~ J oQstet b:;n:ecist.t9S<>;l!6; .~11.
. 31 . Petlman JM, Cunningn~' FO. FeW and .~a.tal
pypoxic :iscllemie certb~ iJij\itr. W'~:O~cs
18th 3d (suppl2l). Nt>rwalk, CR: Appleton ~ Lange
Dec/ Jan 1993.
children. Proc soc &-.p .$iol.Med '199.2; ~0().;266.
33. Jeigmann RM. ~aranoff M. NeCT()tizing ~te.rocolitis,
34. Hayden CK, Shattuck KE,-Richardson CJ, ~dt DR,
Jhouse R, SwiscJ:J.uk IE, Subepensymal, gerii!.inal tD,at:rix
h emorrhage in full term neon ates. PediatriC$ 1985; 7-5:
714.
35. ~vine MG, Holroyde J, Woods JR, Sidcl.iqi T/\, Scott M,
Miodo.v nik M. Birth trauma; incidence and pn::disposing..
factors. Ob~tet Gynceoi.l984; 53:792.
C
 r.

CHAPTE:R 46: DISEASES AND INJURIES Of THE FETUS AND NEWBORN 711

36. SaunderS BS, Lazoritzs, McArtorRD, Marshall P,-Bason
WM. Depressed skull fl'acture in the neonate. J
Neurosurg 1979; 50: :5 12.
37. Torpin R. Fetal Malform~tions .Caused by Amnion
Rupture During Ges~tion. Springfield rL: Thomas.
38. Miller ME, Greham-JM Jr., Higginbottom MC, Smith DW.
Co~)iresslon related disorders from early amnion
rupture; Evidence for mechanical t~rotogeriesis. J
.Pediatr 1981; 98: 292.
39. 2001 Compendium .o f Selected Pi.lblica,tions of the
American College of Obstetric and G}'necology. 24~25.
,_
46. Anpual Statis~cs Mat~ Fetal Unit. Philippine General
Hospitall997 2006.
41. Williams Obstetrics 22nd edition: Diseaee & injuries of
fetus newborn. Mac;:Graw Hill20Q:5; 659-692.
42. Faye-Peterson EM, Guion DA, Wioshon KD. Value of
perinatal au~opsy. Obstet Gynecoll999; 94: 915.
43. Finer NN, Barrington KJ. Nitric oxide therapy f')r the
newborn. Sem Perinatol 2000; 24: 59.
44. Fretts RC. Usher RH. Causes offetal death in women of
advanced maternal age. Obstet GynecQll997; 9 :40.
45. Katz LV, Eowes WA. Meconium aspiration syndrome:
Reflection on a murky subject. Am J Obstet Gynecol
1992; 166: 171.
46. Silver RM, Poster F, Breech OW, et -al. Neonatal
alloimmune thrombocytopenia antenatal ~ement.
Am J Obstet Gyne:::ol 2000; 18.:2: 1233.
47. Gibbs R, et al. Suggestion to Accompany. Neopata,l
Encephalopathy and Cerebral Pal$)'. American College
of Obstetricies and GyneCQlogists 2004.

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Scanned 8y: ~
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47
DYSTOCIA DUE TO
ABNOFMALITIES OF POWERS

SYLVIA DE LASALAS.CARNERO, MD

Summary of Normal Labor

Uterine~'D.ysfunction
Hypotonic Uterine Dysfunction
Hypertonic Utetine Dysfunction
Complications
M~nc;1g~ment ..

Acti~e Management of Labor

Abnormal-taoorf>a.ttermr
Prolonged Latent Phase
Protraction Disorders
Arrest Disord~rs
Predpit3te L?bor and Deiivery
Inadequate Voluntary Expulsive Foree

Scanned By: C
:7t6 SECTION VII: DYSTOCIA

Dystocia or difficult labor is characterized by often made .b efore the active phase of labo.r and
abnormaUy slow progress of labor. The four therefore, before an adequate trial of labor~
abnormalities that may .e xist singly or in Cesare.a..""l sections done for dystocia in the latent .
(:Qmbination and :result in dystocia are: phase of labor are inappropriate.

1. Abnormalities of the expulsive forces Ove.- t:he past few decades, there has beena
~ Uterine dysfunction - uterine forces dramatic increase in the nu.inber or cesarean
insufficiently strong or not appropriately sections being pedorrned. Cesarean section i~
coordinated to effa~e 1p1d dilate the ce~. associated With increased maternal morbidityand
b. Inadequate voluntary muscle effort during mortality; increased neonatal morbidity, -and
the SC,Qnd stage i)fla.bor. inreased health. care cost$. Dy.Stocia'.a ndelective
~. AbnQrtnalities of pre$~ntation, position, .:or repeat cesarean ~bi:ions account 'for the majority
development of t.li~ fetus of ceSarean deliveries.
3. Abnormalities of the matemal bony pelvis -
- . pelvic contraction It is generally agreed that dystocia leading.tQ
4; Abnormalities Qf the birth canal other than cesarean delivery is overdiagnosed in the United
. tbqse of the bony pelvis that form an obstacle States and elsewhere .. F;;;ctors which have been
tc) fetal descep.t. implicated in the increased use of cf!sat_ean
delivery for dystocia include incorrect diagripSis ::
.. A review of the five-year stati~tics of the of dystocia, ep1dural analgesia. fear of litigatlcin,
phijippine Obstetrical and Gynecological Society and even clinician convenience {Uebettni.n ~d
-co.~ling .. l39. accredited hospitalf! ,from -~2001 . to co.:workei$, 1996; Savage ar td Francpcie,
2005 showed that' the incidence of.dystocia in a . l994;ThorpandcoUeagU.es,J993a). Anoiherfatit:ot
totalofl,S74,:0 99 deliveries was 7 .84%corilpared implicated is insufficient. oxytocin stimulation of
to 1'~.73% in 1996 to 1999.. At the Fat Eastern labor (Rouse and colleagues 1999}.
UD.l~ersity Nicanor Reyes .Medical Foundation
-~NRMF),: the incidence ofdystocia from 2002 At FEU-NRMF Medical CenU:r, dyst:ocia ~'vlas :
. ;!;0."2007 was 8.37% com~ to 13~75% in 1996 . the indication for pri.lnary cesar-vanseetion .u f'
. to.2QOO .. 30.86% ofcases during the period;covering2002
to 2007, showing a decrease. from 48~64% in l~
H .. "~ Pely;it..contr.action i$. often .accotnpa,.nie.d .b y
.. to.20.00. .Thiscould. mean .morea,ccurate~osuf.
. .,'u~rmC:.dysfunctionand the .two constitute' the of dystocia. All cases .diagnosed. as dy$tocia.
mnstcomm.on cause of dystocia. Abnormalities underwent cesarean section iU this institution. .
in presentation, position and development may -
'als~. be accompanied by uterine dysfunction. H is necessary to attempt . a better.
A# a general rule, uterine dysfunction is understar..ding of normal lab~r to be able to
common whenever there is disproportion recognize abnormal patterns and m~age dystocia
~tween the presenting part of the fetus and appropriately if it occurs. This eould poteniliffiy .
the' ...birth canal. lead to a significant reduction in the ce~
section rate.
Dystocia 'is the most common contemporary
. in(ijeation for primary cesarean section. Gifford SUMMARY OF NORMAL LABOR
:an(\ colleagues (2000) reported that lack of
.pr~gtess jn_labor was the reason for 68 percertt of The partograph, as conceptuaiized by
unplanned cesarean deliveries in cephalic Friedman, (Figure 47 .1) can be used to assess:
presentations. Almost 25 percent of the.cesar:ean progress of labor, and detect presence of deviaf;ion$
deliveries performed annually in the United States from the normal pattern which will necessitate. .
for lack of progress were in women with cervical intervention. The latent phase conunences WiPl .
dilatation of only 0 to 3 em (latent phase) . maternal perception of regular contractions, and
According to Stephenson (2000}, this practice is in the presence of progressive although...slow
-co~trary to recommendations of the American cervical dilatation, ends at between 3 and -!? cni ...
. COUege of Obstetricians a nd Gyn~cologists (l995a) dilatation, which is the threshold foractive.phase ..
that the cervix be dilated to 4 em or more before a transition. During the active phase of labOr, the .'
.d iagnosis is made. The ~Hagnosis of dystocia is cervical dilatation rate is at a minimum of 1~2 em

Scanned 8y:
~
 CHAPTER 47: DYSTOCIA OUJ: TO ABNORMAlliJES OF POWERS
per hour in nulliparas and 1.5 em per hour in
multiparas. During the preparatory divi$ion of
labor, little if any fetal descent occurs. Generally,
fetal descent begins when the dilatation curve has
~ntered the phase Of maxim~ slope. From the
beginning of the deceletation phase . (pelvic
division), descent is essentially lip.ear, until the
fet~l pr~senting part reaches the perineum .
Friedman's data ~how.s that norma.l labor is
characterized by rates . of maximum descen~
exceeding 1 em per hour in nulliparas and 2
per hou.r in multiparas.
:....-:- ...
..
~._::.:.:::..:_:. -=:=.. ..:7::..-.-:..:~:..:.::__:.._-=:,.~-:-;:..::::..=::;.: --- -
.n~4'T.J.~m.pqsite'ott!;!e ~v~ cUlata:ti(f,n.cwve At}<i
~~~!!~~.. !g.:.:mUPBIQH~.~..!J.9.r:. J~. al~-~~9.m.Jh~
fu~~~~?.Il~-~t~,;~~~ fpm Fi?~_pa~'- ~~7~}
VTER:INE .DYSFUNCTION
Failur-e of.tlw. cervix to dilate or th~ presenting
part to descend is cause for concern. Prolongation
of either the frrst or second stage of labor may .
res1,1lt in increased peri11-ata:l and maternal
morbidity. Uterine dysfunction 'in any phase of
cer.vici~1 dilatation is characterized by lack of
progress. The ql~agemeQt .of uterine .dysfunction
. has .~hangedfrom .the attituc:;l~ of watchful waiting
ta .(1 more aggressiye a,pproach brought :a bout by
the l) re~tion that undue prolongation of1abor
may contribute to. perin~t&l morbidity and
mortality,'2,) use of dilute solutio11's of intr:a,venous
oxytocin .in: certain types pfuterine dysfunction,
a,nd 3) nwte .freque~t use of: cesa.re(l:n delivery
rather than difficult midforceps delivery' when
oxytocin fails or is inappropriate.
Reynolds and coworkers (1948) em:PMsized
that uterine contractions of normal labor are
characterized by a gradient of myometrial activity;
being greatest and lasting longest at the fundus
(fundal dominance) and diminishing towar:ds the
cervix. Caldeyro-Barcia and colleagues (1950} from
Montevideo inserted . small balloons into the
myometrium at vario.us levels. With the balloons
attached to strain-gauge transducers, they
reported that in addition to a gradient of'activity,
em there was a time differential in the onset of the
contractions in the fUJldUs, midzone, and lower
uterine segments. Larks (1960) described the
stimulus as starting in one cornu and then several
: .ilxf;._~.~~ --:~~-= \.=
milliseconds later in the other , the excitation
wave$ then joini ng and sweeping over the nmdus
and down the uterus. .
. The MonteVideo group also ascertain.ed. that
the low~r liniit of con~ctiori__pressure required
to dilate. the .cervix is 15 nunHg. .This ~: is . in
agreement with .t he findings .oi Henclii~s.~<;Ieo:
workers {1 9'59i. who re:p o.rted;.il'ia:f,norP:ral
spontaneous contractions often ex'ert p~ess\lre~
~ ...,. , - - ; .: .~o>"-'J~
ofabout 60 mmHg.: ' -. .,,:: .....,.,.,, .
.. Ty.p es of Uterine Dysfunction
~ Hypotonic Uterine Dys{iin:cticn..: : ~~~''i~
characterized by ab~nce of basal hypertonus, .
pre$CJ;lce of a .non:p<!J grClcl.i~nt .~~-wi.Ul
fl1:!1:~?.:!.~~E!~?.c~!!~~-~'A!:)he slig~f.j 1$t!...!E..
pr~~~~!"~ .?.~g. ~_.f.<?~I!~.fti9P._i~...in~uJJi.!=:i~'P.-t .
to dilate the cervix at a satisfactory rate.
Contractions become less frequent and the
uterus is easily indentable at the height of a
con.t raction. It usually occurs in the activ~
phase o f labor .after the cervix has dilated to .
more than 4 em. This .type of dysfunction often
responds favourably to. treatment w.ith
oxytocin.
2. Hypertonic Uterine Dysfunction- or incoordinate
uterine dysfunction is. characterized by basal
hypertonus "'ith distorted pressure gradient
because of absen ce of fundal don'linanoe or by
complete asynchronism of ' the impulse s
originating in: each cornu, or a combination of
these two. It occurs:during the. latent phase of
labor. The contractions are painJul but
ineffective. The USe of ox}rtocin ~ ~e of
dysfunction will usually result in acc~atiori
of abnormal pattern of uterine. conttactions
and increase of uterine tone. This w:Uf.:usually
respond to sedati?n
Scanned 8y: ~
71'8 SECTION VII: DYSTOCIA

Complications of Uterine l)ysfunetlon 2. Cephalopelvic disproportion and any

abnormalities of the birth canal must be ruled
1. F etal and neOnatal death~ WL . .
2. Intrauterine infection-.s in prolonged . 3. O~tocin is avoided in .the presence of
dysfunctjct)ai -19.b0r.. abnormal fetal presentation 9.nd marked
3. Maternal ~austivn. uterine -overdistention as in hydra,nmi6s and
4. DifficUlt labOrs and deliveries are likely to leave multifetal pregnancy.
psythologkal scan ~n til~ lLl()ther which may 4. Women above 35 years, more than p araS .a nd
a:ffecttu:ture .c bildbe.arlng. those with p{evious uterine .s cars are generally
not given oXytocin because .o i fu.e danger of
rupture;
Treatment of Hypot-oru:c.lJ'terlne J')y$fllnctiol!-. 5. The condition of the fetus must be good - no
meconium stained amniotic fluid, normal fetal
l3efor~ ' a t.reatm.ent plan ca."l be fo~ulated, it he~ rate.
must bcf$:scertame4 that the woman Js in activ~ 6. Patient must be watched very carefuliy for sign
labor with the cetVix at least . 4 ern
dilated and ofhyperstiniulation (more than 5 contractions
cephalopelvic cllspropoJiion .mUS.t be rul.ed'Out. A in 10 minutes), which will necessitate
contracted 1'\iia, j$ most ~likely with clinical disconti.Jluation of oxytocin infusion.
fiil~ 6fll!l9:f;:P..ai -4~~on~Jconj~~e, ~l .p elvic 7. COntinuo:us electronic monitoring offetal heart
sidew_a ll:r. Matly patalld 3) iS~ ~p~e~ ilo~ and uteri,Tl.e contractions.
pro~ent. -.4) saertun ilot fla:t. S} .su~puble angle
not:~~~f>J,~put4s: tbe.~p.te$Cnting;part; :;md bxyto:cin ':is a potent drug and when given
7l-fetaihealt;iseo&a:ge<k-. - : . - intt.avenqusly , : it" act.s promptly: leading to
nbtlceable"..ptogress. 'It should be employed cnly
a:
.. Once the di.agnos,is ~i 9.ctive~;t~b.oi followed .by . .for period of a few hours arid if pte(iictably easy
h~tnic . :u~e :d_~s~ction has .~n tnade,. ..vagin.al d~live\_yurnot i.rnmjne nt, c~~ean -ddivexy
anmiot9my is done ::t 9.-detrtli!pe {:Qie:tl:laraeter :t>f should be ,pe~on:ned~
the ~otic :U'J:lid. Th :papettt i:rtben closely
ob~rveti'ifor 3,0 ,to_, OO :miiu~telJ to
'8 W:hether Satin and co.:.workers sugge;;;t th.e.use of high
aninioto~y:Williin~ve~terine'~tmctions, after dose oXytocin for 1ab6r ~:t;mUlation. The oxytocin
4lf.U~iP.n. ls $~~ at 't> .millilili,it$:per mim(te~and .
-;::4.~~=i~:~=~~=~eart .inmm~1i~{5l-~-6~mii)iinurs~~--~rm'tht:mr eve '~'-"2"0
mfnif&s-liotio eiceea '4"2rtfuuuiliis-~r: ~me.
With high dose aU~lentation, labor was show.n
to be .more than 3 hours shorter, resulted in fewer
Traditionally., lO Jtnit~ .o f '.o xytocin are forceps deP,vecy and fewer cesarean sections for
incorporated :in: 1 'litei< ot :ddCtto!lf! or til~tated dystocia. Utfrine. hyperstimuiation :was more
runget's so1utionan(i .i,ruusedat 'fl rate of 1 co.mm~m with this high do~e regim,en .but no
nillliUlllt pet :m.lnute WlliillY lU1d _titt&te4 ~gamst adverse :felill effects were opserve(\.
\.ttedne eontraeti(>ns, With hi~temen.f~ .'o f 1
mitli~t every thirty :l ilhlutes .w hen neces-sary. ACTIVE MANAGEMENT OF LABOR

.The SOciety_bf0b$tetriciaris lU)d .Gynecol~gists
ot ~Cana4a (sqG q reconunenqs :u1e folloWjng
protpcoL lpiti~l -'dqse of oxytocin of l-2 tn U 1
minute, increa!'le interval of 30 minutes, and
dqs;a,gc :increrilept p(l-2 tirU. The U~u!ll dose for
.goOd taoor is 6-12 m'lfj.minute.
- .
the followit}g precaution~ :are .exe.~ised"with
theuse.o f o'~Ytodn stim\,llation:
1. The woinan sh6uld be iri t:tue labor with the
cervix at least 4 em' dilated.
This has l>een suggested as. an alternative to
cesarean section fordystocia by O'Driscoll, Foley_
and McPonald (1984) . Labor is diagnosed when
painful contraction~ aie accompanied by complete
cervical effacement, bloody ~how, or spontaneous
rupture of membranes. Onset of labor is
considered to. begin with admission a,nd . progress
of cervical dilataijon isnoted' at 1. hour iriterval
for the first three ' hours, and every two hours .
t hereafter. The slowest acceptabl rate i~ 1 C!1 per
hour. Lack Of acceptable progiess is trea,ted With
oxytocin using the high d~se regimen. Oxytocin .

Scanned 8y: ~
 CHAP11SR 47: DYSTOCIA OUt TO ABNORMALITIES OF POWERS 719

is l?tarted at ,a dpsage Of 6 mU I niin and .~d~ced
in.6 mU/nilil it,J:creinen~. D\l~tion of ~oor hi the
hosp(tal ~ equated ~th time $pent in the labor
unit, which .should.~ot ~ 12 bouts. .Afttr.this
Period,caesar->..an ISeciion i~J .ue,rlonn.ed unles$ :safe
~aginal deli~e:iy oould be predicted witmn the h~ur.
,"
= -. Activ:e manag~rr;enbof labor t$ n~t asSociated .
with untoward=materna! or. neonatal nutoomes. lt
may l~d to,sho~n~ l~bor'iri ni.HiiJ)arous won1en
but ba~ .not ccn~iste..,.tly 'led. to a -reduction. in
cesanan.(;l~y~es.
. ~atinent..ol Jlypertolilc; Ut(:tJne.:l)tSr~o:l
Hypertonic ut.eri.~e dysfunction is
characte~ :'by uterine ;p ain thai.a;ppears O\lt .of
propoft4>n to the :intetJ,si~ of the c::outr:a.cU.on and
their ~n:ectiveness l1l:
ert~c~g and dila~tt the
<:e~~x. :Placental abruption lilll$t always ,b e
consideired as
a f>ossible . ea~se of uterine
hypert6hfis; Ce~ delivery must be employed
if :fetal cdlstress is suspect~d. lf membranes are
intact an~ there. is no evidet~.ce or fetopelvic
4isptowrtion'O.t fetal-distress,. the worn~ :nay. be
, sedated.;~i_lt m oiphine or meperidine to '~lleve
. : .~ . ; .
pain and rest the mother as well as'"'i trrest
abnormal Uterine a~tivity, after which it is .hoped
that more effective labor will be established.
.ABNOR."d.AL LABOR PATTERNS
Frie.chnan defmed seven types ofdysfunctional
labor, each of which _occurs singly or in
combination with the other disorder$. (fable47.'l)
Prolonged la:terit phase, protracted active
phase dilatation, protracted descent ftUd
prolonged deceleration phase are
qualitatively
indistinguishable from normal labor in that they
follow the general shape of dilatation or descent
pattern.
'They Q.iffer .from riormal o:nly in 'a strict
quantitative .s ense,' failing outside the nornrat
:rangeof some s pecific .phae duration .o r shape. .
"Seconda:ry: ~rtest of 9-ilatatiotl:!U).,..-Qh':~s ;.:a
pattern cll'a:rige from the 'expected si'gliiOid:ShRp&~
curve ()( ~meat dilatation...P.rogressivecdilafa:p:'o:n:
in tb.e .. active phase stops befon!'''flllt c~fV'ital
dilatatio.n is attained.

. ~.. ..
. . . Table 47.1 . Abn.armallS.bo pattems, diagnQstk'criteria. tu).d m~ods of treatmen:t.

.~,: ....:~Nit. .
~ Tu!A:~ .
~loaptiQD J)bgrdq- >l4hf . Bcdrc;st Oxytocinoc~ .
(Pl'olong!:d~ptme) ddivc&:~
. prpblam

l.~c-;pll;ise. < 1.5 cmlhr . Expecbotand

dilaJatioo sn:wort .
<2cmlhr

l. :rroloogE:dDoc:dcration . . >3br > l hr bxytociOwithcnt I:stifa.bapstcd

~
Phase
2.~dary~tof
Di1af.;ilioo
> .lt.r >2hr Cesarean dclivecy
withCPD . .

4. Pailiueomcsccrit > 1 IlL with oo >lhr

~in .
decclCtatiop phase
or.~o.l,stage

Scanned 8y: C
 720 .SECTION VII: oYSTOCIA

Arrest o f des~ent also involves a pattern .

.change) with cessation of progres~ive .l inear
descent Qc:Curring {Uost o ften in the second stage
of labor when the head is beybnd station 0.
Usually; one hour of arrest ofdesce11t is sufficient
to make a diagnosis of this disorder. Rallure of
descent is diagnosed in. the deceleration phase or
during. the second $~ge when active descent is
.exp~c;ted to . be in r~u progress but has not
CU:rred. The station o:f the hea<i remains high
and d!>Cs not go beyond -station 0.

Prolonged Latent Pharoe

A. prolqnged latent phase i$ one longer than

20 houn in nullip;\rol;\s or 14 houn in
multiparous women. {Figure 47.2) The etiologic
facto" include ~s.sive .~tion orconduction
~.$e~~. U,nf~v()\ln$.1e: .cervix .(e.g. thic~ rigid,
~effaced,. uridilated)..__false labOr,. ~d u~im.;e
dys~ctiQ~. Most women With prolonged lat.e nt
ph4$,e.art:alx:~d.~ t4oJ,;Qqg}y .~~l.l~,a}ld-may
:suffer,' ~oin::illU,ic,i..e.,nd;;;.~~ot~~ilnbal~"'e.,;.Jf
lbe~ :~ .no ~~trabidieatJO:Jl~f~r..,a:-ti.w a:()J1o~ .
Fipa-e 47../Jl.. PrQlbnged latent~ p:rttern (solid.line} is
the on)}i di$0rder thus far obj~vely d4\$fipsable in the
.preju~.tatory di-.:is~oti .6f. la~!~. U is !Ml al:!tn~m.<ll~ty
~tet;ited .b y a Uatent p}l&SO dlllilti,!>ti exc~edipg critical
.~; ~f>\VPwi$ typ~~~QD..Qflbe.lo'w mmsi.e.,rm
oilhi: ~id .~e.~r:ctrn~dila~tiOb.. lt ~s followed by a
no~al8CfiVe phaSe h~;AS :is usti.al)y ~e <:aSe. The av~e
:di:lStation..~e .lor ~Ulli!'ata :O:>to~ . Une),
COJ;Jl~P. ' .
is
shown for
. . . .

4:e~~.Y. ~~ ~~Jtv:e.-y.; a th~~'-:Jieu~i~ ,..~ .. t is f~tal-distr~. Frledman's~~~ded approaCh

Ac~~endeu .q'"ing :stn.J.Jlg ~~clatlve When l$ $Uppott.~(i'tlle..~peu;icx.~;py the, pflar,geuse
. 1;hese~patierit$:awaken b:Ptirs.,,Jlitet.~s% ,wiilhave . dose s of ti~trcotic analgesic$. :E'Xce.ptional~y.
enteied the titive :pha~; t0%win not bC.in labor .oxytocin ay be undertaken .directly if the
mc:Ui::ating ~ey .we.r e in 00~ Jabot~ antJ,.5% Will . additiOnal 6 to 10 hoUr$ deJ.ay 'by rest wo~d be
have ineffeCtive COJ;l,t;rq.ctU)ns,.'TQ!s la$t ~\l.p of ,Clipically unacceptable :;rs .i n the presence of
pati~ts ~Y ~n~ 'fro.~ ~ .s tim.tion. if ~horipamnionitis~(Figure 4 7 ,.3)
tJl.~_contili:ihdieatiri.il$..AnuiiotolllY.<Willn<>t
accele~c:".th~~~t~nt::pMse-,an4:-';is..:diSe,!)\iJ"aged
.because -brtlie -.tpo/o incidence <()(taise la~r.

Prolonged lateJitt phases of ,lab<>:r ar:e not

.:ominon and SQkcil.,~d cbllea~e$ (1'977).:repotted
a .3 to4 -o;o inideJ1Ce r~gardle"$S -bf parlt.Y~ FrltdJnan
(1972) .report~d th;3:.~ :pr-t>lQngation of thl;! l~ient .
phase d.id notadv.er:s~y influel);tef~tal iOr ~tet:nal
l'ilQrbidity a nd morthllty. Data snow'that pati~ts
with.prolonged late~t.phase ate .n o more prpne to
develop problems than gravida~ with normal latent
phases. Thus, a patient w~Q has a 1aten,t pha,se
longer than 20 hours should b expeeted to evolve
a normal subsequent dilatation and d~scent if
perniitted to d<:> so. 1t cannot oe. too strongly .$tated
th'at patients who are delivered by cesarean
~ection during thJa~ent ph~efor np.other i'eaSOn Figure 47.3 . . Prograln of IIUlllaEeinent .fiJ.r patients With
than their lack of progress are.:belngsubjected to pr.o.longed latent phase ~ The principal recommended
this opera.tion unnecessarily: mo.st of the titrie. appn>ach is support oand therapeutic rest by use or large
doses of narcotic-analgesics, applitable' to 1!11 but a;bout 2
:C esarean section ha.s no place as a_- J:Pethod .o f ~tof~vidas with this disorder. Exceptionally, oJcytocin
treatment for the prolonged latent phase without infusion ~ay be undertaken directly if the additiona16 to 10
other clear indi~ations like docUn}ented CPD or hours ofdclay .by rest wol.J}d be ciini~y unacceptable.

Seanned lly: C
 CHAPTER 47: DYSTOciA OUE T o ASNO"f~MALITIES OF POWERS
Protraction Disorder.;
Protracted active phase dilatation me~s that
the maximuw. slope of dilatation is less than 1.2
em per hour in nullipar-ous or 1.5 em _per hour i.n
multiparous. wome n. Protracted destent m eans
descent of the fetal head is 1ess than 1 em per
h()\lP .iq .n.ullipar.o\l$ <>r 2 em per hol.lr in
:rn~ltiparous women~ {J?-igute 47.4) 're:re underlying
pathogenesis is essentially unknown. The possible
etiologic factors inctude .malposition, excessiv~
sedation, oonduction ahalgesia and cephalopelvic
disproportion. Twenty eight percent of the.s e
wor.uen have. CJ>D and require caesarean section.
H c:po has been ruled out, t4e therapy
recommended by Friedman . is physical and
~emotionql. support, and a prolonged labor can be
antiaips,ted. ()pe shou.ld guard ag!linst the
.temptation to ertec.t mstruznenUJ. delh.+ety in t4.e
~sesJ.)ecause ~ts born .u.nder Sl.~ch condttion$.
do not Wt; :wen.
Continuous fetallnonitoring is
essentia\. As Jong a~ progress is being made and
there is no:'fetal distre~s~ the labor process may
-~ allowedto continue. Majo"rity .< >fthese patients
Will have. uninterrupted progressiQn and usually,
vaginat de~very. (Figure 47.5)
. .:'. . .
:. .'::- .
. ,..:.... .
~.. ~~---?:,f i' :~~~~!~t:~.~ y~,~ :i~~il~-;; .
----- ~ --- -.- ----- - -- ..
FigUre 47.4, Po>traction disorders or labot:, depJcting (A)
protracted a.ctive~phase dilatation pattern with abnormally
Slow m~Uiil slope ofdilatation; and (B .protracted tiescent
pattern with maximum slope of descent less than prescribed
critical limits o!normal. These labor aberrations are similar
to each ~the~ Ul many ways and frequently OCCUJ' together
in the same patien~ They are clearly different from the
average r.oi-mal dilatation and descent pattem s .
Scanned 8y:
721
~c&sproportioft
Cq>!'~
.- . -
~
.~
l>n~~l
l~b:J
Fi~re -47.-s~ R.~eoL.,{fuende"9 inana_gemerit pri>gram.for
patientswitlr.protolction:disordertr,0 rice reeogn'iUd1'tbeSe
labor a~ons -ate best handled bcpectantly"~th;_:fuU
support fpr:.emotional anQ. physic.aJ.need~- c;p'e.J:>emt~en
to av.oid anytbj:o~ ~t !XlaY ev~remotelyiphibit~on
in these .ong. slow labors. ~e dQCU,mentati~:ofr~
dispwpot-.ipn justifies terniillP:ting .the labOt bY ~
secti<J.n ~d s.v..ettlng the <:liflii:ulties of ~ent h-e:-e~
FOrfuose~Ql!owed to ~hor;itisesSe.ntialto avoi<hhe ~-
of instrumentation at delivery. )! ,,, ;\~c ~ _
- .
Before the arrest disorder can be diagnosed
in the f irst s tag of labor, the ACOG (1995)
su ggested that the following criteria should be
.met: 1) the latent phase is completed (i.e., cervical
dilatation is a m.in.Uhum of4 em), and 2) the ui:enne
contraction pattern exceeds 200 Montevideo units
for two hours .w ithout cervical c hange.
In assessing the optimal contraction pattem,
the effect t;>f anesthes ia should be considered. One
randomiz.e d stui;iy suggested that e pidu r a l
bupivacaine analgesia a dminis tered before 5 em
of dilatation prolonger;l the flr:st stage of labor and
increased the incidence of c~sare~n delivery in
nullip;3.rous . women; An increase<.:! inciden ce of
malpresentations and operative vaginat .delivery
has ruso been reported with the u se oLe.R~dural
anesthesia. .
The "two-hour rule" for-the diagnosis of'a rrest
in active 1abor h as recently b-een challenged
r-..
~
 722. SECiloN VII: .DYSTOCIA

.""':'
(Rouse, et al. 1996). In a clinical trial, 542 women L\l(}'T
were managed by a protocol in which after active
phase arrest was diagnosed, oxytocin Wa$ ~dated
with the intent to ~chieve a. sustained uterine
contraction patt~rn of greater than 200 7.
~
Montevide0 units, or a mlriimum of'6 hours of ,...
oxytocin a~entation if the con.t:ractiqn pattern
-~uld :Xl~t be -a:~hi:ev. The prqtoco1.:resu1ted in a "
high rate~f -vaginil a~liyery J92%)wlth no severe
adver,s e maternal or :fetal oll,t.cO.rties . Thus, . :;?.
,.
t.
"II 1 .- g
i : :-::c
~-

.exten~iing t)le minimum p.e:riod. of oJ~Cytocin f "'

JiUgmenta:tion for activ.e phasearrestfro~ 2 hours

..
I
;

to 4 hoursappears ~ffecti~e. .

'l~ is a, .lp!ltter of the most seriolJ.S import;ance

wben .progre~sive cer:vlcai .dilatation '1>t<>ps., or
progl-e.ssiv.t! .fetal descent ~~ts du,:rin:g labor.
$.ecQ'tld:a.ty,aitest qf.dilatation:9cc~Jis wben-cervioal ..
di'la~ti6il ~tops =m .the active pha:se (~Uin
Figure 47.7 .. Aj Prolott~ed .4,ecelei!Uion ;p nase _pa.tfun..
-~lq~J !or.2:~Pil~ or .rn,o.r e '{F~~e -47.~} .J'.rOlc.t+,~ed B) Failure ()f descent' iri the <l~le.ration -p~ .fUJ.d second
-4.el~ra1i9tl. pbase -.oq::lirn when it . last~;iop.:g~r ;stage..' . . .
a
than... f,i(n,u-~ in nul1ipar-a~ .'O:r i :ho~t: in
multi,par:ae;l(F..ig\lie,:47~!h)'~-'\:m:est~of -~esce~t i.s .. . ... ....
:c~sa:ti-o.n::-o-f';a~scent ~pl'o'f~i:es#o:n:. ~~the. ~lVic
. diviSl,<>n of 4\,~r for '1 --hour or Pt-6re.{Fig(J.ie' 47;8)
$;ailU;te .or .~eS:<tent -is. 1ac~ .iJ.f e*cu;'d
:de~~t
ilifiwg fAhi;~iVic':diVi~ion-vJith,th~ ,i;tea.~. .-~t,$tktion
0 o r,8.bove. ..

~
A-
.r
!
I
1-~l
... ;
:.'.\t'il!
. ..
r"~:ai
:;
"
.rt

I
I .: E ' !
l I
e
i
,.,'-!-.......;:...,-.&
.
i .
1. ;

.g .. j '
l
!. ..
~. ) n I 4 J t) :_ ... ..
~
... o<-.=-. L__. _ __ un<>
U .\Y...:Fitr.Wr: u~ k"
l .A<>:a !"" . iocm r ""_j

Figure 47. 8. A) Prolor;tge9,-sec.o nd s~ge.of)at>or.13} ..Arrest

of descent, charactc;ri,2;'ed.'by.-halted -9-dvari:cctncnt of Ictal
stai!>n in the second sb,l.ge. .
i .

Most patients (52%) w ith arrestdiso.r dcrs have

CPD an.d r.e quire ce~arean deliv~ry. O~er
. etiolog-ic factors includ:e hypotonic uterine
'
dysfunction, malp<)sition, e.xce ssive sedation -and
~-~~1:\L\i{l(.\; anesthesia.-
L<i<X! i =I QU, : t!l . "" J
Figure 47..-6 .S econdary air~st of. dilatation pattern with . I( the patient. d oes rrof .have CP.p:, laPc>i :t;ah
doC_tpncnt:ed cessation of progression in the :a ctive phase(A). usually be a~loweci to ev_olve., ).Jt~rotonic

Scanned 8y: ~
 CHAPTER. 47: DYSTOCIA DUE TO ABNORMALI'nES OF POWERS 723

stimulation with oxytocin infusion will effect Precipitate Labor and Delivery ...
.:

further dilatation ~d descent, but it is essential

before undertaking such stimulation to ascertain
that the peivis is .adequate for the fetus. The post
arre.s t slope can be rela.t ed to the slope ofdilatation
or descent that developed before arrest. If the post
arrest slope is as good as or even .g reater than the
pre arre~t slope, vaginal delivery can be
anticipated. If the post arrest slope evolves poorly,
caesarea..'l section is indicated. The specific fetal
a..Tld infant risk for arrest disorders appears be
greater than that expected for comparable norinal
labor;qFigu~ 47.9)
-~ '
Nleslof dilatilicn u des<:enf '
~~phase
faiklte of descM
According to Hughes (1972), precipitate la.bcr
terminates in e~pulsion of the fetus in.less than
tr.ree hours. Precipitate dilatation is diagnosed
when the maximum slope ofdilatation is rilote.
than 5 em per hour in nulliparas or 10 em per .
hour in multiparas. This may tesult from an.
abnormally low resistance of the soft parts of the ...
birth canal, from abnormally strong Qterine and
to abdominal contractions., or very rarely, fr.om
absence of painful sensations and thus a lack of
an. awareness of vigorous labor. Mahon &nd
colleagues (l994) reported 99 . pregnancie-s
delivered within three hours of eommencement of
regularcontractions. Short labors were~iated
with abruption (20%), meconium, postpartu.m
hemorrhage, cocaine abuset and low Apgar sco~s.
Most (93%) of ~e women were multiparas ~"ld
. typically had uterine contractions-m ore eft~ t llru:l
every2 minutesd-Figure 47.10)
J. ,, : - - ..';

.. :I= I
.Treatment

. eesaeoo
~
l Oxytocifl I ..c
.. . "

:: 1~ ~itsponsof~. 0

I
J
A
...... ...... j

... ':-...., f
j,---,.,-Ho-le$j)OII5e-
. 1~~~
u ---.,
1
,. "
....
.. .,
I \\ '.
r - ~j)d~ r .i
\i

,,\
i B I I
I I
. '
' I I
I ce:saean section I I
I
I
~gurc 47..9 . . Management schema for gmvidas Wit.'l arrest I
disc~c:rs.. The most critical aspect ;:;f evaluation in tflese I I
_patients is a.s sessment for cephalopelvic .d isproportion ,I I
because this fac tor is commonly associated. When .... -" \
encountered ih patient with arrested labor, disprop<>rtion I
d emands cesarean s ection. For the remainder, oxytocin is c I
0
in order and tan be expected to yield g<;>od results, if the
pest -arrest slope is at least as good as the prearrest slope. j 'I
II I
=
A
I
I
Prolonged second stage is diagnos~4 in I.
nulliparqus wom.en .who .e xperience lack of
continuing.progress for 2 hours witho\].t or 3 hours Figure 47.1Q. Precipitate labor patterns, rept~nted b'y
with regiona1 anesthesia. It is diagnosed in parous {A) precipitate dilatation and (B) .precipitate d~~nt, as
women who experience lack ofprogress for l hour d efined by their excessively rapid rates oC progrt~e cervical
without or 2 hours with regional anesthesia dilata tion and fetal descent respectively, which distinguish
(Figure 47.8 B). them from the course ot n orinal labor {broken lines),

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724 SECTION VII: DYSTOCIA

Maternal Effects Inadequate Voluntary Expulsive Force

Precipitate. labor and delivery are seldom When the woman in labor reaches full cervidll
accompanied by serious m~ternal complications dilatation with descent of the ..head, she starts to
:r the c~rVix is effaced appreciably and easily ~ down everJ time the uterus contracts. The
dilated, the vagina has been stretched previously, combined force created by the c otttractions of the
and th"e perineum is relaxed. Conversely, vigo:rous utetus and the abcknnit"lai musculature propels
uterine .c ontractions combined with a long, firm the fetus down the vagina artd through the vaginal
cervix and a vagina, vulva or pe:ti.nel,tm tli'At resists outlet.
,stretch may lead to rupture of the uteru$ or
extensive lacerations of the cervix. vagil\a, vulVa, The magnitude. of the force created by
or pel'iAeum.lti"s in the$e latter conditio.n s tbt\t contractions of,the abdominal musculature may
.a mtuotic fluid embolism is 'l:JlO:>t likely to Occur. be compromised and prevent spontaneo usvaginal
The ute:ru!l that contracts vigorously before delivery when the patient .has been given-
dell"ety is likely to be .hypototiie after delivery conduction analgesia (lumbar, epidural, caudal,
resulting in )lemorr"hage "from 1he placental or intrathecal), gen'eral anesthesia, or heavy
implantation site. sedation.
. . . .
EffectS on -Fetus <Jtid Neonat~.
'"'-." Management
Petittatal mortality artd morbidity ftom precipitate
labor m_a y oe increased cortsidet:ably for the Careful selection of the kind of an8tg~sia and-
follo~g- reasons: - the tim~g ofits' admili:i~tration-are:in1pOf1ant to.
avoid compromise of voluntruy e xpulsive efforts.
l. The tUmultuous uteri.Qe Cb:Otraetion$ prevent With . I:ate exceptions, . intrathecal analge~ia or .
apptoptiate ute.rin~ -b lood .f low and general anesthesia should -not be" administered
oxyg~ation Qf;the ;fetal bl~~ upt:U all con<Utiol).s for ~safe outlet"forcep~ delivery
..
have been tnet. With con ti-puous epidural .
2~ There.si$tance"bfthe:birt;h<-e anal toexpulsion . analgesia, .it may be necessary "to allow the
of the =fetal' :head may cause intracran:ial paralytic effects to we$" .offso t])at the wori;lan .can
trauma. g~-1}~~!~ :~.1}~-~~pgqt.m_ri;tY- .P!'~~!?.~{! .~l!ffitirn!..Jq
m.9.Y~ th~ f~WJ h~.d..int.o ..W.siti_on appropriate.for
.3. During .an unattended birth t.;.e infant may otitlet forceps de1l:Very. The -altf!matives, a poSsibly
fall to the .fioo.t and :b e inJured or .m ay need difficult tp"idforceps delivery or cesarean delivery
resu$dtation that is not immediately are 'l!llsatisfactory choices in the. absence of any
a.v~ble. evidence -offetafdistre~s. In some. in~tances, the
ut.g e to bear down is overridden by the
intensification of pain or bearing down. Long
Tr.ea~mcnt sta,nding paralysis of thel1bdm;ninal museut.ature
a$ih poliomyelitis or transection of-the spinal rord
Unusually forceful :;pontaneous uterine may ai~o ~ve rise "to insuffiCient expulsive dtorts.
eontractions are not likely to be modified . .
significantly .b y adnllriistratit:m .of analgesia. Any For. the woman who. cannot bear down
oxytoxjc agents be~ng ~dministercd should be appropriately bec~l.Us~ of. pai,n , analgesia is likely
stopped "immediately. The use .ol tocolytic agents to be of considerable penefit. Perhaps the s.afest
such as rito~qne and pa"r entera.t magnesium ' choice for bOth fetus and mother is piJrous oXide
sulphate is unproven in these ein;umstances. Use mixed with equal volume o f oxygen and provided
of genera! an~sthesia with agents th~t impair during the time of each contraCtion, At the same
uterine contractility such as halothane and time, appropriate encouragement and instruction
isoflurane ls oftel) excessively heroic .. are most likely to be of oe nefit;

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 CHAPTER 47: DYSTOCIA DUE TO ABNORMALITIES OF POWERS 725

POINTS TO REMEMBER

Dystocia is the most common contemporary indication for primary cesarean section and almost
?5~ of ~rean section de-liveries performed -in the United States for lack of progress-were done
during in the latent pha,s~- This is contrary to the recommendation of ACOG that .the cervix be
~iiated i!> 4 -em or mo~e before .-diagnosis of ~ystocia is made. Cesarean section for Gystocla in
latent phase of labor is inappropriate.

Labor may be presumed to have begun when the woman has regular painful uterine conttactions
that brin_g about demonstrable cerviCaleffacement and dilatation.

The latel"!tP.hase of labGr com~ences with maternal j)erception of regular contrar:;tions and io th~
presence of progressive although.slow cetvi~l dilatation ends ~t between 3 and 5 em dilatation
which-is the threshold for active -phase transition.

Hypotonic Uterine DysfunctiOn is. characterized :by ~bserice of basal hyperton.us. presence of a .
nonna( gradient -wttem
With fundal dominant:e; hut the slight rise in pressure dutir.g con'tractic)n is
insufficient to dilate the ce...Vunlt a satisfaetor}t ~te; It u$ually oecurs during the active p~ of
!a~r and responds favorably to treatment with lixytbcin. -

H~rtonic :uterine Dysfunction 1$ charactertzed:trJ-basal hypertoriuswrth distorted pressuri:i~~~~~Z-':

~use oh1bsence of fundal domln<,mce.or by complete asYr1chronism ofthe impulses onglnalifl9. ,-.
in:each cornu.lt ~rs. during the .latent ph:ase of labor 'and -contractions are painful but -ineffeclive:._'.
This wtll usuaily respc>nd to .sedation.
. . .

- - :. - Prolonged latent-:phase "(>~0 h"oors in: nulfrparous or .14 hours in multiparous women) :dOes:'~-- ~, ~
..:::~;;::, .adl/e.~ely influence fe~l- or mate mat morbidity :~md mortality.. if there is no GQntraindica~nJ()f.,a.,~.c-"'~ ..
to 10 hour delay of delivery, a therapeutic rest 'is recommended using -strong sedatives. When this.: -~-
patient Cfflaken hours later, 85% Wlll h<:Jve-en~r~<tthe active ,Phase, 10% will not be in Iaber indicaon_g_
they were in mise Iabo~ and 5% WiU.havdneffettive
-..... _ .......... .. ____ ,... , ____ ......,..
contractions.
... .. -,, .. -- -- ._ _ . _ . . --~~ _
. __ _, _ .... -- . ....... - ... .
~---- --~ - - -~ -
~- _. - ~ __ - -- - - - -- ~_. ,_.;.. -,..-, , _, . -~ - ~

Pauents Wt1oare 'aeliverecr6y.~rean seaf0n'dl:iiin9 the ,atent phas~ io~-n~ ~the~ rea-~n ihan
Ia~ of progress are.being subjecled to -this operation unnecessarily most of the time. C~<i'r~n
section has no place as a method as a method of treatment for prolonged latent phase withOut
other clear indications like doct.Jmented CPO or fetal distress.

Protracted a~tive phase dilatation means that the maXi!TlUfTl slope of dilatation is less than 1.2 em
per hour in r)UIIiparous-or < 1:5 em pernour in multiparous wO"men.

Protracted descent means descent of fetal head is < rem per hour in nulliparous or <2cm per hour
in tnultiparous women.

.JfCPD has_beenruled ouh the therapy by Friedman is physical and emotional support, and continuous
, fetal monitoiing.-As long .a'S,_progr~$.~ is being made i3nd there is no fetal distress, the labor process
-~y-i:>e ~!lowed to c0ntinue. Majority of women will have uninterrupted progression and usually,
vaginally delivery. .

Before arrest disorder can be diagnosed in the first stage of labor, AGOG suggested that the followi~g
criteria should be m~t the latent phase is completed _(cervix is at least 4 em dilated), and t.iteilEe
contraction further exceeds 200 Montiv1deo units for 2 .hours without cervical change. . ,~<

;...u .,..:

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126 SECTION Vll: DYSTOCIA

Secondary arrest of dilatation occurs when cervical dilatation stops In the active p hase (maximum
slope} for 2 hours or more.
.
Prolonged deceleyation phase OGCufSwhen it-last long-er than 3 hoursmnulliparns or 1.hour in multiparas, .. .

Arrest of descent is cessation of deScent progr-ession in the pelvic division of labor for 1 hour or mors.

Failur:e of descent is lack :.o f expecte<J descent during the pelvic di'lision with the he;;~d ai station ow
above.

Most patients {52%) w ith arrest disorders nave cpo and require cesarean <lelivery. Ot1er .etiologic
~ors inelu .hypotonia uterine gysfufltio.n, malpositior!, excessive sedation .and anestheSia:.

lf the patient does net have CPO, labor can usually be allowed .to. evolve. Uterotonic stimulation ~th
oXyt{)Gin infusion wii! ~ff~t further :dilatation and descent, but it is essential before undertalc.ing such
stirnulaoon tO ';i~rtalh '~tnat:u,e .~ !s.adeqtta:te tor ~ fetus. lftlie.!)OSt carr:est:stoo~ .is :a s..good as
or ever\ great~ than.the:pre<arre$t ~t~pe. ~inal delivery -can be an'ticipated. If the po5t .arrest slope
evoN.e,s pooJ!Y, .eeS:arean seei:C::'ds :lh~I:Gate<t '

. Precipitat~ laborterminates'in~u!sipnot~e fetu:s '{n less than3 hOurs. .Fi.recip~tate dilatation isdiagnosed
.~ . ; ftl_e,.m~urmslo~;ondt{a@.tloo~fsiJnoi:'~:~~n:;S:.eni.~per- hrJn iouiliparas-or;10:em~:perhour in
. mu~: ThiS,may. r~stJit,':from ~:~ny.'lQW .rez~,Of:the. s<:lft .partS bf'th~zpitih ~nal, . fo:m;
., ' . abnc>fmany W,Ong:ute~',qh'd':<iQd.6mlnal Coi'itractions, oivery.rare!Y;fiom ;a bserices of: paiflful sensations
and thus a tacK: ofan awareness;ofvigorotlstabot.
' . .
; . Matemal:,~ffects.:of.,pr~pitatede~.ery ,hlclt.tde:.ropture of the ,o r extensive:-racerati~ 'of the uterus
. ..:: ceryix,::Y?gloaz.pt- .p~~r>~m..:ttis~irl .tt;~~~~.ccndmO!''is',that.amn!Otic fltiid :~rriboli~ !jsmost m.<ew:~o :.
QCetlr: ., .

P.erir.3tai.. rr.artality- and-mcrb1:0lty.f.:orll<vr~mte.'kb(')(:may~be1ntreas.e&cot'lsiderably t>ecause~ bf

hyr}ooxygenc.ti9floHhe- f~-bl6od. in~phtrauma ~nd :otherinj~Oe$':

. Inadeqi.lat~. yc)luntar exptil:$Ne ,forces ~rv:he~ the .pati~t h~ been given rond.utUpn 'anaiQSia,
.general.anesthe.s.ia brh.~ sect.ation. :
..
'
Careful selection of the kind of its.o;~dminist~tiwds important to av9id compromis.e of voluntary exPUJstve
..

:{L-
. __,._ _ e_ff:.....
0rts. ....;....__,~..,_,....,_,.... .......,;-;._.,...,........_.,.._.......;.,;__.,..,..-"""..,...,..........,._ _ ___.____...,.-,......-....,.._"'--"---......,.."----..........,.._~-..~
_ _ _.......__

1- C\lnningham FG, e~ Wili=s{).b.stetri~.pnd edition. 4. Beau do!n_'F, .c t -al. ALARM I~temationai: A fu.o~ to
McGraw Hill.COmpanies,, Inc. .20Q5. Rcqu.ce.M!lt~:~d N~onatal Mor-...ality arid Morbidity.
4t:h ed. s.ooc. ~oat
2_ . SumpaicoW, et al. Textbook ,of Obstetrics. 2nd edition.
Association of Writers of the Philipp ine 'Te;tt~k of S. DepartmentofObstetriC3 and Gynecology, FEU-NRMF
Obstetric3 and Gynecolo~&, Inc. 200.2 Medical Center, Statistic s. 2002- 2007

3_ Dy!>'to~ia !lnd A)JgiD;~ntatiq.n .. Pf Lti.bor., ~0.07. 6. l'Jationwide S tatistics, Philippin e Obstetrical-and.

Compendium of Selected Publications, ACOG ~ctice Gynecological S9ciety, ..2001-2005
BulletiD. 2003 ; 49 {2}: '125~7~3 .

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 48

DYSTOCIA DUE TO
ABNORM.J\.LITIES OF THE FETUS

Abnonnalities jn Fetal Presentation

Bre.ech
Shoulder
Brow
Face
Compou11d

Abnormalities in Fetal Position

Persistent Occiput Posterior
Pe~istent Occiput Trans'lerse
Asynclitism
' :
' r ,

Abnormalities in Fetal Size and Shape

Fetal Macrosomia
-Fetat..Tumors

Shoul~er Dystocia
Definition
Incid-ence
Risk Factors
Diagnosis: The ''Turtle" .Sign
Mechanism of Shoulder Dystocia
Compllcations
Fetal Injuries
Matemallnjuries
Reduction Maneuvers
The "HELPERR':' Mnemonic
The "ALARMER" Mnemonic

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 '728 . SECTION VII: DYSTOCIA :~

..
. :INTRODUCTION Table .48. 1. Frequency of various melpre&entation..

315,564
. . : The fetus, referred to as "the passenger" plays
:~ :sjgnificant role in the outcome of labor and
.Malpresentation 11,061(3.5%)
delivery. "Fetal dystocia" or difficult. labor-due to
abp.or:tnalities pertaining fo the fetus usually Breecll .8,1343 (2,6%)
: : O'fCUTS 'i n the. second s tage of labor characteri.zed Transverse lie 1,33'1 {0.42%)
_. ;Qyp~longed d'trration or arrested descent_. Oblique lie 139 {.04%)
Face 235 {.07%)
: , ..' Fetal dystocia may occur when the fetus ha:s Brow 41 {.01%)
:.t>.ne .of the followin;g apnonn~ties: .. .Co~P,<>ti.l:ld . . . 163 {.Q.%)
Ms.lp~~eri~~d :twins
::.1. .~ Ai:morma:Uy. pos~tio;n~d in fh~ ~irt:h c~mi..l
'So9 {0.25%}
. ' : ". . . .; . ,.
. (nWP!~~ti,<_)n) mal~~ftiqril . . . . R~,Pine Obsti/tf..1 and fr..JTleWlogica1:~
. .2~- _Large for the -pe~vic open-jp.g (macrosomi~) . ATJ.TW.(ilS~atisif<:S, !2005. . .
.< ..s.~ . Abnormal shape (fetal tumors, .acardiac
...
. co-tWinl
: ~ . Itnpacti~n of the anterior $hou1de!" (shoulder weeks; tc 7% :at 32 weeks .an4 1-:3% at .tenD..
. . -: :dystpcia) How~ver, a term fetus in trr.e eCh-presentation:fiUi!
.. even revert spontaneously to t:eph:~.Hc
'-... .i0f the aboye conditions~ malpresentation and presentation just prior .to onset pflabor.. '
. . . ~atPositi.On co~ectivcly constitute 'tbe.m~ q>m~n . . .
:'. . .::. ~ ;oHeta:l.l:dystociiu:.o<::cu.Hirtg:>appro~t~!yt-in .. .. P:rerlispasin:g -'f~x;tors:;for.~:breech p~ntatiOil'~ .....
....s~.t ofWHabbrs..Gu.r.locatstalistics :Show t!iaL include .ptematurity, .uterine ri:.aJ.fonnati~ .:( lr ..
:. . :_t}ley..:ronstitute 19 percentof the obsttu~ :lal:'Or fibroids, J:>.<?1Yhy.'dranul.ios; '7cy s'll:ort uml).~ :
,. .... ~;~ ov~ inciden~ of. 5 ..4% .among lalx>.ring c:ord,, pla.~~n-ta :PJ::f;$~ .fx~ . aonoi.m:ali~:;{eg...
: .Vr.~ (PpGS Statistics, ..;2005).. - hy.dto:cc;phalus"? :an~ncc_phaly. :neck ina.:sse~: ... :,
'.. ;, . aneuploidy), ':and .multiple.:g~tati~n. ... . ~. .
-..~. ~. .ABNoRMA.LITIES.~-m; ~~.PRESENTATioN~ . ._ ..
. -: : ;. - .
-. . -
. .. ..
.. ' . ~~ ..ftus enters the pelvic cavity 'i n vertex .... --4 .-. .
' .. . .,;(<'i:C!ifpii.t),...pr:e.s-entation. .in -~o ~t ..~a:ses ,.. .An,.y .: -Br.eeeh-pre:sent.atiien-~whenthe- buttoc:b:....:
.. .p,:f:~en.tation . other -than occip u.t is .. called andj-or. the feet are.- tliep;~s~ntmg .parts:-:orr:'- .-
'~ro~l>resentat:lon" which increases the probability abdo:rn.ipal e~ination. (L#l;Pold's man-euv.ei), -th~ '
'O!::p~long_ed or ob:>t;ructed lq.qpr (dystocia) :ai!.d head is felt :i.,TJ. tbe upper_ ~bdo.rtienana the~
jtit;iy,'ne_ed \;esarean delivery. Our data ~w a3.5% in the pelvic b ripl. Auscultatlo:n l(}qttes the- fetal .' .
. .il;tci(l~ce of.malpresented fetus.es and '1.o perCent heart higher than exp ecte:d with a verteX _.
.. .i9f.ihem wer.e delivered abdominall.y . (PO:QS presentatio:n. .On va;gin~ ..~ation dUrtpg..-:
. ~..d:~-- 2:oos) labOrJ the-.b uttocks and{or f~t.ai-e felt. Thick;~-.:. .
- .~~~ .-
: 'i m~c;onium".is . normal.
,. ' .Abnm;m~ fetal presentations tha,t ~result
'.t;q .dystocia include breech, shoulder , compound The types of breech presentation are as folloW,~:
.-ao.atface o'r brow presentation. Among .these, the (Figure 48.1)
.most common is the breech presentation (Table
4~.J)~ Frank (&;tended) Breech; .:
oq:mrs when ~th legs are .flexed at the :
. Breech.
'\ .
Presentation hips and extended ~t the knees
.. Complete (Flexed) Breech
Breech presentation occurs in 3-4 percent of
- occurs when 9oth legs .are flexed at th~.'.
an deliveries, qur local data report a 2.6%
hips :and knees
h::r.ddence. rt is the most common type of
malpresentation comprising 75 percent of our Footling Breech . .;
:i n.alpresented fetuses. Its percentage decreases occurs when a leg is extended at ti.le hlP' .. . .
.W-ith advan~g gestation from 25% prior to .28 and the lmee

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 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS '729

FliUre 48.1 Types of breech presentation. A.) Frank breech, B.} Complete breech, and C.) F.ooilln~ ~ecli:

Mechanism of Labor 4.) Birth asphyxia (neu.rqtogic datn~e)

.5 : ) Dam~:ge. to-abdominal:organs ..
.,
In br~ech presentation, the baby's bottom
. (rather-th#J...the feet and knees) is commonlythe BFeech.presentation Js .a :po.ten$.f~1)11>blem
~
.first to d~end through th~ materna,! pelvis and primarily because the :presenting part;..i~):~'Wor
emerge from the vagipa At the
~ginning of labor, dilating we~ge wl-Jch can cause the bdid:''tQ':.be
,.. the ,baby.-ds in oblique position. As the baby's trapped, during d~livery~- often .com:ptessmg. Ule
~ 'bottom isth~ ~e size as the head in a term fetus; : umbilical cord. Fel~ -hea.entrapmentlA-a_y,~$ult

t descent~~curs witho\lt difficulty..4 delay in from an incompletely diiated eervp(.ot:ftPmilack .

descent is aciirdina! Sign ofpossil:>le problem:with of time for the head to mold and. n~tiat&(lhe
the delivery ofth.e head. ln. order to begin birth; maternal pelvis. In a .full term retu.s the
intenw:~t;;l~on -h~sto <>ecur. This happen~ when bitroclla.nteric diall)et~ is -~~~t tl:l.e ~,e,-s~ ~s
the...m!)tlie~pel.V:ic..Jloor-.intisctes:,Ca.u~-:llie...haby. . th6..bipade~aLdiamet.et.aru:tlb:.'~bu~..th
to 11Jinso-thatit ciln-be:bQmwithone hip-directly cervix .as .. effec.tiv..d_-.as .. th~, beruLdoc;s.:..in..ver:tex
in front o.f the -.o.th~r . At this point, the pr_e sentation. However, if the baby is premature,
t;iitrochanteric diameter of the fetus occ.u pies the the h ead size is relatively larger than the b<;>dy. so
.Sp;troposterior dia.neter of the pelvisand the baby that it is poss ible for the baby's body to emerge
is f'aqpg one .o f the t:pother's inner .th~ghs. After while the cerviX is not yet fully dilated resUlting
the deHYery of t11e body, e.Xtemal rota:tjon occl.lr~ to head entrapment. Oxygen deprivation may
as the ~liouldets .e merge and the baby's be~d occur ;:>.:.'1d if prolonged, it may cause _permanent
enters the .maternal pelvis. The ct>mb~n::ttion of neurological damage.
maternal muscle tone; uterine contractions and
operator's maneuvers cause the baby's head to Breech pres entation increases the risk of
flex, chin to chest. Then the face emerges; and bra chial plex-lis injury, s pinal co~d birth trs.uroa
finally the back o( the baby's head. and perinata~ death if .delivery is done by .an
.unskilled birth attendant.
Complications
Nuchal arms, wherein one or both arms are
Fetal complications of breech delivery include the wrapped aroun d the back of the neck complicates
following: 0-5 percent of vaginal bre~ch deliveries. This may
result in neonatal tra~ma including~achial
. 1 ;) Head entrapment pl~.xus injury. ::1i1
2 :) Birth tr~uma .(broken neck, _brachial plexus . . ;;;... .
injury) Cervical spine injui-y can happen ;When the
3.) Cord prolapse fetus presents with . a hyperextended neck prior

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 ~
;~.
~--------~--~~------~-~~~~~~.~~----------------~--~~
-- ~
730. SECTION VII: "DYSTOCIA

to delivery. Hyperextcmded neck in breech (star- prolapse.so that the elbow, arm or hand may be
gazing breech) is present when the an.~le of felt in the vagina.
extension of the cervical vertebra is rnore than 90".
This can be diagnosed byultrasound or radiologic
~ation.

Cord prolaps~ is commo~ in breech

presentation particul~ly in footling typa ofbteech.
It .m.ay not always J"eS.u).t in ~vere fetal heart rate
decelerations unlike when cord prolapse
complicates a vertex preseniation. (Manag~t
ofbreechpr.eserrtation is .discuss~d itt Chapter 50)
:;

Transverse lie and. shoulder presentation occur

when the kmg a;cis of the !etus is petp.endi~ular
to that o:C the mother such t:b:~:t the Shol.).lder is
over 'the ~Me inlet andbe."COJ:iles :the presenfu).g
pait, the head in :one iliae-!o<>ia.and. fu~ bteeeh in
the .:other. '?/hen .the fetal longaxi~ fvfiD.!J'ail. :acute
ID::lit.le.~th ~'\~ Iria1;cin~.'l.a:Xis;:arroblique:lie.tesults ... ._ . . . . r .. . ~r .
';:,: : ,. :..'~1.. ' as . . .
. ...;:. ~fraii -U)i-.r.' . ' d''' !. 'efc''tted :itO f"...gure,..,8;2 ...,~ransvers~-1i~.- This .et'...ts.m, ~e=.!l~ 1'3'
vp.b.u~ ~:s.:-~~J . .~ ~J:an : sr. ~ . ~ . '; ~ . in.riglit.acrom:'iori..aoriurna.titmor(RACbA) poSition with
1
u:nsta"ol~u~:'because ~~en: 1ab0l: 'Qegiri:s;,,.lt~:~:s: the fetal back directed an.teri9tly.
:oonverteditQ.eii;bet.a 1qngifu~a1o,ra.:~sv.er:se . .. . . .. : .
ile:. -1iitr ~$t'i~tics sh:o...i :at :its oincid.ent~: i's
~ged\~0!4~cent(P0GS:A.nriuiit:.Statistics/ .:
1:993;~'$00~ - Mech.illt:lsm oj.Labor.
.. .
-
Th~ c6m.mch causes of tran.sveise.lie are: A 'fetus in transverse lie can not. be ddiv~red
~ .m:ul,if{>a:di)r., j).~n~iu.I:~u~ ah&6ilien,. 'prde~ni
rl vaghj.~:i' ~a. wm.jla teq1llre ..ci!'S a.re# dci;ivery,
..:ge:~tat'iOriT'Pi~"Cetrta: . ~,Pt~ta:~.iif~e a.PorfiJiiY:: Uirfes;-marteuvel"$ hlCe eX:temiliephaiic .versioii
~trh~<:>S:-~4 On.trn:ae~Fii.'ivts: ~ . ... ... is dorie: 'If labor"i::on~u.e- 'aPit:-fu.;'"fu;~~s
rupture-, fu.~ fetal shou1Q.~rts..fo;:-ed. into~J;lepelvjs
Dfajjnorls . but.a.rre~ted l?y tjle .margill:s:of th~ ~Mdruetu:t>~'n
.descen,t. The yortespon9.ip.g arm fr~xi_u~p.Uy
'Jiansve:r-Se lie'can be suspected :by'i.n:~pection . prolapse;,_ If labor conqnu:es 'furt:her, $ituation a
alone. The abaoirieh is unsually ~q:e and t:h:e called "ng~ect~d trari:sver$e lie en:sue~. T his

iu~d;t~s is ~nuy. slightly above th~ tit:Ubili<:1l:s. resul~s ~..&:h~n the . sh.oul<;ler is fir.mly ii:npac~d in
the up~r .p~of the ~h~s with the-fetal. head in
On .abdominal examination {Leopold'.s theiliac fossa: In an
attempt t9 en,1pty it~ ..cc:;n1.tent,
m.ari:uv~t), r{e'ither the h~d nor the buttocks ean the -qteru.s contracts ~gorously r eswting-to the
be fclt .i nthe'fundus, :the head<is:in .one. iliac fossa fortnation of a pathologic retraction ring a:n d
a.IJ.q, the breech in the other. .When th.e:fetal back thin~ing. out of. $e 1ower uterine se~ent (Fi,@re
is anterior, a, smO<>th hard r esistance planeis felt 48.3). This situation puts the mother and hede'tus
across 'the front of the abdomen and when .it iS . at ~ve risk 6f uterine. rupture. . .
. pbSterior."smallnodular.par:ts are:felt. (Figure 48,2)
. -. . An ,.extremely preten:U fetus that \yeighs.. Jess
On vaginal examination, the th~x<PC. ~ - be .. than 800g can be expelled vagi~~Uy by
reco~d by the " gridiron feel :.o f the :ribs, the. c:Oiw.upl~Cato corpore: In this situation, the fetus
sc.a .pula and clavicle can be felt opposite the is folded upon itself, the .thorax pecomes tb.e tnost
fuor3.x; .t he shoulder maybe felt but not ~ways. . . dependent .part appearing flrst in the v:ulva and
. In adVa.nce :labor, the shoulder becomes wedged . the 'head 'and the rest of the body pass thr.ough
b. t,lie pelvic ..canal and. the harid or ann may simultaneously.

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 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE ~ETUS
Figure~4,8.3. Neglected ~.n;:;verse ije. Pathologic retraction
. ring develop;> due to the centripetal force ~erted by tl1e
contractip_g :myometriura in .t he upper ~ent . while the
lower~~-~tco_p,tinue$ to thin ouqm.tiiit n~,ptures.
. CompUcat!oit:s
. Prolapsed urilhillcal cord is .a common
complication in transverse lie when the bag of
water r Uptures. In the ~bsence of the fetal head .
in the ..bi.tth .ca,naL.it js . relatively ..easy ..for the
urobiliGa,l cord to. prolapse .t hroughawidely.dilated
cerviX an<J this will .need an \lrgent cesarean
delivery. Howev~r, progno~is is bette,r ilia.> when
cord prolapSe. complicate~ vertex presentation.
Rupture of the u~erus is a dreaded
complication which 1nay occur ifthewoman is -left .
u:tattended c>r not delivered on time.
Management of transverse lie and shoulder
presentation
> , If the woman is jn active labor, .delivery-is by
cesarean section whetherthe inem.branes are
intact or not. Atte mpts to .conv.e rt to a
longitudinal lie by abdominal manipulati.o n
will most likely fail. In modern practice,
cesarean delivery is done whether the fetus is
dead or alive.
,. .
} If the woman 'is not in.Jabor or in eatly labor
arid the membranes are intact, externa l
Scanned 8y:
731'
cephalic version (ECV} c~n be attempt~a:
provided there are no c:ontraindications to the
procedure. ECV involves applying pressure to
the mother's abdomen to turn the fetus in
either a foxward or hackwaad direction to
cbnvert to a cephalic presentation.
If EGV is .successfu! 1 proceed with nonnal
childbirth.
If E:CV fails or is not feasible, deliver by
cesarean section.
} Monitor signs of cord prolapse. If the cord
prolapsl!s and delivery is notimniL.1eiit. deliver
by cesarean seetion.
Brow Presentation
Brow . presentation is the rarest type of
malpresentationreported at .01% or 1 in lOOQO.
.. . ....
It is ca-used by. par+Jal. extension o( .t he fetal head,. .. I
so that the occiput is higher than the .si,llci2U.Li.Jt;, .:W-.
. - < . ... - ..........
contrastto;a well flexed,head .(vertexp resept;ationj..~.,. :-,. .
wherein . the.occiput is lower.:tha,n th~.~~~pu~.::;;; r.
(Fi~ 48.4-A~4'8.4-B). The fetal he.a d .a:s$U;m,;s;::::.
.a ~sition midway .. l,)etween . run
-fl~on. :(occi,p:ut)~ . ;( .
an<;Lfull. ~ension (mentum or.fa~).: n.i~l:RP~r;'t:io:q.:~,-"'-~
of th fetal head.between the.or.bi~l tidgeJui(tth~;.:;..' .~:: .
anterior .fontanel presents at the pelvic' inlet and.,...
the presenting diameter is occipitomental.
-:- -~
: :/!}}:..
-~9;.
.-.~~~f:~
Figure 48.4A. In a well-flexed head (vertex presentation),
the occiput is lower than the s.i nciput.
~
7.32 SECTION V.H: DYSTOCIA .

conversion to occur with an average-sized live

Occipl!t fetus once the mempranes have ruptured.

):> If the fetus is 8.live, deliver by 'cesarean section

):> If t;he fetus is de'?-<,i: ~d .

the c'er'vbc is not fully ~nated, deliver
by ~sarea:n Setticn.
the ;Qeiv;bds ~Uy .dilated.. .deliver by
ceSaiea..'l. s~ction .
Do not deliver brow presentation by va~uum
extracti6n or fo~~eps extraction
~
binClpU
~ t -~

F~ce Presentation
Figure 4~~4B. ln tr.ow presentation, the O<riputis illgher
tllan the Sinciput. Face presentation is caused by hyper-
~ens~on of the fetal head .so- that t.l).e occip].lt is.
in .cont~ct with the fet.a.l back and th~ chin
.(mentum} is..pr~~nti.ri.g (Figtire . 48.~). It u;mally
,DfagndSi:s 1-:esul"tS:froni further:~~n$icn 9fthe fethl .h ead
during.desc~:nt. in .a fetus ini.ti,aHy in brow.
:;trn aBa~-:-~a.~,nmre1:ba.nhalr,of. . presentatbl:}.; .b'..l.r .d ata report iu::mcj.dcil~ .or'
the feqU' h~d i~ ..aboye'the,~~sis.:vci:bi~:~d: . . 07%.
the Ccclput is :~p:a:t,n~ at '~ ~gher le~r.than 't..'1.e
sinptput. .On;vagmal~~ .the ~ieriot'
~on,tanel,~~fro-pcta,l! ~fu;ri!$: terbit~r. ~c;l,nasat.biidg'e- ,, .
ar-e ~:ra.:L~Jtowe"!.eij-. tbe:m~ih~~;:bin 1:a,te';.i;lb.t-..' . .
reachabl~~by~ilie;;exam~ningi~~g~~;;,..,:,: : . .

B::-ow pi:eseritaU'cin i s .uris~b.ie a:n4 :often

c onverts spontaneously to .a fa~e .o r ~cdp~t
.p resentation. The p r ognosis for ~al delivery
-is. depeo de;nton the ultimate presen;tatiorL Ifbrow
~~ists, dystocia occurs.

If the fetus is small -an~ pe11.j~ ~s 1arge7 1~~t

will be easy. B.u.t -With a1a!'gci- fet\l~; engagem~nt
is n ot possi~lesince th~ pre~ritit)._g oecipitoroen WJ,
diameter is dispropc>rtion~te1y big ;Cor :the pe:lvic
irJ~t unless ~ar:ked moldipcg :<><;c~rs which .C an
deform ~e fet:af head. The Ca:f}l.lt ~uc<#ianeum 'iri"
brow presenta'tiQn is found over the for~e~.d- Figure 48.5. F ace presentation. The presen'tingdiam~ter
in face pr:esen tation is trachel6-btezroatic:(aashhl lirieT
.
Managemerlt of I!r:ow Presentati,on.

In brow pr~sentatio.n, e~gagement -is usually

impossible anO. ar'r.ested.. l.ibpt:.is co~mon.
Spontaneous conversio~ to either yenex .or <fac;:e
preseotatfon can rarely occur -~Cept when 'the
f e tus is small or when there .is fetal ~eath with
mac~ra tion. It is Unus ual .for sp,OI+t~neo.u,s
Etiologic factors resu lting to this :presentation
are: ~ontracted pelvi$, pendul9us abdome~, Targe
fetus, anencephalic fetus, neck enlargement a nd
cord !:Oils~

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 CHAPTER 48: DYSTOCIA DUE lO ABNORMALITIES OF THE FETUS

Diagnosis

On abdominal ~ination, a groove tnay be

felt between the occiput and t he back and the
cephalic prominence is palpated at the same s :de
as the feW back. On vaginal examination, neither
the occiput nor the sinciput is pBlpabl~ bui rather
distinctive-features of the fa~e: -th.c:;~Quth and two
malar prominences -a re palpated. it is poasible to
mistake a breech for a face 'p resentation, beCause
the a.nus may be mistaken for the mouth and the
ischial tuberosities for the malar prominences.
Distinction can be made by the artangement of
these 3 distinctive :j>Oints: th~ anu$ and i'$chial
tUberosities are arrtuu~ed in a straight line in
br.eech presentation, while the mouth and mp.j.ar
pr.Qniinences are a.rrenged in triangular pattern
in (ace presentation '(Figure 48.6).
A Chin eoterior B. Chin pY.;terior
~e 48.7. Positions .in face presentation. The chin or
. mentum is -reference point:-in :race pre~tation and its
relation ~th the ,maternal pelm .is identified,:. , ..
A. Left m:entum oF c:hin anterior . -~ N:. _... - ~.. :' ' = )..
B. Left lilerttwn or -c:hin msterior

. In mefi.tuJU.':postepot,. flcidori hetlie'he~u,\.1~.- ..

F.iguro 48~6. In face p.r'Csentation, the two malar bone s
and mouth can be palpated in a triangular pattern (arrows).
Mechanism of L<;Lbor
I:n . fa~e JH'esentation, it i.s n~~:essa-ry to
distinguish chin (nientulll) an:teriot pOsition from
chirt posteripr pbsitibn (Figu~e48. 7), because fetus .
U;l the latter position can not be delivered vagl.nally
unless ro~U.on to mentum anterior occurs.
im,'peded by compr-ession -of the Jetiillifuw a~~t ' .
the sympbysis pubis.. With fetal d'eS:cent:?lhe
tesis~an~~ . e.n~p~p~erc:4 }).\?-,~~~~- ~:b; o~ciput
towards -the fettil l>ilCk while llie clilii--descends.
Wt-1'li' er:-- a-esceriT~"ls-TDi'"" eae.<r~ilce "~'tfte -
- ---- ----- ------~-~-------~-~-~---..~-- --- ---- - ---- ----
hyperextended fetal n,eck Can. riotJurthe.r -s pan the
sacral conc~wity' whiCh meam1res about 12' crri m
length, thus labor is arrested. A fetus in chin
posterior position can be delivered vaginally only
when the head rotates -"~:tld assumes a mentum
anterior posftion. The wdmal 'ov~ments of labor
.involved are in the folloWing (>1:4-er: .engagement,
internal rotation to mentum anterior, descent,
flexion and external rotation. After anterior
tdtatibn and descent, t.'lechin ,p re.s ses agains t the
symphysis pubis. and the head is delivered by
flexion wberein the nose, .eyes, brow and ocCiput
appear in succession over the perineum. The face
is distorted .by.edema bu_t this wULstibside in few
hours.

In mentum .a nterlor; d<;:scent and deliv.ery .of Management of rae~ Presentation :.:-"
the hea~ are accom-plished by flexion. The cardinal
movem~nts of labor are in the following order: . For chin.q.nterior position
engagement, desc~nt, flexion, .ani:{ external
rota:ti.on, '> If the cerv-ix is fully dilated

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 734 . SEGTJON VII: DYSTOCIA

'
allow labor to .proceed to .honna.l childbirth Causes of compound pres entation are
if there i~ slow progress and there are no conditions that prevent complete occlusion .oftbe
signs of obstruction, augment labor with pelvic inlet by 'the .fetA-l head.
oxytocin .
Dia gnosi's .
):. If the cervix -is not fully dilated cn:l:d there are
no sign~ :-of.obstruction, augment la9or with -D~griosis can be:. made -onlyl:>y an in.i:emal
oxytocin; . observe progress as with vertex' ~x.an:iination wr.ich. will disclose the -pr~nce of
prese n~tion. an -extremitY, :that ha-s prplapsed w:td .situated
,a4o_ngside the pre~n-ting part
For Chlrt. Posterior Position
Management of Compound Presenpatl'on .
)> If the cervix is fully dilate~ 'deliver by cesarea."'l
section. . The prolapsed pat:t: should. be lei'l alone. ,~ost
)> If e cer'vix is not fully dilated, monitor often, it wi..U not ln~erfere wi~ ~.abor or wpl tttract
de~t 1 rotation and pfOOg ress. lf $ere are spantaneou~iy. If it.appe6rs to prevent t:he descent
signs.-:of obstruction, deliver by cesarean of ~e <fetal head, the prolapsed arm should be
sec.t;ion. push~d gently . upwaqi a~d t he. h.e aC.
> If :fu;:: Je.W.s .isdea'd~ deliver py craniotomy or simultaneously dovmwa.tU by .fund:hl pressure.
..
Spontaneo.tl..$ deli:ve r.f can o.0cur when the
.fetus is very small.ordead~d.-macentted. Arrest~
'CompQnnd PJies;;D:ta:tion .. . labor occill;s::i4-the.~ul~k~p~$e..
-. .:- . ' '. . . . .
. .
Compoundp:resntaj:i<tn'-~s. aefined..;a$ tl:l'e.- > Repl~ceme_nt. o:f th~ pi-Ohipsed':artn. :is
.presenee of:an eXti-erillty .akJ~gslde 0~ presehting . soetimes :JsSiQ~e . _ . . .
p art, like whet;J.. an ~.rn:ds pfc!a~:.alpngSide t;p:e - ' . 'A~s~st the woman to . ais:ume theJa:lee-
.fetal:;;ht:a~~!i!l.P:J:>o.th. ~tn.~ ~~:L~t.th.~tfetirl:).liead :. .cl~;~_t: J)o;iiition.
pre~t:~~t?e ~.s'#l,llfi~:Q.:s~y: ' gute.48:'8:): .. ?ush':the- a.I'JX!: -above ,the~:pe'i-vlc::briril. and
.. .:~: : . ~ .... . 'i ! r' : : ; ;i . .. . . . . . . ..
~old it ther -~~ a'.~c:>P.~~tio:n Jillshes tp.e
. . ~' It .~ .. nta:neousl
.. .SP,?. ,,,,... ,,.-... . ....,.'?/'. -t........
e-'Sdtve... __. if .fetusthe
... _ .............. .. head.intq Uie .pe~v.l~- ..-
. .withdraws-th~hand:-lf-.the-fet1..xs-1mti-a.:tm:'~ar-e Procee""d""wjln .manage'inerif 'for ~o.fiiia..l
. c1ii1aolrth.... ,...... . .... .. . ... .
-re1ativetr~.nn:d~~~-with:-ii-~matenuil .-~.

pelvis, vaginal -dlivez:Y stiU be poss~pl~,but in<o/.

~th s9me ris}c.of.mjucy-to Ut~ -ar.m. f> If the pro.cedu:re fails .~r if th~re is cord
prolapse, deliv~r by cesar-ean.section.

ABNORMALITIES IN FEl'A,L POSITION

The most common positiOJl for a baby
during labor is head down with the ba<;:k of the
head (occip1.1t). facing 'the front of .th~ m-other
(ant!!rior.)._.Usually, .'tne ..fetal -h ead enters the
matern:~. pel'{is~th the $a~- suture-positioned
alQng the. ttansv!!rse. Q[. opliqi.+e. ~m~ters .,of the
pelvic inlei. 1,'he h~ad ii~ engages iri 'the -military
attitude, wherein -the hea~Lis somewhat deflect!!~
arid the presenting diameter is occipitofn;mtaL
With descent,_.the fetal head undergoes-'flexion :as
it-encounters the resistance of th~ Pelvics_id~waJls
Figure 48.8. Co[;lp~und _presentation:. An txtiemity is 3fd pelv.ic,-.floor th~s ;chat!~ng the ~resentin~
. alongside the fetal head and both pres.cnt. in the pelvis :dtam.etet from occtptto .. frontal .to a :s hort er
_-s~ultaneously. . . sub9ccipitobregmati.c . Ina well-flexed Yertex, the

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 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS "'735

fetal occiput is l ower in the vagina than the Great pain with pushing, especially oh~he side
sinciput. As the head reaches the midpelvis, the or another
fetal head rotates (internal rotation) so that the
fetal occiput is directly anterior in the maternal
peivis and the sagittal sutur~. is positioned along The most common abnormal fetal position
the antet:o-.posterior diameter. Subsequent causing dystocia is ~hen the fetus .is in occiput
deliveryis without
.
difficulty.. posterior wherein .the fetal neclc is some:Vhat .
deflected and a larger occioitofro.Q.tal diameter
r4alpOsitions .are abnormal positions o( the rather t.'tan the S'ubOccipitob"i-egma.tic diameter of
fetal head relativ.e .to th.e matemai .p elvis in vertex the fetal head must pass thru the pelvis (Figure
present,ation. They can .cause pr.otonged pa.iiiful 48.9).
labor. Abnormal fetal positions that can 1:4use
dystocia incl-ude persistent occiput posterior
position, persistent occiput transverse pos ition
and asyn~litism.

Although there is more. than one possibl<;

cause .(or the following problems, the occurrence
of one or ~ cl~ster of the fcllowing sho\lld raise a
high sus picion for ba.py_-m alpositio.n :

"severru days bf tiring pre--labor 'Or 'falSe; labor

~before' ~e' labor; mother m~y begin labor
exhau~t~d
A tendency towards post-mature pregnancies
. ,..a.."llltvverdue babies
'::,A baby that t:l<>es not engage ~fore or even
,: {:well :i nto "labor
. 'Feeling .lots of hands a nd feet in front by ti1e
mofu~s belly
P~QM' lPt,m~uun~. ~pmJ:~ of Membranes)
Diffi~tyJ'Jltdirtg"tlrt!b-a'by's:h-ero-ttorre~wh~te
yotr'uW'"ally'wotild nnafl1em.
'Slalle4 lab.or - labor that stops betWeen 4-7
c~ c;~.Jid does not progres~
Prolonged labo~; especially it?- the pushing
.s tage
'Back labo.r' - painful contractions felt mostly
in _the bacJ~; . $.~rQ~!l {-~th posterior lab.or s rupture, epidural .a:nesthesia With.l)igh ra tes of
because the baby's hack is pri:ssing agamt t
the sacrum (low back); High need for pain
medication, since the pams are abnormally
difficUlt
'Edtl:9' "t hirisiti6.n' - showing the si gns of
transition (na u sea, chills; high pain levels ,
' shakiness;~ etc.)""betwee.ti 4-7 .em instea d of
betweeri 7:.. 10 em
'Early j)ushing' - feelirtg the urge to push before
being fully dilated
'Anterior lip' - dilating to abo-qt 9.5 em but a
small 'lip of the cervix is stubbornly left
'Stuck baby' - a baby that .gets stuck before
passing the ischial.spines -(0 station) and does
not ~escend even after hours bf pushing
Fip~ 4a.9. Occiputpost~rior. ~ition;,~p~tixi~.~ri6r
poSition ~- w~en the 9<:ciputiei po~~ ~t;tomto
the maternal pe1V1S. The.head ~ngagesin.tffilitaJy a ttifude
and the presenting diameter i& ocei.pitofrontal.(dashed llile)
because the h ead cart not Uildei'go futi"A:Xion .cfue to the
r~sistanceoffered: by.the-sy.mphysis:pu~anterlorly:;{ +)
Factors associated with occiput posterior
inclU<:le nulliparity, mate_mal age >35. AOG >41
weeks, birth w eight 4,000g, artificial membrane
operative deliveries anq obstetriceomplications. 1
Diagno$ls
Occiput posterior position .ood:urs when the
fetal occiput is po"sterior in relation to the m atemal
pelvis. On al?dolninal examination. the lower part
of the abdomen is. fl a tterredt fetal limbs are
palpable anteriorly and the fetal heart rriay be
heard in the flank a rea. Diagnosis is.:.u} digital
. vagin a l examination which . cap deterfiHne the
orientation of fetal sutures and fontana~~ If the .
physician can. not m ake .this .determina tion,
transvagina l sonography can .c cnfirm head

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736 SECTION VU: DYSTOCIA

position.2 On vaginal examination, the posterior Persistent Occiput Posterl~r (POP)

fontanel is towards the sacrum and the anterior
fontanel maybe easily-felt if the head is deflexed. Persistent Occiput Posterior (POP) results
when there is failure of rotation which happens
.M echanism ofLabor ln Occiput PQstenor when the midpelvi.s is contracted. This .b as lon,g
been recogni.z:!d as.~it important problem of
The ~ciput ~sterior positic:m tn!lY be normal intrapartum management. It is associated with
in early labor. Approximat~ly. l0-20 pert:;ent of_ deflexion of the fetal head and an increased
femses are in. this pvsjtion at tbe O.U t$et of laPor incidence of prolonged :painful labor, operative
bU:t most of them will rotate anterior.ly. However, delivery, postpartUm hemorrhage,' vagiria) trauma,
most of the occiput posterior pres:e ntation$ a't matemal infection, and neomitalmorbidity.3
delivery are the result of malrotation of <><;cip~t
anterior position to occiput posterior position
during la;b9r. Incidence

In occiput po$terior, the head eng~ges in Pers~stent occiput posterior position is the
military attitUde With the occlpitofron.W. diameter most common malpo~ition at delivery, with an
as the initial p~ting diameter. in 87 percent in'c idence tanging .b etween2%ap.d 13%;'Jt:~
of~$, th~ 'bett,d ,)lnt;l~tgoes internal ro~tion- to in approximately 5% cf sing!eton, v~rtdt, -tertll.
occipUt antetiot,po~iti:Oh ..follow~d by Jt~on. as it laQc!"S and is more COtnmOO in nulliparas than jn
reaclieStfue]>clvk.floor changing the pre$entiilg multip<~.ras. 5 About one third of persistent
diatileter to'a - .shotter d.i ilmeter which is. posteriors begin labor as posteriors. an~ fail to
:~u~ltQ~tlttfo~owed~Y"lJ,nco~pikated: ~tate;' the oi..l)er ~tw.o:..Wtd~ -. d.evelop through a
delivdj (Figure 48.10). Howevep~ it..it .dO"es n9t mGlrotationduringlabQrfrotnanin!t;fullyocclpito-
rota:te, the fetal head presse4: -aga;insLthe :anre.rior positibn.
symphysis pubi~ is .pre'Vented from un&ergoing
flexit>n ... up~n -., dese:n t, ..~pus . ,*he< larger : . .. .
. ocei~Jd.{to~~l~et_e:t;~~au-t.l;l~presen~ . .. Outcome of Labor
di8Jrietei.1heJ~~a~. fh~J.deliV'ers by flexion with
the .fet~il~~ uj). -.
With a persisJent .p Osterior, .both tll,eJi~:t ~d
. . S~<J!!~.:~.~~~L~i .~~!!9X ~~..P.r.Olonged~!. CO~Pared
POstffiorP.resentanonsarc i:iohiiatfhey.Jij~f v6fu. fu~ Qc:.<~ipY.t an.t~ri.or ,positj,on, there were
teridl(ipe"rehinvCly nghtedit~ "ihey.:Ui;ke m6r.e time significant di,fferences in the duration of second
to deliver end ~use mor~ back pain than the stage ofla:bor, with a mean of3.1 .houts for occiput
"anterior' presentations : anterior, 3.6 hours fbr occiput tr~sverse and 3.8
hours for occiput PQl?terior positions.6 Ho~er,
longer second stages do not in themselves cause
wt>rse t:Patemal. or neonatal outcomes.

T'he. li~elihpod oi cesarean section or

instrumental delivery by forceps or vac\lum
e.x traction is greater. Arnong nulliparas, the
chance of a vaginal birth is reduced by 26%. 5 T-he
spontaneous vaginal delivery rate of 4{)010 iti the
occiput posterior group and 84% in the occiput
an.t erior .group emphasizes the. adverse influence
of this malposition on labor. outcome. 3 About 12
-~ . .. ,fl..~:.,:; percent of cesarean deliveries for dystocia, are.d1,1.e
to POP. . .
\V~t;;~ ~. , :
' ... ~."::".' ~ ~ J ' ' I :' :

. Figuze 48~10. Meebanism.oflabor in.occiput posterior; In
mo;~t case3; the hea<i: underg~ jl:ltem?l.i::otation 'by 135
to .occiput .ariterior position followed by flexion changing
the pt:e~en~g diameter to suboccipitobregmatic.
Compllcatioris
Persistent posterior positions are associated
with an. fncreased "incidence .o f prolonged

Scanned By: C
 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS
--------~~-----~----------------------,.:.
pregnancy," prematur.e rupture of membranes,
oxytocin inductiot1 ~nd augmentation,
.chodoamnio.n itls, severe perineal" and vaginal
lacerations, excessive blood loss and postpartum
infection? It poses a ~ign.ificant risl<: factor for anal
sphh"lcteri njuxy. even am.on:g multiparas, beca,use
of the greater cephalic diameter ptes~nting at the
perineum. It also causes tremendcus back pFJ.n
when the baby is ''in a posterior position, becaus~
the. bony part of t:lle head is pressed against the
bony part of the pelvis and some women feel the
pressure even between contractions. Thi-s -c an be
fa:ijguing for a woman.
Persistent occiput posteriQr position a:tdelivery
is assOCiated \vith higher risks of adverse neonatal
outcomes compared with neonates delivered in the
O(;ciput a.Q.terior position. This may be related to
long~r labor o_r higP,er in<;idenpe
chorioamqionitisas a downstream effect oi
. ' . '
p.er$~stent :o tciput posterior position. Persistent
oCciput posterior pOsitioJl is .a mapifestation of
"c e.nJw.lo:-:p1Vic dispro;portion, res ultm:g in
m~lposition/nialrota:tion and longer labor,
sU:J:>se<ruent~y leading to hi.ghet ratC!s of
in~ap~ trauma, infection, and operative
.ddiveries. This may~ jn.~cituiethe higher rates
.o~ro,\tal morbidit.;f. This into.n:nation may .be
imp(sttmt in cpunseling women who eitperlence
petSistent o cciput posterior position in labor.
Babie~ !;>oro in occiput po sterior position were
.!!lorelikely__!Q_-h!!Y..~.tJ:.ll~..P-id$Y..mdJacial.:nenr.e
pal~ :Mte.r fomeps.-:deliYety .as..C9mpared to those
delivered from the anterior :positions. 7
- relaxed. If the vaginal outlet is resiStant to stretch
Ma.n agement
When the bab~r retnains in a posterior position;
. the mother is more likely to experience a longer
than average labor (both .frrst and second stages)
and would need the use of oXy-tocin to augment
(speed up) lah9r, epidural pain relief or cesarean
delivery for prolonged labor.
, : HaYing.theability to.rtloyeand change position
during labor' . especially upright position; can
increase the chances of moving into an an,t erior
position.
Oxytocin .and artificial rupture of membrane,
can cause a ba:by to move deeper into the pelvis
reducingthe chances ror.the b aby to make~ full
rotation and move into proper position.
737
~ If there are signs of obstruction or fetid heart
rete is aonormal (less than 100 or more than
180 beats per minute) deliver by cesarean
section
::> lf the membran~s ate intact. rupture the
membranes.
> If the cerviX is not fully dilated and there are
no signs of obstruction, au~ent labor with
oxytocin."
> If cervix is fully dilated but there i$ no descent
in the expulsive phase, assess for signs of
. obs tructioJl, if n9 signs of obstruction,
augment labor With oxytacitl. .
> If tbe cervix is fully dilated and the fztal head
is at station -2, p~rform ce~ ~tion
>- If the head is at station 0, deliver by vacuum
extraction or forceps.
of
U the fetusis in p ersistent occlput-. pos~rio~
position in.. the secon-d ' stage of
lal)or. the
pOssibilities for vaginal delivery
. are~.;-;
. . , .....
. ;-:,.;
.
:<
.
l. Spontaneous delive.ry. ::::"' ' - ._:,~.;.;::
2, Forceps delivery With oc~iput posterior.'. ,.. .
3. Manual rotation .to : anterlor-~:fo:llowed:. by
sPontarieaus ~r f6rteps deliv~H,,;-~;~,: ... "}t,~:
4. Forceps rotation to anterior an&d'li,Vety.;., .
......................................... ____.......... . . ........ _ _______
~ .:.-~ ~ ..:..._ ..... -
--~ --- :-~
Rapid-sponta.Ij~ous- vaginal deli'9.eiy,ca.n--take
place if pelvic outlet is roomy and the perineum is
and the perineum is finn. latter first stage and
second stages Of labor tnaybe,prolonged. Forceps
celiver y is often indkafed "due to .maternal
exhaustion. Makin~ a generous episiotomy will
minimize the need for 111o.re traction.
Severe molding ca...-i spn;~.etimes elongate the
fetal head so that the scalp may appear' at the
introitus ye_t . it .is not yet. engaged . .Careful
palpation abpve the_s ymphysis p~bi$ may disclose
the fe~;:1.l he.a d t<;> be ~l:>O.ve tl{e pelvic irtle~ and
prompt ce~em delivery is indicated.
Manual Rotation
' ..
~
'~~
Manual rotation of the fetal head is so'tfietimes
used .in. an effort to r~duce .the ne~d for ~sarean
delivery, but data on its success rate and safety
are limited.
Scanned 8y: ~
 738 . SECTION Vll: DY.STOylA

M~mual rotation is don,tt by puttirig t4.e A variety of m aternal positions.and movements

physician's hand pa).m upward ir}.tp t he v.a gina
{Figure 48.11)..During a contraction, the hand
serves as a wedge to flex the fetal hea d wl:llle the
fingers exert a ro.tai:ing for~ to b~g \:he occiput
to the anterior.3 Cesarean. section .is lower.ed to
2% with .suCGeSsful rotation as. compared to -34%
when rotation failed. MUltiparity and mat-cin~ age
<35 were a Ssociated with successful re~tivn. 9 "' fetal position an..j deliyery. 11 Hands and knees
Attetn.ptj.ng .r ota tion "b:efor:e -full :d1laticn
appromn~tcly f#pled the ris.k -offail~ Rota tiQn
d~n1e Sftei: fail:u.re .to pro~ss in; la~r W.~a~ed
the risk of failure co.n:;t>~:d ~~h prophylactic
r-otation. C~6I.ean. dt;liirecy r-ate was tnatkedly
rugher.Y,he:n:ma:n.ual r~&,tipnT:a:il~ than w}len it Persistent Oc~ip,ut Tran:;y~e
su.c::ceeded. Success ra~es w.ere si.to,ijs:r .for the
occipu:"t transverse arid OCip1,tt _posteri9rpositions.
.i\1l:women who ~eli;te;r~ vaginally .aftet :S\.lCCes~ful
-Pianualrotatioti delivet::ed in the occip~t ~t~rlor
. positi0n; w.hjle :tho~wb.o d~liv~e4 v~&n.a,ny -~ter
fail.eci ~riuw~ rotation P.clivett<d ;ir'> fhe. qcclput
Po steri~i p:).si.ti~n..ro {!e .R4,y,. ~$_. -~POB), ~ ..
have been proposed to resolve cper,-sisterit ocip\lt
posterior .o r asynclitic fetal positions. These
include knee-chest, 1"\ands-and-knees, pelvic .
rocking , . side-lying. or .a symmetrical sitting Qr
~eellr..g. systematic . reviews concluded. th(l.t
assUmi."'"lg tl:),ese .pcsitions for a specifie4. period of
time n~ar the end. of pre gna:n cy had no effect orr
exerc ise with pelvic rocking from 37 :weeks
gestation at the onset qf l abor did not reduce the
incidence. bf persistent ocdput .p osterior position
at birth. 12
Ocqput transverse P:Osition occurs when. the .
.fetal ecq.iput is .in th.~ right .or kffof .th~ maternal
pel..is with_ thesagi:ttaJ. s 11 bJ.r?2 Jong the t$.hs'icrse
diameter. <)f :the m aternal p elvis. It is U.suall.Ja
tran,;sito.ty position par:ticul,arlywh~"J?. the pclvi;S ~
noriPfil. b ei.aiise. ~sually., ww:iil rotate tow.azds thel .
~teriqtpo.,Sition,_:If m:tati;c:a;.~...s:;~~ of:F.>or-
expmsi.Ve .foi:ces, . ~d. th~e- is ~o. cep~<r.Pclvk.
Pi,spn:>JX?rtl8n/the <X:cipu~ pa,n be:ro.~t~:man~
ant~rio:ply-,.or-. posteriorlj .:fQllowed :by.. f()tceps
deliv.ecy:.~t~tivelY., . ~e~d.'s.fqreep~ may:& ."
.~ppii~. ~;'t:O~te:tO. ocf:-_j.put.~terlox;,post~'ia,nd:
then;deliv:er:.tlu~ 'D.e&d:.Wit.:h~either~e: eimle{i>fteps'
or with Simps:on>s .or Tucket - Me -~ 'f~

' Ho~eyet;li-llie 'J)e!VjS_..:1:3 .:OI.$e:p1aii}~iif

~; tffiii~se posfti~ii li,lay~ver.srsTiild"~tli :
further d.escent the head may -~9- up 1n a :d~
transverse ar.:rest _that wo uld nee'd ces.area:il
d elivery. !It an. a ndtoid pelVis, fue fetal. head may
not even he engaged, yetthe sea)p-is ~dyyisible .
in t4e intrott:L).$ as a consequ.;ence of s ev:e rc
inol~g- In .this cas.e , ceSa.re;rn. de.livery :is elso
ind~ca~d.

~yntitlt>m

Asynclitism is the lateral d~flexion of th.e' fetal~

Figure. 48. H. Manu.al.ro.tation in occip~t pOsterior. The
P~. ofthe'.hand.~rv~ a s Jl. wedge, t(>flex..t he h ead dqring .
~-con.tl-p..ction; while the .fingei'3 exerl a rotating fo~e"to bring
the occiput to .anterior position.
h ead in labor so that .t he sagittal. s~ture is not in
the midline of the bir-th :~anai: :(F.igur:e .48~ 12),
de~ected anteriorly towatd the ::s ymphysis .pubis
(Postezjor a sy.ncli_tism:) .or pO.s teriorly t oward the:
sacrum .(Anterior async;litism) . .Mild ~ynditislll
is normal. Extreme. synclitism interferes wi~
d~.l.i.vecy ~~may re.sult:to failure to pr.ogress...The
.fetapiead is angled :slightly to ,o ne $ide,. malcing .it
a
more dillkult to'clear. passage,tlu;ough.theb irth
-canal..

Scanned By: C
 CHAPTER 48: DYSTOCIA DUE TO ABNORMAliTIES OF THE.FETUS
-~
~g:uie :4$.12. .Ari,t~rior asyncUtism..' rhls llead i~ in right
<>Ccip~t t.railsver$e (ROT). 'thhe sagitttll su~~ :13 deflected
posteriorly towat<ls th~ $aet'Utn, the ant-trior parie.tal bOne
.(left p;uietal b!>ne) will be presenting 8fldwill be th~ s!te. of
the caput. TI).e left -f:a.r wm a\sc l?e e~llypa!p&-bl~ .
; 1
... . . ,.,
. ...... '-
-'''':-:
~~.. labO.r -prf:lgr~s$es. the .-eltS.miner -s hould
a~-:t_flin 'i i :a~cli~sm is pre~nt. lf: one of the
parieu.il~h0i1.~s. precedes. #.1~ ~ttal-suttl're~ tbe ~ 48.13 .lte"tahn~crosomia. ThisJti~iV$>n.rlc.fetu:s
.beadJ~~~ide.."td .-~sYnclitic. "When .~Qllti~m , w"igh~d ~~ -~g~an~.w-asdclivered by-ee~;~<m.;::i.i:l'::, .
is peiSistent in oeitber OC.cip~t anterior. .o ceipntor
posterlor position, forc.e,p.s -,assi$ted .vagin~
delivecy ~he ~~Jpful, fur.cbi't~~-:~~jl~Pl?.lro.
Kie1land.f.o:rt.e~i$~tru:~mo:st.~corpil;lQb.ly~ ..
oUotte_psJor.this..plis!)Qse..th~--s~qing-1Q(il(: of~"Qle
instruJ:Ilent l!illow$ atcurate c~pluilic applieation
follp\'7ed by correction of the asyncliti$ttr~. How.ever,
other types of obstetrical fo~ps.ean :& So l;>e used.
ABNORMALITIES IN :FETAL SIZS
Macros!>u:tla
Another fetal factor that can contribute to
dystocia is macrosomia, which is d efmed as fetal
weight of 4500g or more {Figur-e 48. 13). :Ma~y
factors affect ba by's ~ize at delivery. 'fhe t;nost
common reasons fota la.r ge baby -a~ ., J)9.$tter1n
pregnancy, gestational diaJ?etes, n:iat~rt1al obsity
and mul!.parity. . variety,_ ~f J!lli~euvers that may be used to .help
Estimated fetal weight shoU:ld be .assessed by
Leopold's maneuvers in all patients ution
presentation to la_b or a:nd delivery. Unfo~na:tely.
it cari .b e 'd ifficult to accurately .p r.edict
macrosomia. Obtaining an estimated fetal weight
Scanned 8y:
T39
using ultrasound may be considered in' the
presence of diabetes mellitus or if maternal o besit:y
makes the estimation of fetal Weight difficult.
Overall, ultrasound predictions of .fetal weight fall
within 20 percent of actual weight in the third
trimester.
~~:~x:.?::: ~\ . ' ~' -~';~.~-.
,; , :. _;.i .1 ~ .. .
. Th~. pnniar.y..concern.in..macrosomic.fetus-i s
the risk'Of shoulder dysta:cia--so- tha.tcfut:icians-
oftentimes opt to pnx:eed With cesarean - ~elivery
\\-ithout a trial of labor in pritn!gravfd patients with
a fetus believed to be macrosomic..
. . . . . . . . . . .
Whep: :,large. babies-are delivered . v~g"inally,
delivet;{iof t.'le shc;>~lders may be .p aitic;ulady
chali~t1glng; . for; 'the di~m:eter measured -froltl
should~r tO. shoulder (bisaS;Tori;Ual cUameter) may
be larger f:h;in the site o f the head .. In such cases;
t.'Je deliveririg doetor or .midWife .may have trouble
completihg the delivery" even ijiou_,gh the h ead has
a lready emerg.e d from the vagina. Such
complieatioi1 :is3mown .as .shoulder dystocia. When
shoulder dystocia . is encountered, tbete are a
effect delivery _of. the should~rs and artl)S in a quick
and safe .manner.
' . -~<
-~~r::
. .t;.:
If theifetal weight. is < 4,500g . (in -~~en ,_
without diabet~s) and augmentation o{ labor
restores normal progre.ss, labor can safely
~

continue. If progress is s low in the 2M s~ge of
labor, women .are ev<3Juated to determine w~ether
. by forcep$ or vacu;tJ.m e~actor
delivery
. . is safe ~d .
appropriate.
ABNORMALITIES IN FETAL SHAPE
Fetal ano~~s can cause dystocia. T.b,ese
include b,y~phalus, .en<;ephalotOele, enlarged
:abdomens b'r ri.e ck ~d rump tum9rs that .'may
:opstrucf lli:bor. AbR.oimal fetal shape like in
ac;rrdiac hvin canals~ cati:~ retal dystocia.
Hy~phalu.~~is. ~c~ssiV:e :accupnl'tation of
..fluid in tb;e b~.accoin;panid :-pj:-l:iiaqocranium.
If fetal head -~ed~ ~cili dystothi:is encount~red
due to" ~ph~(r,~l:ric Qisproportipn~.Diagn,~s is
usually IJ:laA-~y.:..:.ill~s<:>und
.. !.t.F :y;- . ':-+~ . . " ' -~atiOtr
" . - . . . .
~8.l4),.- w~.th~,~i?'~:of~~ -~teiai -v~~trlcJ~ 3,Iid
th:e~rem~.:~rteX i.s .m.~$u"r.q an.d: s~ -of tb~
head:is ~~#ith..~at.Q( .thy,~?truc:and the
:a,q:dpme#:';~e<;S.~i6~tak~)';~Mti:ril;l~d:c-may ' ..
be reduce4\ibY.ido~g;;~~p~y:iitis..~o,.llilow.'a .. .
.,.;~.,1' ,....,,::..,. -r.t.~ '. . . t'' .. 'L.-': '}i ' . '
va~ U.<;;illte'f'!~. -'"'"'1-J.s~:'\S'-a" - ~c~ttue. ":J ~1em a
spin_~ Iiee9l~#.:~sey! ~ '~p: t.i;1~t~~d~d ~o:ve
the t}UkL:-~ ,~tm!~~~t:i:on, htee':Ch:de)ive:r-y. :.
. can;,~:~.~;,iU.p;;to~~erqun:;-:a5lob.g.!:neea,te;iS-:.
then~~ 'traJ.:l.s yagirt$U;Ythrough the'V-.Iidened
sutures.-A tran.sabdo~al" ap:pr.o.aeh ~also be
done. ~<fW~*-f. W~t~ . i$;~~e~ d,l~t~ . th.at this
-proce4~-Ih\!~be're$.~&.e,d<':otrtrfcir""fuose~i~tus-es
witli:~~i,ro-r.-:p't~girosi~-tpt.~-wne-ir:'lliere-are
concqtni~tkthal~Qm~es. Otb.etwise.,.- d~?-v.ecy
i:s . ~ean.
gone by . seetion. .
. t:era.toili~t-
Fi~ 48:~4:. Hyd.roc'ephalus. This i';nm.~trliS9~d ri"age
of'O~Gtive'.hydrocCph~us v4th disrupted mi<W,ne echoes,
thinned out corti<:ai' mantle" and incr:eased ..size.:Of th~
c:r.aniUII). . ...
!;?ECTlONVII:OYSTOCIA .
Another fetal malfonnation that can cause fetal
dystocia .a re abn6nhalities cauting abdonrlnal
enlargement like :megacystic or marked bladder
distention, ascites, tumors !.ike liver tumor and
sacrocOccygeal teratoma. Diagi;losis is also Jl.lP..Q.e
by ultrasonography. For 'm arkedly distended
bladder, decompression procedure can be d.vne
by puncturihg .ih.e bladder to evacuate the fluid
after which thf!.Jetus is deli~red vaginally:The
pr~dm:e is d6n.e under uitr;asou~ gl,l.idance ~Y:
tran,sabd.o:mina1 -or L.'"ap.sva~~ :apprqach, the.
latter. onJ.y when.'-the :r:vix;$S::aliea~y" dUated. '
... : . ~\... .'-:_ . . . . ..,..
'For .r~tru ~~ts..of.~~-rmo-us ~izC~ llke. ~erO
cocdygeai 'h!~toma .o r n:a:sophazyngeal tumor-S,
\vhith~ ustial:ly ~olid 'tU.IDOrS Or for .fett\ses with
grot:e~que shape like !n ~carOiac fer..t~ de1ivery is
don.e bjc~<;afekisecli<>ti."{Fik,w-eS_ 48.1'5.& 48.:16) .
m>gu
' i.L' + . re
.
:.
.dYstocia
A.. Sa~cyge.;U
. N~pharyngeal mass
C, !Jegacysti~(bladder
>----~~~.....,...;;....;.---~ outlet oh3truction} .
Figure 4g .i~.. Abnormcil fetal shape. Fetuses with abnotinal
shape .or.~n~out;may.not pass through the.birth -~ anQ.
sho.u!d ~ -defivere~.by cesarean s.ection. . . .
A. A cardiac co-twin
B. .C~nj oined- twins
Snanned &y: C
 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS 741
..- .~ .; .

SHOULDER DYSTOCIA extrem ely poor positive predictive valUe;.i;.and

therefore do not allow the obstetrician to
ShoulderDystoeia refers to the entrapment of accurately and r eliably predict the occurrence of
the fetus within the birth canal resulting from shoulder dys tocia. 13
impaction of either the anterior shoulder (most
common) aga inst the maternal pubic bone (Figure Preconceptual Risk Fac-t ors
48.17), or the posterior shoulder (least common)
again~t the bony protuberance of the sacr.al bone 1. Previou s shoulder dystocia
(sacral promontory). Cccasiqnally; both shoulders
may become impacted. It is often recognized after . 2~ Materriru obe sity
delivexy oi the fetal head when :gentle downward :3. Maternal age . .
traction .fails to accomplish delivery. Signifi~t
dystocia include any delivery' requiring one or mere 4. Multipafity .
ma nerivers in addition-to downward traction on -
the fetal head to achieve delivery and if the head- 5 . Abnormal p e lvis
to-bly delivery interval !s more than 60 seconds.
Previous shoulder dystocia sig nifieantly
ihcreases theriskofrepeat shou lder dy:Stocia. The
risk of a woman having a :re:eeat shQlilder dy$t()(::ia
once having one
is Ti:-12%1 14 a 2~fo)sk.higher
than the baseline risk,of:.O.S%.
. . . .. ~. \.,.,. _;__::.! (.:..... ' . ,~ ~: v

.. A mother~ . w:eighCprove.s. to.,be.,sgri.iji~tly .

correlated \ vith .shoulder dysto~ia. ;H.ciw.~Y.~r.,
wheili~r this is a pritnazy ~fiect or. merelyrefle<:lts
the ..fact ..that ..obese . wboien :tend, .to .have larger
bap ies is riot clear;o_Bahar.(l996f(ij~P.Otdi.ndan.y: . .
differende .in-shbUlder;dystocia:Qa:se(f:io'J!.rmat;ei:nal .
age alone;s ;.P l'' 'i, -,,-,.;>~..; :,~:.
. :: ~ . .... , ' ,/' . . ';..i"t.:.:

. :Mat<:rniU a,g is ~ .iisk .factor for $hOJJlder

dystoci'a--b
.
e'Cau-s-e- ri:tatern!d' obesH-.~
a.I..J' I
~.- 'diabetes . '
exces~ive weight gfi'in a nd'i:fistttifirental delive-ries
Figure 48,17. Shoulder dys~ocia. The anterior shoulder
is ~patted under the symphysis pubis. are a.ll common in :older wbmen.

Mos t experts .fe el that the relationship of

Incidence
The occurren ce of shoulder dystocia reported
in literature is .0.5% to 1.5%, or 1 in 67 to 200
deliveries. The incidence reported in our local data
is 0.2o/o. The incidence a ppears to be increasing .
a s birthweight increa ses.
multiparity and sho'-tlder dystocia is secondar.f
rather thari primary. As With matem:3.} age, by. the
t:im,e a woman becomes multiparous, she becomes
at risk ofhavinglarge.Qabies, obesity and diabetes.
The only prima,tY association between multiparity
and s houlder dy~tocia is the fact that :nultiparous
wonieri are more likely to have precipitou s la bors
which. has been linked to increased -ri s k of .
shoulder dystocia. 16

Although it would make sense that a decrea se

There are multiple risk factors that have been .in certain pelvic dimensions would increase the
a,ssbciated with shoulder dys~ocia. These can be poss ibility of shoulder dystocia, there are n o
generally divided into3 categories: ~Conceptual; supporting data in the literature linl~~:i~ it to
Antepartum, ruld lntrap_a rtum. However, mOst objectively tneasured pelvic shape. T~use of
experts in Obstetrics believe that -s houlder . pclvimetry in .o bs tetrics has been discard~ .except
dystocia can not be predicted . . Mo s t of.thes.e in cases of congenital or pathologica1 pelvic
p.reccmceptions an~ pr!!n~tal n sk factors have d eformity.

Seanned 8y: ~
 742 . SECTION Vll: DYSTOCIA

Antepartum Risk Factors Intrapartum Risk Factors

L Macrosomia 1. Instrumental delivery

2. Proloq.ged second ~tage
2. Diabetes -3. Multiple risk factcn;
3. Excessive weight -gam
4. Post-dates / Postterm Labor th~t ends in instru'meJ+tal va,ginal
-- delivery {forceps or vacuum) is associated with a
higher rate of _.shoulder ctyst~1a. Baskett (1995)
Macroso:mia is the most significant risk factor reported a .t enfold increase . of shoulder dystocia
for sho\).lder dys-tocia. It is d -e fined -as gr-owth _in, inidforceps:d~livery. 19 .rhe inCidence of shulder
b eyond 4000-4500 grams regardle~s ~f .gesta.tio~al dyst~ia is -increased ~hen the seC!;)nd stage oi
-~. ge.1-r StwJ.ies have establi$hed .-{JignUicant l~bor ~s prolonged, combined .with for:ce:ps deliy-ery
relatipnship .between. increasing birlhwe~i: -a nd the ~sk.~c_oines :even .hi.gher. However., it is not
the risk of shoulder -dystoCia. For births not de-ar whether- th-is :wo.uld r-epresent an
complicated by m aternal diabete~.. the risk of independent risk factor. It rrught metely confirm -
~houlde;~_ dy_st-o..cia in~r~ea,.s:~.S .fr.~~ 5% for t 'h at labor dis ord.e rs are more _c ommon in
.birthwd'gh~- ~tween 40QM~-50 -~~ w 9 .~%; macrosomic babies a,."'ld that macroSmic babies
:rcr oi.'tiliw~igtit -~t 4~~;ro .:grams to.24%. A~ong are more likely to experience shoulder .dy-!>tocia.
. ilia~~c-:m.Q:fA~. t.he(:ti~k ~f_'s~oU19-er :9y~tdiia is
fur-ther increased to 20,.,~0%; 011e .qf -th~ most Th~ gr.eate;:;t risk Jor shotildet dy~tocii oecurs
impo~nt f~c:tpl"S ,~b_cn;l:t .-rn:a~rp:so_:tiiia, iS..the ID t.hQt,e :gto,mJ.s Of .W-omen whq h~ve l itultiple risk
. ;diff~~~t~x~t.-gro.w.th-ii>il~~~~~~h$d:;'chest" factot-sdTti~~~ct>:inbm:ation"'Pf~etat- in'i6::oS<>mi.a .
.an-d frti;il:k;~~q~estatit>u-.-p~s~-T.~~!l;>a&~s;tru;nk_. seco~d:s4t_ge:1ob.ger-:,'than 2- iioUi:s:and~~e~~- ()f
siiC-~:-.~iea inofe ~tnan-~t~t'tllt:-~h~d thus .- - opera~v~-~~~ :d~live,ti ~ete <assod..ited.-with
.wi~~ipg;~:~~~-~fshptt$et-'d$.$tocia.Mos't . shoulf.le;i,dy~t:~:irv-nii'~paro~s:.-yv~in~n:~- An
eiipiG:ja.ns.t#Y, -bJ;l;.uJtra~.o#~~j)hr:to:-"-pr;ed_iyt' - obese'Wo~:~th'it~/~e-t)re'"Pr.~-~eight
: ~n:Ua;.ibovie~r,:.esti.tttat;Wn::of"1'et.~.l}:$~\-:b-y ,_. _gain ~:-ap;<V~g~~tational<~d:iabetes- wiil';have a.
-u.ltia~*~~P~Y- lias . m~. errot--r.a;p.~g.frqm sign,ificantly .: : s re~:t;~r-~.Jik~lih:<?:9.~ .of -~ ~y~ng a
300..:5oo:. ~~? ACOG~:r.:eC.J~mil:l:~;r:\d~ :pl@n~d macrow.mic -~:~il,-,~P,9Wd~~:ay.;~~:than a

:=:::t7.~~!f~ti!?~~=;- ...::.~~t~:]!:;:::~::e
11
fu'wo:meii::- ;wi'tli' dia~tes.'l -titi;~~;.;-it:-:;.;~;t be
re~ero~edthat h~ ofca~s of~l\O.uldci ~St-OCia
o ecur -in .infants whose' birth-weight is less than
409:0 ~gia,ms. . .
awoman en!h d!ab:tes, la~g~ few~. p;o1o~ged
secoTl{i -stage of kroor and a_foreeps ~- .I n
such situatio:n, the risk of shoulder dystc-cia
.approaches 40%.

_ . -N~t .-t o: _mae:.tos.p,fD-ia, t he _fac.~or dosdy. Relc:vant Maternal Cznd Fetal Ana.tom,y .
_ :~sso:cl:atec,i ;Witl;l. ~hoti:ld:r :dyst9cia.: is.matemal
~be~_ iil;-p~.c:Y. :Eabie~.:Qfdiabetic;tn.Qthers 'T_he key ~a:temal anatonii<;:a1 dements in
had:a three h> fouifou:ld incre:ase ;in the .risk of shoulder dystocia are .fh'e p~bic bone, wlllch forms
sho:uldei- d:Ys~a cop:tpared -Wi~ ~babi~~ pf non- the-anterior: (t;rbpt~l) 't)o_i:der. ofilie ~lvic -inlet,.and
dil3:lkti.c m~t4~x;s: -This Js because thes~ .ba bies th~ sacrum; which fohns the pOsterior (rear) border
.show a.:pattem -qf greater shoulcl-er, chest arid of the inlet.
abdominal-growth 'in response to .hy;perglycemia.
. .. The fetal shouiaef~-must pa.ss 'th(ougb~the
Maternal.weight gain .isa se.c ondary.x:i-sk factor pelvic inlet, -and in doing so, successfully squeeze
w:hLch ir.ldie<;L_tes- risk .o f ~houlder dystoCia on:Lypa_? t--the pubic :bope-an&sacrum: The qimen'Sions
. when -$ereis '- acconipany.ingf~tal macrqso~ia. of the_ fet <il. should .et.s represented b'y the
measurement takel} f rqm .' tl)_e outer dige of on~
Postd.a tism, an-9- posttenn:. pr.egl).ancies have shoulder-to the outer edge of~e. op_posite shoulder
been .as~ated with _shoill4~t- ~ystocia because (bisf:!.cromial diariietei:l is .oft~n.larger. than. the
. :of the 'tend_eri.cy <>t: the . bab-ies. t~ become distance measured between -th-e pubi2 and sacral
rnacrosomic the longer they stay i,_n utero. . bones at the pelyic inl~t. -As a result; it .i s .es_sentiai

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 CHAPTER 48: DYSTOCIA DUE TO ABNORMALITIES OF THE FETUS 743

that, as the fetus traverses the pelvic inlet, the
shoulders rotate obliquely to permit passage. If
the shoulder fails to rotate, dystocia may result.
Th~ "Turtl-e Slgn"
symphysis pubis. Once the ;>boulders are
impacted at the pelvic inlet, the fetal head which
has already left the pelvis often r.ecoils .tightly
against the tnatemal perineum. This is tenrted the
"Turtle Sign", the first sign of shoulder dystocia.

. T1:te first sign of shoulder dystocia occurring is

the .:turtle sign wherein the fet.al head after Dystocia of the Anterior Shoulder
emerging recoils tightly ~gainst the maternal
perineum. After delivery of the head, the fetus When the fetal shoulders fail to adequately
seems to try to withdraw back into the birth canal. rotate upon reaching the pelvic inlet, the ~teri6r
Digital examination rev.e als that the anterior fetal -shoulder may become impacted on the
shoulder is stuck behind the pubic symphysis. mater:nal pubiC bone. -This is by fa~the most
common form of feta,l dystocia. The sho~lder may
Once dystocia is recognized, the mother spontaneously dislodge with further. uterine
__ shoul~ be stopped from pushing -until the contractions, \vithouf harm to the fetus. Many
~boulders have been freed. Excessive ic;>re must such. cases of dystocia likely go unnQticed by th.e
.n ot be .a pplied to the fetal head or neGk and fundal delivery staff. If, however, the shoul-der impaction
pressure rnust be avoided. becaUae these actions persists; fetal injury_may occur;
are- UJ'Jikel.y to free the impaction and may cause .........
'i njury.to:the infant and mother. Dystoci~ -of. :the -P.osterior -Shoulder .
. .
.. ....:::~.~~~)- -~--.~. ~--~ :>:
Dystocia--of -the-.posterior -showd$r .-.i:t;l:;\YJ!J:llso
. - - result from inadequate totation.~JPf:r.cth~,4$~:a1 -
To tinde:-stand what occurs in shoalder shoulders as they enter _the pelvic-L'll:et. hv,this .
dyst~,.,.:()p_e must recall the mechanism of normal - ca.se, .t he. posterior-shoulder. (nearest the .Jrtcthers
. delivctp~.Although the -bisacrtitnial diameter of a spine) imp"-cts . ~gainst the -prqmq;r:tt.Qry-,.o.(,ithe
x-un.Y ~~~rill fetus-I s -greatert han.t he biparietal sacrum~-, Tbi$-is::the 1ess cotnnioriJ6~. .
Q{'dystocia
-
. diam.et_~~- the shoulders ar-e mobile an.d . ' :Xrl):;lj; ,.!.: ....;. .. ~~ ~.;:.:: :
compressible andthe pelvic inlet is nonnally wider Fetal Injuries ReJated to Shoulder -~eia .
in,.tlieot>Uque dia'met~ than the art~~~tefior.
. l>u:rilig-+~baf, --Uter ine eont:raction$-lead~to-flexion Fetal:morbidit-rfollowing-shb-uld-er :dystocia
a,nd:engagement-oHhefeta:lhead; Tben~ttenters results from asphyxia an:d:ttauma:to the petipheriil _
the pelvic inlet in the occipitotrans.v.erse positior\, nerves or the skel~ton.
with the shoulders -lying anteroposterior at this
stage. Int-ernai rotation of the hel;ld: .<><;cUts as th~ Prolonged .or severe shoulder _dystocia may
head reaches the level .eif the ischial spin~, while lead to serious injury of the plexus of nerves
the shoulders rotate to the obli(lue -position. Fetal supplying sehsation and function to the fetai
head extends as it comes through the pelvic outlet. upperUm.l;>, and can also result in permanent brain
The .shoulders pass .through the pel\ridrilet in the damage as- a result of inter.n1ption of the fetal
oblique position. The posterior shoulder enters cerebral.blood flow.
first, coming to rest in the sacral hollow or over
the sacrosciatic-notch, while the anterior shotil:der 1. Brachial Plexus Injury
follows to lie over the obturator for:a:rhen. As further
descent occurs; the anterior shoulder-emerges The most common injury as-sociated with
from under pubic ramus and the shouldet"girdle shoulder dystocia is injury to the brachial plexus.
rotates to-allow the delivery iJ.l the antero-posterior The brachial plexus is a group of nerves located
position, which is usually assisted by. lateral in the lower. neck., formed by 5 .nerve roots
flexion of the body. It is important to appreciate emerging from the spinal cord as it runs through
that in shol,llder dystoc~ the point of :obstruction - the ce-r vical spine. This plexus is respo~~.ble for
occurs itt the inlet of the pelvis. Us\ially the all the sensory and. muscular function~ of the
posterior shoulder enters the pelvis, but the. correspondin;g upper litnb. During .dystc;?cia, the
anterior- -shoulder. haVing failed to rotate td the forward propulsion of .the fetus as a -re sult of
oblique- position, remains trapped behind the uterine contractions and maternal bearing down

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74~ SECtJON'VII: DYST001A

and ilie impaction of the shoulder, cause the ne;tk;> obstruction of the venous outflow from the 'Qrain
and the :nerve plexus Within to stretch.. -RepetitiVe due to ~mpression of the neck in ~e . birth canal .
and mtensive stretching may d_amage .the nerves . '. .
of the plext.is. 'fhe nerV-es may tear (avulsion), .but Matemal Injuries Related. to Shoulder Dystocia
ne\lrological impai.rment can also arise as -a -r esult
of simple stretching of the nerves. 1.) J>ost .partum he morrhage
2.) Extension of the episiotomy and fourth degree
Most cominonly, the nerves of the CS .a.T.ld C6 lacerations
nerve roots are ir!jur~ resu.J..ti.Rg 1Tl the clin~~ 3.) C.er.vical and vagin.al.lacer.ations
findings Of Etlr.Duchefliie Palsy: . the in.fa:rit -1oses 4.) Loss of bladder :function
the power t<r add1..1ct the arm ftqm. the sh,oulilet, 5.) Uteriile rupture
rotate the a~ eXter.p;ally and SUpinate the 6,) Sep;;u-ation of the ,maternal pubic symphysis
forE'.rm. Th'e characteristic posiQ.on con"$ists of pubis .
addildion .and iti~a;l rotation .t)f.th~. .arm with . 7 .)"Femoral cutaneous nerve injury related to
pronation. oi the for~ Thl.s ls also known as overzealous use.o f the McRobert~s .m aneuver.
the. waiter~~ tip position w:herei.h the 3:J;"tn. 'is 8.} Puerperal infectl.on . ,

intern.ally r.Ota~e.d and pi"QnateP,, t.'l.ere i~ no .ae{ive

:add,u~n: or -elbow flq':i.O~ fuwer tp. .ei>;t~ fu., . Red.u~~Q~ .$!"!1ne-g.yer~ ..fQi' f;)poul~~r Dyst.pc,i a.
for~ is retained. b:t;l.~ thebi~ps reflex; is a:"~nt (:the ""'~PERR" . Mil:emoluc}
:and .t he outer ~~_'Of :ili.e.fuin ID:a,y have :s~me _..... .
sensoiy impa,frniep.t..- Po:We:r.sin -t he 'f orearm and. ShouJder dystocia. is a frighten:ing ..em~rgency
~d-~p ~rpeSer.Ve9---.u.oless:;the..low..er.:part,of,... in the de'H very r:obm_ Manage.rb.ent of this
tll::e-pleXu:s-.-iSf.:aJ.so~~Jnr~~4fti~,'>prtsen("..e<~if!harid..i ' ,em~rgency. 1s.:po:$sible :vrherp4h'!,,obstetiidan,
. gra:s p _.is. 'a> .(a~or.able.:-pr~.gn;o:stic:~ign,.~;;'f:l:tis.t... mainta,ins caln:l.A~ss.-as .he a,pplies th~ qillerent
.coniplleati.6n' U"Sl.;1~Y'reS:olVe'~~m 18 months. . : ~euve.;-s-_to o_ve;rcome :shoulder. dy.stoci.a.

Ra:r<brac~~pl~$-inJ~~~.Khtrp:_p~~~~sY ....; Thm:e-<ar_e: 411~L~Lshould.. be. avoided wh~n.

(injuxy:of.1he:~7,,=:cailin.di~il-n~x:ve:~t:OO'tsrmayi~., . .. :fared:Wit;h:frili.-situation::po -N ot! 1..: P:u11.2..f11sh,
ocC\Ir. Cl.inial pic'ti.rres ...of:tl:p.~- -hijury.1ncl~de~'a 3. Panic ,~44 . .Pivot.
pa.:r:a.lyw.i -han~ :eJ:elisiweaJme8S -~,cou.~~ed
2.'9..P.llo (pj:c)sj~~~,.9...,mjg:sis.;__~,t](~_L~il.m_rM)_i1'.Jh.~ . ..Th
: e,..:.rut~
...,_PERlLm:n
_ r .
.. ' 2...1 __.1S~,a..cmic:<...tooL
_ . . , . ~~onr .

sy;rn~~#ic~.ofthe)itstthota:~cr:oOHu::e.also till~t:o:ffer.,s,_a.str.uctu:reci-ftamewor.k~for-Cb_P.i,ng;~ th:

U;!jut.e'ci. sbOUldet.dyst.ocia,. :nre8e maneuvers.are deSi.gn.ed
to do one.of -.three things: .
,.,.. . .
. . f'ra!.;ture ;on,. tJ:te Affected
.2. Bone . . ..
~de
1.} Inctease th:e functional si.?;e ofthe bony:pelv.;i.s,
(McRo_b erts maheuvet)
_.One_-$~r~ .q( br-~e;hia:t- -P~~~u:~ pr:t,l~.ie..s. ..~f~ 2~) lDecrepie the.l;>i:Sacromial qiameter oflhef~PJ,s
~d .withfetal -b<>i:l~ Ir:a'cb;tte :ih.tlle affyC~d
{~up:qipubic p~~ssute)
~id~.. ~ost. ~~~or:Jy the, c.~vi.cJj!, Ratd.Y, .11tdjal-
3.) Change tpe rel~tionshjp of the "Qisacromial
~e m ay resUlt frori},. either dystocia ;or' f:rom
diame ter within the bony _pelvi.s (Wood.1s screw}>
the v~ou's maneuver s ei:Q.ployed to relieve t..'1e
d.ysto.cia..
The HELP-ERR .Mnemo.n'ic Action : Pla-n for.
shoulder -dyst ocia are ~s follo~s: .
.3_ Perinatal AspJ-gp:i4> Brain Dqmage and Death
H':ca:.n roi'.help."
... Inte~ption ofad:equate-blOOd flow tothe fetal E Evaluate f~n episiotomy.
br.aln .{hypcpti~) may <;>CCUi;' dl..lrin,g p rolonged. L .Legs .ilexeq and abducted
~ houlder _dystocia. This is a rar.e .b ut :Potential {McRobert's maneuver)
d.evastating o.ccu r:t:etl'Ce, :and :may.: res.ult . in P Suprapubic Pressure .
. permanent:'impq:irmerit.of l:?Jgher bciin-tunctions E'Enter. ma:neuvers (Wood's. Screw and
or in _extretne cases, fetal death. -Blc:>od. flow :Rubin.manehvers)
- in:t~rruption i s :due to the ~ompression of ;the R ~emove th e posterior arm.
umbilical :~pr:d (interru.p ting fetal OJ-.."}'genatibn) and . R Roll th e pa(:ient.
~----~----~------------------------_J

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 CHAPTER 48: DYSTOCIA OU.E TO ABNORMALITIES OF THE FETUS ' 745

The ALARMER Mnemonic has same maneuvers
as the HEL'P~RR Mnemonic
A Ask for help
L Lift/hyperflex legs
A Anteripr shoulde.- disimpaction
R Rotation ofthe posterior shoulder
M Manual removal of the posterior arm
E Episiotomy
R Roll over onto "all fours"
Although there is no-indication thai any of
these techpique$ i~ superior to another, together,
. they effectively relieve the hnpacMd shbulder. ,T be
order 6f the steps is not important and each may
be employed effidently and appropriately.
Persisten~;;e in any Qne meffectiv~ maneuver
should be avt>ided. Clinical judgment always
should .~e the progression ofproGedt.Uts used.
Iha)I~etse fails 1 :~ympt,ysl6t6my .: deidotomy,
Zavanelll marie~vet or hyster otomy .are . the
illaneuvet"S ofla st resort.
canror"lletp
. :. ......~~:.: :.
Thfs >refers to activating t.l'1e pre-arranged
protocol or requesting the appropriate personnel
. to respcndWith .ncessat}r eqilip$ent to tbe ~bor
a:na-:a- e1ive cy umt: ''The":ctib~atstp in add;ressitrg
the emergency management iif sno.waer dystocia
is ensunng that all involved hospital personnel
are familiar with their roles Md responsibilities.
This delivery team should inClude a family
physician or obstetrician, an anesthesiologi-st, a
pediatrician or neonatologist, one .or .two la bor
nurses and a neonatal or nu.n>ery nul'$e.
performing an episiotomy can wait until later in
the sequence . If fe tal manipulations can be
performed without episiotomy, severe perineal
trauma can be averted without incurring grea ter
risk of brachial plexus palsy.
Legs (Me Roberts Maneuverl
The McRobert s maneuver is generally
recommended as the first step taken o'n cedystocia
is .reco:gnized. 13 It is effective, simple and easy to
do. This maneuver consists of flexion at the hips
so that both t:naternal thighs iie against her
abdomen (Figures 48.18 & 48. 19}. This procedure
results to cephalad rotation of the symphysis
pubis and .f lattening of the: sacrum. 13 'When the
woman as.sumes this position, the posterior
shoulder is pushed over the sacral promontory
allowing it to fall into the hollow of the sacrum
-. and the symphysis pubis slides over the impacted
anterior shoulder. -successful redilction ofilie
impacted . shoulder with McRoberts...~maneuver
alone is reported at more tban At!>%~" ~nibined
with suprapubic,p,resSur.P -successm te.''isreppned.
at more than 50% (Ge.a ry. 1995)~- lfur~es ,'atld
familjmcp1bers pre~t at the delivery 'Call-P.rc'Vide
~s:sist.a.nPe .for this maneuver~ ~e..nmst-:be .taken
. not to-:be aggressiVe in thi~ maireu\r~~a~th.is~may
reslllt to femoral n~rve injury. ~-..::..: ; : : :' c_;;,j.. _: .

Evaluate for Episiotomy

An episiotomy is a surgical incis ion of the

penneum made to incJ:"ease the diameter of the
yulvar outlet during childl;lirt.l). Howev~r. it is not
done routinely in all deliveries. It .should be
cons.idered when s hQulder dystocia i s
encountered. Although the primary problem is a
bony impaction and episiotomy will not rele.a se
the impnetion, Ulis procedure will provide 'm ore
room for intravaginal manipulations if rotation
m&neuvers will be required. Be-eause most cases
of shoulder dystocia can be relieved with Figul'e 48. 18. . Md~obert's position. Legs aie . ielevat~d to
McRoberts ma neuver arid .SUpra pubic pressu::-e hyperflcx the hips bringing the thighs a gai.'1St fhe a bdom en.

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r-..
~
 746 SECTION
.. . . VH: DYSTOClA

.Fi~ 4S. l9. Mechanism. in -McRo bert's PQsition. TtJs ,position results:~ cep~d J;"otationof the
:sy'lllphysi:s pubis and fl~ttcning of the..sa~m. The .sym p~ysis pliliis slide-s :pver t."le imPacted
antmor shciulde1". '

~~pl1l_p~M~ ~.re-st;:ilre -(.I.!az%3:a!i M~euv~j the :anterior shoul':\et is wedged beneath .the
.-..... ;=:-:.- s~physis. At times,'ltis .n~~,.:t9 pl:J.$ the
Supxapu}#c, ...pr.e~-sp..J:;:,e. i$.;the. -~pdO.mi:nal fetil's up into the pelvis slightJ.y-toa<::eomplish the
. .. ,: appr9'~~t91'sdi#9d'!te.r-.tl:'te<:jm:pa:-~t~d"$:ite:t<f<W --lnari.~itve'fs-~~."ltqt-f:rtiop.: ::ma~e't~ve.ts .require =

.sh..oulder.:Itis-orten :p;erfon'l;led,:iP,-co'tljuricUon::'wifu. episi6tomy'to :gairt -~sh!rior vagfnal: s pace for .the

. th-e McRoberts = illaneuve.r, :or. .sh.c.?rtly thei:eaftet.-if physiC:ian's h and. . . .
the ~cRo'Perls. is .unsucessft~L~~ Wh~ ~~ti
:Zn'~enver;:p,;.nsist$~of~do~war(,tpt~~ur.:e.'~P.Plied.
:Y.(~~~tbt:<,rheel!:of;.,the.:.h~nd 1.~t.'e~)1'r-ab0ve.: the:.
inatemalp"U.bic.;bone.:nv:er-:.t:b,e.:pcisteti;)r:~as;?ectcf" : i.
I
th,e ailt!!-ri(l.r s.h;~nrl:der~ th.r.<>u_gh tpce ~.t~m-al
abd:om.inai,~JFi,gure 4.8/20}. Th.eln.t~nd~d"effect . < .. :f' --.~~- .

-1~-ro:pusS.t~:Qaeted:sho~~r bdow.fu.c lf.\!.9-,~. .

.pp.l:ie~ .en.co\;1~a;ie~r~ta:tion. of: the. sh9\UP.ei.'.~e ~o
:Uil;!qbli(rifi:iJ)Oiitlon, -.an,d :t he <ittt~tior .:~~~Q.er 1;0
slY> ii~d.~r :tf.ie syrilpiiy$is thus .rr~e'mg'lt ;tO .mqY,e
.'f.t>.rw~ th!o~gli:~e. we~ :Inip.~y; tiie:.:Pt~s~re
;ia.~ :b~~;o:J;ith1.=aus. -b :ut -~.f . d.~~i~-~;r:y: .)i liot \
acco;m;pll~hp.i.: ~!:~'kihi:m'O~on;is..f~IJ?mc;.#ded .
.t,o. . ~~~ge ~~-:Sl;lou1a~i' fi-ofu.-:k;~~Vt:ne pt+ti'ic .
:~~PltY~s: :WJ)-~~- #i~e,uj,r~t sh.o~l.d~ :.~ . rattemp,~a
W.hife cO'nt~nu~irig :do:Wnw<'!-rd ttactio;n. :Pr.P"per
. .:l'Psitio~g'of th~ }~~d~ at =a. :poli~t tiirtly above .. ....
fu~;.p~biC bOny=is. c:ritiqiJ,.~~.F>.r~=ssur~appliOO. at a . .
higlier.l~Yel 'Will cc'mpres~ :the ."t):te,r'US .and. m~y fl~re -48.20. ~uprapub~c pressure{Maz:z.anti maneuver) ,
Firm pre.Sst:.re is ;<i.ppUcd to the pqs~enor aspect of Ut.e
aggravate th~.hr~hla,1 :pieJo.:~s.sttetch.q:r u mbiliG}u anterior .shou1de(:U.sin$;e h ~el 9f.the, h apd-plac.ed iri"tlie
com ~mprci>sibtt .an-g. :fetal h ypoX:i,a.
: 0 ' 0 0 0 M 0 0
supr?-pUbic area o'f'the al:idorn~ to rotate: the ~oulder
" l . . . . . .. girdle-and bring it atong-tne oblique diameter.
~nt~~ Maneuvers .U~~emal Ro.ta~i~}
. .
. : Th.e .en~r or-. "internal :.r.o'ti:i.ti~n~ ;~~euvers "Enter' maneuver~ -include thetfollowing:'
. ir~ vagfnai ;~pproahes .:design~d to: ma'riipU:late
-th~ i.etil~ .~o t.o~te the anterior shoti~dci:: ~tQ.~ 1.. Rubi,n II .(Fi~re ;1S-~1). .
oblique plane and ~nde.r the matemal :symphysis. 2. Wobds corkscrew (Figure 4B/22)
.These'maneuve:rs can be difficult to perform ~vheq ;3. Reverse W.o<xl$ cotk~crew {Figure-4~L23)

Stanned 8y: C
 CHAPitR 46: DYSTOCIAOUE TO ABNORMALITIES OF THE FETUS
Flg'Ure 48.2-1 . Ruoin,JI .maneuver, ("Enter" maueuver 1).
Two fmget$ are insertcl:vaginally, pla.c~d over the -posterior
j1,spect <i!the.anterior !ilioulder,.forward p~ssuie towards
the chest 1s applied to add-uct the shoulder girdle Md
deqoease its diameter.
Figure' 48 ~'22. - vrooas cotRsc"i:'eW maneuver,- ("E'nter"
maneilYtt ~~; 1WO fingers ru-e ptaee<i:-o-~~'th~ IDi~cWn"!!pect
o( the posterior shoulder 11.pplyillg upward pressUre to rotate :
.t hesbotilder 180 degrees. Tills is done simultaneQusly with
Rubins U m-aneuvC<r.
FJgU:re 48.;z3. Reverse Wo.o ds maneuver, (")j:nter"
maneuve~: 3). Two fingers are placed over. the posterior
asp~ of the posterior shoulder, forward pressuie.is .CJ.pplied
to adduct the posterior s houlder and to rotate the fetus in
the opposit~ direction.
Scanned 8y:
747
The Rubin II maneuver consists of inserting
the .fingers .of one hand vaginally behind the
posterior as~ct of. the anterior shouider of the
fetus rotating Ule sho~der to~ds the fetal chest.
This motion will adduct the fetal shoulder gird!e
and reduce its diameter. Doing' Ule McRoberts
maneuver at the . same time Illay facilitate its
success.
If Rubin II is unsuccessful, the Woods
corkscrew. maneuver is attempted. In Woods
corkscre.v'r~aneuver the physician places at
least two finger$ op the 'ant~nor aspect of the
fetal posterior sboulder applying gentle Upward
pressure rotating the posterior shoulder in the
sa:me direction as with the Rubin II maneuver to
180 degrees in an attempt to rotate the posterior
shoulder to the anterior position. The Rubin II
and Woods corkscrew maneuvet.s can be
combined to increase foces, by using two fmgers
behind the fu"1.terior shoulder and two rm~ers of
the other hand .infront of the post~Ji<?t~.~~cn~l(ier.
belivery is att~mpted once the shoulders~ move
in :oblique direction. if~(, 1 ,.~;i'':.,';.;;. ~: ;
.. Ifthe-Rubip.s Il or W9Qds.corkscrevimaneq,1iers
fail, the reverse:WOOds corkscrew.:~AA~llV~; JAaY
be bied.Jn.thisma:rieuver, the physicihli'~:Jj.p,ger.s.
are phiced on the back of the pas~P.ol!.~q~der
and the fetus .is rotated in the op:t><>~ite direCtion.
This . tnaneuv.er addu~ts the fetal po.~terior
sho'uloersouCbCtne .i:riipaCtecrpo-sifion'l'iito
oblique pfane' 'to deliver. . .. . .
an
Remove the Posteriot Ann
. .
Removing t.h e poster ior arm frotn. the birth
canal shortens the 'bisl'l,cii:>riiial diameter, allowing
th,e fetus to dtop int'6. the sacni.l hollow, freeing .
the impaction. ..
This involves placing the physician's.hand in
the vagina and locating the
fetal arm. The fetal
elbow is th~n flexed and the for.earm is delivered
in~ swe.epingmotion over the .anterior chest wall
of the fetus (Figure 48.24). The posterior hand,
followed by the arm and shoulder, will be reduced,
facilitating the delivery of the infant.. Often, the
fetus spontaneously rotates as the atm is f.emoved .
The anterior shoulder will then fall urt1ier the
symphysis and deliver. The upper arni" should
neverbe grasped and pulled directly. n o ing so may
frac;:ture the humerus.
~
 748 SECTiON Vll: DYSTOCIA ...r

Figure 48.24 . :I~emova.l ~(the--posterior ami. The P<>sterior arm is

l ocated: cl.bOw is flexed,
fcre:um. isdeliVered pya $weep4;1g motiOn across !lie chest and face. nus maneuver. will shorten.
the bisacromia! -diameter. .

1 '!,'ft '

Tti~ pa,ti~ntis rolled:fr6m:lier#~t;m.i.po~J:tion .

to the '!all~fours p0siticn '(FigU.re 48,25}., called
:.thb .Qaskin's maiielJ.V~r .!lS It. i$ a e; rltpid a.nd
e.ffectlV:e~~CN :.r~r:. f4e ~r:tl.cti:tt of!sbquleie~: .
.. Q.yst0Ci8;. ~~ .tl;l~ sn.i:)U3,&:.r :wm--dJ:~locrge idtirini; : .
the.act~r~~ . s.9'.fuat:.~s~~~~:oy~ffient'ruo:n:e -'
~y ..~ ~s'4!fi.g~nt to :~~l~_g~ tQ.~ itn_wctiQ.~. i~
ad.di~~n
--~H ~~~v ...~. _ ~-1.;,1.;1.,.e--...~:sitiOni6hartD'P
't:<'rieef.l;' nn
.< . -:;~tfompkted:
t;)__.. . . ,

.gx'a"'J.it80tionaL.f~n:cesmay aid -ilf.:the ilisimpacti~n

of th~ fetal. shoulders. The phys~cian pro~de's
gentle downward traC.tion tc deliver the posterior
FigUre 48.. 25.. Gaskin's :all.:Ofou!'S" pi:>~tioil. .A change m .
shoulder with the :aid of
gravity. The all~fours.
the maternal position from lithotqmy 'to ait~fours" ..w ill
positi():n is compatible with an
intrav.a gina1 dislodge the showde):'S by gravitationai force, 'allowing
manipulations for shoulder dystocia whi<::h can delivery Qf .t he posteDO.r shoulder by rotaf:ion or 'by gentle
then -be
..
re-=atte:tn:pted-
. . .
iri thi~I new. -pqsition.
.
This do"?ffiwa.rd traction.
position ma.y ~ disorif!.Uting tb p{lysicians.io .th8,.t
p6rl0rmL>-r.g-a'f~non:nl:il deliveries in fr..is position
inay. p~epare one for inore emergent situations. Deliberate ClaviCle ;Fx;acture
Many h a:ve questioned the practicability of turning
a f~qgu~d, fubori:hg 'W;6~ah rapidly enoug-h to Clavit u lar fractUre or 'Cleiuo.tor'ny i.s d.bn.~~by
deliv.er 'a 'b aby -within the 4~t) minutes. time dir~ct pressure on the .mid -portion of-the .fetal
available, particti.l9Xly w hen the patient 'is un:<;ler clavkle (Figure 'l8.2o). This. redu~es :the shoul~er~
..epidura!:anestl?-esia .or other maneuv.ers have used to-shoulder 'distaz1ce or lne .l::iisacromiaf diameter.
:UP much of.the allotted.t:irn:e. Cleidotomy.is .normally employe.d ih a 'dead. fetus.

Maneuvers of Last -Reso rt Zavanelli Maneuver ..

If the HE'LPERR" .IIi.a neU:vers . ar'e Th_i:s maneuver_ is done by . c;ephalic

unsuccessful, severa} technique;;; :have .b ee~l replac~men(followed by cesare an. ..
!s ep.t~on .
d'escribe~ M ~st r es<?r:f" ~mineu~~rs:. : .. . : : Cephill.ic repta_cem~nt. is ~one by. r.evers~g_: j:he

Scanned By: C
rlfV
~r
~ --~--:---C-HA-P.,...TE_R_-:-'-48_:_D_Y....,Sl"-:-OC-JA-0
7U =-E-T_O......,.~AB:-
:. cardinal movements of labor (Figure 48.27). This
maneuver consi{>ts of rotating the fetal head into
a direct occiput anterior position, then flexing and
pushin~ the vertex back into the bit;th cailal, while
holdingc ontinous upward pressure ~1'\tll cesarean
delivery is accotnplis.hed. Tocolysis may be a
helpful adjunct to this , procedure. _S erious
materr:1al H:;;.uma can be incurred in this
procedure.
Figure 48.27. Zav~elli maneuver. Cephalic replacement in zavanelli maneuveds done by reversing the
cardinal movements of labor. It consists to rot ating the he_a d to direct occiput anterior position followed by
flexion before i~ is pusqed back ip.to the :birth .c anal.
Scanned 8y:
. N_O_R_MA
~.-
. L--:-It-IE:-:-
S-0-:::F-:::T-H-=E-F-=ET-U-S--~---
7.4$
Abdominal Surgery with H:ysterotomy
A hystero.tomy .incision is perfo~ed. after
induction of gener~ anesthesia,, after which the
surgeon _rotates the infant transabdominally
thr01..lgh the incision, allowing the shoulders to
r otate, nmch like a Woods corkscrew maneuver.
The posterior arm is delivere.d through the
incision, the operator then rQtates the shoulders
.to the oblique position to effect "the delivery.
Va,ginal extraction. is the.n accomplished by
another physician.~
Symphysiqi:cmy
Syniphysiotorrty27 is a useful treatment option
in severe shoulder dyst.ocia. 21. It involves.
intentional djvision of the fibrous .cartilase of the
symphysis ptJbis under local anest:he:;ia. this
results m s:eparati_qn of ~e pub~e bones with
subseq~ent ~crease in the pelvic Ca.pacity, and
release of the hnpacted shoulder. It has been.used
more Widely.in developing countries put ' sh~?-tild
.be used onlywhel)..all other -euvers.bave..f aiied
.. . . " .- . 1.. ' . '0:1 -~ ..... .. ~ '~ -
.and capability ,of cesa rean delivezy:"~''~"'i's'
:u.navailable.26
Th~ -~ecliniq:u:e -i$ also quiek:i:irtd':~Y.<!t1 .
life$aving "for thefetus. 'The. woman is .-placed 'll'l
:. ~:~ : ,..' .'-~-~~~~-: . :. ~
. .
~
 I
I
I
750 . S!:':CT10N VII: DYSTOCIA I
I
the lithotomy pOsition with assistants to -C()ntrol hazard with thi~ technique i s damage to the lawer' I
thedegree o.f hip adduction and restrict .the u ri..Ttary tract and anterior vag4J.al wilL
-separation of the pubic iXmes. Lor.A'113.neSthetic
is .jrifiitr~ted _intC> ~~ -s~~hys_is I}~bis as~, a Shoulder dystocia .is a~mmon source.- of litigqtion
u.nn.ary catheter 1s mSerted so th.jic the uretbra becduse pcirents and 'their advisers findit diJfic:Wt
can be. displaced laterallY. and the' fibfocartilage to accept that. the probiem could not :w.::e been
of -thej oint divided with a scalpeL 'Th.e potential predicted and circu.mvented. ..

PoiN'fS TO REMEMBER . .

"Fetal dystocia" or -difficult labor du e to abnbrmalit:es pertaining to the fetus usually o'ccurs ir: the
secono stag:eof Jabor. -
.. Causesof""f~~! dyslocia_;;!r~ malpre~ntption, malposition, macrosomia, abriormalfet<;~Lshape 2nd
shoulder 1mp~n.

MalpresentatiQns -.ir.cluae 'br~h.. sh6ul4~. :fciee, brow anp Ompound presentation,

. . .. _, . . ... .. . . ..... . . '
. .MalpoSitiO{l lndU:Qe pet:S1stent .~PI:it, pogerior -(POP), persistent -occiput .transverse ;and asynclitic
,... head.. rtt~ipas~n:qin
. . .-aus'e~-~itiful.~bo[
. . .
.

.
~

.
. - . . ,. -. ~acroso{nlti;-dennd1:tls-~feti:it-vkfuhtiffi?;e,~n~4.SOOg -ls anotheN::ause <?f-fe~i dysioeia:'Risk"f~~tors" .
for '!'nactsbmia:ihcliid!'P.C)sttenn.'g~tion;~gestational :diabetes -mellitus niaterr!al obesity' ana
n:n11tikafjt}t::_ - -...
... :Fetat--an~;>r-l:tatie~ ~nd -t~ri'\~ ~sm,g .~ljeraijon_ in t~tat-shape .~n c;ause. dystoPa.:Examj:Jl~-:,are -.
,;.. ;t:OnjoineoJWif:\?:-~r:r,e lo61Wlg :~iac-tffln,<llydr6ceph3lusj;$3Cfccocygearteratomaandobstr..:iL~ , . -.
:.~i-ioary.):;~~r....t;L,~ ;,:..--.~-~-,;:...:::: ... ._. :.. ... ' ...~: . . . ,
.. . . .
-~~-~,~~L~"..k>i!iJ:.Qb~~~j~{eroer~~"due.f:o .entrapment.of.tflecfetus-causedbyimpaction;o~
~Jm~r !h~. <!nterior:or.p()S!eri~r ,$f\O.Uld~r. -lt G:all occur:even ~n :cases without-identifiable riskfactors.

Redyctioh.tn!'meuv.e rs f()r the impacted .~ho~lder is a ~mu~t kn.ow s\911" _fer all !1ea!th personnels
atteridin_g ..~.dJ~!.ivery. When t~ wtlb ~-:situation, .don't pail~ and be prepared to adopt a :systematic
apprqach.su~ .as the
HE:t.;PERR;and ALAR~ER action plan. ..

The :J;IE!:.P5RR Ntn~m6n!cA'cti~-; BJan~:for shoulder dy$tocia means:

H- C.pll for H.~lp ..
E- EV:at~te fGr Epis~ton}y . .
L -:.LetJs ~ft'xed 'ana, ~bd-~ cted :{McRo~rt's .maneuver}
p ::~supt'cipub.ie P.r~.(Jt:e .. . .
::7 -E:nt~r: maneuvers fYJooo~s -scr~w and Rubin maneuver) .
. R- Remove 1he .postefip/,~1mi
R- Roll -tf:le pG!tient .

Th e ,AlARM~~ Mnemonic Action Plan -for shoulder dy$tocia means:

A- A'sk f9r hJp
L:- Liftlhypetflex legs
A- . Antenor ~houtder :dlsi~ction
.R- Rotation of the posterior shoulder
M- Manual removal -oLthe po:sterior arm
E- Episiotomy
R- Roll over onto ~all fours~

Saanned 8y: ~
 CHAPTER MJ: DYSTOCIA DUE TO ABNORMAUTIES OF THE FEtUS
REFERENCES
1. Cheng YW, Shaffer B. Associated. factors and outcomes
of persistent occiput posterior population. A
.tt.t;r.,c?~~tive. c.ohprt study from 1976 to 2001. J Mat
Fet Neonat ~ed:2006; !9 (9): 563-568.
2. Zahalka N, Sadan 0, et al. Comparisonoftransva:ginal
sonography with digjt.al eXIUn'ination and
traniabdomina! sonograpby tor the deter.mination of
fetal head position in the second stage of labQr. A:in J
Obst.et Gyr.~col 2005; 193: 381-386.
.3. Fitzpatri~ M, McQuillan K. In:iluence of persistent
.ct:ciput ~terior on -delivery ou teo me. Obst.et Gynecol
- '2001; 98: 1027-1031.
4, Yancey .MK, Zhang J, Schweitzer .p L, Schwan: J,
Kleb!Uloff MA. Epidural anesthesia &Ad fetal head
malpoSition at vaginal .delivery. Obst.et.Qynee012001 ;
97.: 608---612,
5. PonkeySi!;, Cohen AP. Persistent fe.t al occiput posterior
pqsition: Obstetric outcomes. Obstet Gynecol 2003;
101: 915-920. . Gyneco12004; 190 {6): 16()4..1607.
6'::~~ J, Xiong X. Effec~ of fetal-position on second
duration and labor outcoine. Obstet .G ynecol
s t.ege
2005; 1.05: 763 772.
1 ~ :l>e&.rtML. v~ delivery .fMm the penUstent oceiput
.. :~,_~;pQMerl9r Position. InD.uerice :o n JIUit.emai arid neonatal
..morbidity. J ~eprod Med 1993; 38 (t2): 95S-96J.
a. ~ Y}.J. MacKinp:on CJ, ~t al. For Clliu~ Practice
()~~~!rt~~~~.!_I!j~!..Q~Q~JID.c:~ l?rQ~JY,cy~ yagitl,al
birth.: J ()bstet G~Cl:Ol Qan200J\:; 26: 7 477 7 61 ..
9. Shaffer BL. Cheng YW. et al, M~ual rotation of the
fetal occiput: Predictors of fiU<X;es~ ar-t! delivery. Am J
Obstet Gynecol2006; 194: 7-9.
10. Camille LR. Pauline S. ~amial rotation in occiput
posterior or -tnu.l~v~rse r>o~itions; Ri$k factors and
consequences on the ce$MeB.ll delivery rate. Obstet
Gyn~l Sutv 2008; 63(2)::83-84.
11. Hofmeyr OJ, KU:lier R. Hands and knees posture in
or
. late pregrtancy labour for fetal~alpositior.. Cochrane
Dl!.tabase Syst Rev 2005; (2): CJ)001063.
12. Karlininia A, :eha.mbe.r lain ME. Randomiscd controlled
triaior effect of hands and knees J)0sturing on incidence
of occiput posterior position at birth. BMJ 2004; 328:
490.
13. Gherman RB, Shoulder dystocia: An evidence-based
evaluation of obstetrical nightmare. Clin Obstet Gynecol
2002; 45: 345~361.
Scanned 8y: ~
751
14. Ginsberg NA, Moisidis C. How to predict ~ent
shoul<ter dystocia. Am J Obstet Gynecol2001; 184:
14~7-1430.
15. Babar AM. Risk factors and fetal out1:9::1e in cases of
shoulder dystocia cum pared with normal deli.ePes in
a similar birthweight. Br J Obstet Gynecol1996; 103:
868~872.
16. Gonen R Effects of a policy ofelective cesareau delivery
in cases ofsuspected fetal macro so~ on the incidence
of brachial plexus injury and the Tate of Satetm
delivery. Aln J Obstet Gynecol 2000; 183: 1296-1300
17 . .ACOG. MacroSQmia.Practice Bulletin No. 22, Nim:Qiber
. 2000, Fetal Macrosomia.
18. ACOG. Shoulder dystocia. Pr.actice Bulletin No. 40.
.November 2002,
19. Baskett TF, Allen AC. Perinatal.i mplications of81-.oulder
d~toda. ObStet Gynecoll99Si 86; 14-17.
20. "1thta SH, Bi.ijold E. !s ~normal J.abor.a.ssodati:d with ',,
s hoUlder dystocia in nullipa..-o\ls wom.er.'? Am.J;:O bstet
. ~--:\,: !'~: . . ~~t-:.!:;\;?t::~- .
21. GQ'bbo .R, Baxiey .~G. Shoulde'-" d~~~rln~~R.=.:
AMancecJ We Support in Obstetrics proVider c:OU'iite
eylla~s. .AID.etican Academy o f Family 'PhY$iclaris.
2000.
-: ....., .....~. . .
22. Gurewitsc-h ED, D.onithan r..(: EpisiOtotiij ~;{~{tj:f
~pulations in managing severe shoulder ~ystOcia:-
a coJllpari~n ofoutcome. Am J Obstet Gyne<:912004;
'191 {3): 911~916.
23. Sturdee D, Otah . K. Yearboo-k of Obstetria and
Gynecology, Volume 9. 20.0 1. Royal College of
Obstetrics and GynC!:ology, London.
24. Woods CE and Westbury NYA. A principle ofphysic:s
as applie11-ble to shoulder delivery. Am J Obstet Gynecol
1943; 4.5: 796-804.
..25. Bruner JP, Drummond SB. Meenan ALand Gaskin IM
.All-fours maneuver for r educing shoulder dystocia
dwing labor. J Reprod Med 1998; 43: 439-443.
26. O'.Shaugrtes.s y MJ. Hysterotomy facilitation of the
vaginal delivery of the posterior arm in a case of severe
shoulder dystocia. Obstct Gynecoll-998; 92:o93-695.
27. Hartfield VJ. Symphysiotomy for shoulder dystocia. Am
J Obstet Gynecoll986; 15$: 228.
28. Oberman RB, o uzounian JG. Symphyseal ~paratiort
and transient femoral neuropathy associat~;th the
McRoberts m!Uleuver. Arp. J Obstet Gynecol i~8; 178:
609-'610. 1''
 "'

J
'

.- ..

.. . . ..... ---

'

J.

.......,_

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 49
DYSTOCIA DUE TO
ABNORMALITIES OF THE BONY
AND SOF1' PARTS PASSAGES
DITAS CRISTINA D. DECENA, MD

Overview

The Passage '--

Bony Pelvis

Soft Tissues

Maternal- Fetal Effects of Dystocia

Changing Concepts

FetaJ,.pelvic Index

Role of Imaging Techniques

Scanned 8y: ~
 ~~----------------~--~~~~~~~~--------------------------- -
SECTION VII: DYSTOCIA
.. ~

OVER VIEW deliv.e ry. The gynecoid shape, being the female: .
pelvis has an oval shaped inlet, c:liverging midpelv.ic.
Dystocia distingui~hed by abnormal . sidewalls and distant ischial. spines. The android :
progression of labor seems to be .the major pelv.is .i s the male . pattem with a heart-shaped:.-.
:. il;lplcaticn for most cesarea...J. s~ction~. The.-e are inlet, convergent sidewalls and prominent kcnii
-s~eral factors (powers, passenger and passage} promonu:>r:,' and ischial spines. The anthrqp<>_id
.fuat centribute to abnormalities .in fabor. Overt variety has an oval shaped inlet with the iargest
'r~c contracture as seen in patients with rickets diameter i n the anteroposte!"i or while the
:( Q.lili ~d Nielson, 1994) is more hlstorital and pla~lloicl is .a. broad and wide pel"hs.
. th~ te~ cephalopelvic di~proportion .t .o mean
.. ~tioiteq'!d J>etv:i,c 4i~etet.s i~: q"P.e~tionable. The To a,ssess the size ahd shape of the pelVis,
'p.assa,ges Will be. discussed thoroughly but the tli~ical pelv~etry is t~e. method. currently.
:iUteJ]>iay between the fetusand the pdvi~ i~ a ve;y
utilized. A useful protocol for dinkalpelVU:Uetry
-~~nant.factor that results in failure to progress is detailed in Figure 49.2. 2 S ~ch clin1cal
i4,'laoor. measurements will calculate the pelvic ip.I et,
niidcavity, and outlet whiCh are the various
plan'!s that the fetus must pa:ss thro~gh for a.
~ l'A~SAGE vaginal delivery. The diagonal conjugate as
measured from the sacral proinontory to. .the .
'fhe passage includes 'the bony pelv:is, (nan1~1ly, inferior margin of the symphysis p\l,bi.s on internal.
th.e pubis, ilium. ischium and tP,e sacru.:n} examination would signify the anteroposteriqr.
in;duding .the resistance provided by the. soft diameter of the .pelvic inlet. The interspinous
. tissUes (cervix, >~terus: V.agiila<!and pelvie floor:or diameter of.. the :.midpe~vis is' the..:measUiem~nt.... .. ...
: eyeD. ;presence ofpelvic tumors or ,low ly.ing between the isclrial.spinesand the outlet woUld.
'PllicentaJ. Tht shape of the femc,Ue b9ny.pelvis ~an be represented by in the intertuberous dianiet er:
. .~pl~!)sifitd .into .one . cr illore qf fpur broad which is the distance between th~ ischi<i..l:.
~tcgoties: gyneco~d. anthropoiq, :anfuoid and .t uber-osities. Any shor.tening of .the ~bbve
. . 'p~ll8i(t(Figure 49.-l),bycaldwell and .Maloy. 1 measured :diameters. co:ril,pared..to a critical :lin.:iit:.,
.. ... . ~oi:lg the varieti'es of. pelVises, _J he gynecoid ,and .. may signlfy contraction that may contribute. to
. :~i:PJ~poid are the most favorable for a vaginal .a n abnormal pattem of labor.. .
..

(~iqy ~
Gy.n ecoid Anthropoid Android P l atYp.e!loid
Pelvic'lnlet
\r(lde~t 12 em. < 12.cm Hem 12 err.
t ransverse

~
diameter c,f
- . ; .
,. in1et.
Antercpos!erior
-
11 em > 12 em 11 em 10cm
diameter or
~ -- Inlet
Forepelvis \o/od.e Divergent Narrow Slraighl
Pelvic rriidca v ity

[ij---
~rjt::
Side walls
Sacrosciatic
notch
lnclin at ic n of
Straight
Medium .

Medium
Narrow
Oackward

Wide
Conv!!rgcnt
Narr ow

F orv1ard (lower -
\'Ville
Forward

Narrow
'&\ sacrum
lschiill splnes Not' prominenl
third)
Not prominent Not prominent Not promioeot
p.,lvic outl et .-.

~)(~
Subpubic arch Wide Medium tlarrow 11\r,:ic

t0~ Transverse
diameter of
outlet
10 c m 10 CIT\ <10cm 10cm

'
. .
Figure 49.1. Characteristics of the four types of female bony pelVis. (Modified from Callahan TL, Cau ghery.AB, Heffner W
.(eds ): Blueprints in Obstetrics and Gynec<)logy. M<:>lden, MA, Blackwell Science, 1998 , p 45.

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 CHAPTER 49: DYSTOCIA OUE TO ABNORMAllllES ot= THE BONY AND sot=T PARTS PASSAGEs 7'55-

<!) Elllinua.tlb n ot pr~Cncne. of @ ""etost~.n"'~t of t r a h"'-"0,..0

....... ,
c:r,.1 ,,.rornont~)' c:na.f'1"\oet8f' of pefvic 'I Not

.
. '

<!!.> 1\.t:u:O'ISU"'er.'
.(D -e.u..n..,uon ol orornkMJt\C: Cl'f
-~pine;; . ,. dU'"olor
o t' tnt~rptnou,3

. ~ ,(li-~--- ~-
.- ........ -~.
--~ -;""' ----)
.. -
..
: . '
\

. ~- , ~ '~ 'I ,
8 ,:- r- ),[ 'f' ,.. / .
s ~~ -?- "
~-
;e . ., . . . 7JT::..
,. . ".,....?
.
' . . \
) '
.
,.
.
.

.. '-,
' (j) Ectk'notlon of ,.,f'CV"''':t'4n~~ of E;r.tmatohn ot lnus.rt ub6r0-:rs,
. J ; ~ . cooey>< . . diarnet,r

'-t: ~-.~
. : "f
, . - ~~~

'"'''' ~
. ~--r'~-. .:-:::
. '-'~ ;{4~::. : .

FlPre 4~. A protocol.!or clit:iical pelviinetry. ' ,' ..

. ..-
.-

Bony Pelvis through this plane and .the head engaged. is

Oftentimes, engagement occurs during labor, in
Pelvic Inlet Contraction nulliparas it ma y occur during the last weeks of
ptegnancy. When it does so, . it is conilnnatory
.T he pelvic inlet .is regarded as contracted if its evidence that the pelvic inlet .is adequate tor the
shortest arit~r:4;)pqst~;rior d.iameter is less. th;mlO fetal head. With .vagina) examination, the station.
em or if the .greatest tiansverse diaineter .is less of the lowermost part of the fetal head in relation
than 12 em.. The a nter.oi>osterior diameter .o f the to the ischial spines is determined. Figure 49.33 .
pelvic inlet is approximated by measuring the will s how the relationship o'fthe.lowest part.o.fthe
diagonal. conjugate which is greater by 1.5 em. occiput to the plar~e of the m aternal ischial spine.
Therefo~. inlet contraction is usually defined as Abdominal exanlination is a less satisfactocy way
a diagonal conjugate of less than 1 LS em, to show_ engagement. If the head is not engaged,
Transverse diameter of the inlet can be measured the examining fmgers can easily palpate the lower
only QY im:~glng .pelvimetry and so p.e lvic part of the head and will converge.
contraction 'may be p o ssible even if . the
anteroposterior diameter is adequate. . . Inlet. . contr?.-ctioi:l produce.s ab~mal
presentations. Wtth the head floating f'r~ ovl!r
To . show the adequacy :<>! .the inlet, the fetal the. inlet' or resting .laterally in orie of the iliac
head particularly its biparietal dia meter {largest fossae, very slight irifluences may .ta:u~e th~. :fetus
diameter of the normally flexed head) h as passed to assume other presentations such as face a nd

Scanned By: ~
 756 .SECtJON vn: DYSTOCIA

shoulder. However, cephalic presentations still Midpelvic Contraction

predominate.
the midpelvis is assessed at the level of the
ischial .spi~es also known as the inter spinous
diameter ~.nd generally is the smallest pelvic
diameter. Average midpelvis measUrements are as
'follows: interspinous,-- 10.5 em; antert>j>osterior,
(io.m the lower border of the symphysis pubis to
thejunctioqofS4-S5, 11.5 CIDi posterior saggital,
midpoint of the interspinous line to the same point
in fhe sacnun is 5 em. It se(;!ms more difficult to
as<;ertain midp.e l\iic contraction . Even so,
.c ontraction is present if the total of thdnterischial
spinous (10.5 em) and posterior 'sagittal {5 em) is
undet 13.5 em and below. If the inter-ischial
spinous diameter- is le'ss than 10 CQl midpelvic
contraction is inferred to be present. When it
measures 8 em , the mi~pelvis is contracted.

It is difficult tc assess the midpelvic

OLO CV.SSIFJ9.TtON NEW~IFtCATION
(s.,bject;..,., te'S1im31cd~in
dimensions preCisely, however, clues as to
"""'"_'"""_ .
4it>lal.~)
contraction exist by the presen~ -of prominent
ischial spines, convergent pelviC'-~sidewalls.and:
Figure 49.3. The relationship of _the -leading edge _Q f the. Jl3.0'ow .s acrosciatic notch. Midlvic. con:tiaction
preseutiJ:Ig partohbe ietus to . ~le plaileof,the,mat~al
ischial spines deteilPines'-tl)e $tati,cn. f3te.tion "+!f-(3 (old is .associated freq uen:tly witii deep tra.:risverse
cla:ssificatior..) or +2./+5 (new ~assification}is ill~strated.~ arrest of the fetal head. : ~.odn indUction is
contraindicated -and cesarean sectio:Q: is the
. .. : - . . method:of C.hoiee in niidpelvic '.COiltraction~

.1'able:49.1 illusttat~s the ave~e s.nd critical
. :-:.. ..vaJ.u e of..the pelVic miet-measur:ements .w hich m ay
.s igilifycepha1opelvic disproportion.~
' '
.4
Table 49.2 swn,marizes the average and critical
pelvic measurettlents by x~ray pelv.rn,etcy pf-the
nud {>elvis.3

Tii.ble 49.1 . Avernge 3ild trlti~ limit values Jor pelvic . Table 49.2. Average and critical limit value!l for pelvic
. m~enu by x~ray !>etviJPetry: JP'Ca.Surements by x-ray pelviri:letzy.

Dirune~er Average Vll19e . CiitkaJ Umit Diam~ter .Averagevaiti.e Critical limit

Pelvic Inlet 'Pelic Midcavity

AnteropOsterior (em) 12.5 10:0 Anteroposterior (ctn) 11.5 }Q,Q

T~sven;e (em) 13.0 12"Q Transverse (em) 10,5 " 9.5 .

Sum(cm) 25;5 22 Sum(cm) 22,0 19.5

Area .(cm2) 145.0 . 123.0 Area (cni~) 125.0 106.0

The "Q iticallimitv&lues cited imply a b igl;ll.ikelihood of
cephalopelvic disproportiOn. {Mapted -from-O'Brien WF.,.
cdc\Jo RC:. Labor and delivery. In Gabbe SC, et .al. {eds):
Obstetrics: Nonnal.a nd Problem Pregntmcies, 3rd ed. New
. Yo~lc C~urchill Livingstone, 1996, p 377)
The criticall.i.mjt value!,l cited imply'a :higldik'eJihood of .
cephalopelvic disproportion~ (Adapted from O'I;Jrien WF,
Cefalo RC: Labor artd delivery. In Gabbe SC, et at. (eds): .
Obstetrics: Normal and Proble_rtt'Pregnan<;ies, 3rd ed. New
York: Churchill Uvingstone-, 1996, p_377.

Scanned 8y: r-..

~
 CHAPTER 49: OYSTOCfA DUE TO ABNORMALITIES OF WE BONY AND SOFT PARTS PASSAGES .
Outlet Omtraction
The pelvic outlet is rarely ofclinical importance
and usually occurs .concomitant with midpelvic
contraction. The it:lterischial tuberous diameter of
8 ~~ or less defmes outlet contraction. The pelvic
outlet. seems to.form 2 .triangle:;; .~~ the ischial
tuberous diameter making up the base of both.i
'fhe...apex of the antericr triangle is the infenor
posterior surface o f the symphysis pubis and the .
sid~walls ~;tte the pelvic rami. The posterior triangle
is .l imited by the tip of the coccyx with no bony
sides. .
Production of perineal tears is more common
with narrowing of the subpubic arch wi~ f;he head
bej__11g formed .increasingly farther down into the
peri..ncum and so predispp:?ed to lacerations;
Anatoiljjc abnorxnalities: of the reproduCtive
~t.Jil~Yc~lise abnonnalor prolonged labor.It
may '~ dtl'~ to ab~nnall.ties in.fbe u .t erus, cerviX.
and thevagina; .:~e .pr-esence of pelvic mas$es;
-~gpL~e birth canal and .low implantation
of the. p1acenta. ..
.Abnotulal fl,1$ion of the Mullerian duct!) or
~!!!'.~Rfabsorp~.Q_Itt~~_p!!rm1@51Jo :!Lvmietx
.Qf.oongemtal.roalf_ru:ma.tio.ns ,oL:tbe. uterus...SUCh
:t;nalfonnaticns may predispose to malpresentation
or abnorinal fetal lie, . cervix down to the vagina to give rise to a complete
During pregnancy, uterine abnormality should..
be Sl.l$pected if there .isbroadening of the utetL"le
fundus , abnoru).al lie or presentation, history of
repeated abortions, as well 'a s .f indings of abnotffial .
location of the cervix in the vaginhl vault. The
d.iagnosis is confJ..trned by 4ysterogx:aphy during
tl).e non-pregnant state.
Patients ..should be given a trial oflabor if there
is no abnormal.lie or, presentation. Failure of labor
to progress .would ind'icat~ the need for an
a.bdomin~ de.l ivery.
Prolap~e of the uterus is rare du-ring
pregnancy. Ustially, by the endofthe.iourthmonth
of gestation, the uterus .ris~~ out 9f ~e pelvis.
Occasionally, the uterus fails to do so. In most
cases; it is only .the cervix that protrude~ through
Scanned 8y:
757
the vagina. Most patients with uterine prl>tapse
have vaginal delivery, but arrest of progress may
ensue. In such cases, ce~rean section should be
carried out.
Uterine torsion is the rotation of the uterus
on its long axis by more than 45 degr.ees. It is
very rare during pregnancy . The clinical
manifestations are that of pain, shock and
obstructed labor. Uterine ruptur.e is the .most
serious complication of uterine tornion . Treatment
at or near tenn is by cesarean section.
C.ervicai.Abnotmali ties
Following exte;nsive cauterit.a.tion of the .cervix,
it may become so stenosed that dilatation and
dfa~emen:t ttt<;tY not take plac'! d.u ring labor.
However, in sotn? cases, cervical s~~o.~is maY
gradually yield during labor beca.u.:~e oi the
softening ohissues during;pregnailcy. In cases :of
unyielding cervical stenosis., ceSar-ean APQn is
cairied out. . '' .
~ :. ~~. - f ~ . . .
. . .. ~ . ... ....:..:- i~j h. .
In agghitination of the ~enial cervicalto's ;
. there i$ the presence of a. small eitetnal.os that
fa,ils to dilate after a full . effacement:.:usualiy; ..~
simple 'digital i:rrecha,nical dilatation is:.:e~ t.t:>- .
dilate the abnormal cervical os.
Vaginal Abrwrma.lities
ln ...r.ar.e...instances, a septum can be ..present.
that divides the vagina. It may extend .f rom the
longitudinal septum, or if found e ither in the upper
or lower portion o f the vaginal canal, nn moompiete
septum. On the other hand.. there are .in:$tances
wher'einthe upper vagina is divided from t;he iower .
part .by the presenc~ {)f ~ transverse septum.
Usually, .th.e diagnosis of the presence of .a .
vaginal s~ptum is made when there is failure of
descent of the . pre~enting part. Excision of the
septum m~y be requiredto permit vaginal .delivei-y.
Pelvic Masses
The presence of pelvic masses may con1.plicate
the C.OUrs.e of labor. A. Gartner duct cY~SJ .may
protrude into the v:agjna and through the 4}.1foitus.
It may slip.aJ:>ove the presen.tingpart.dJ.?.nn'!'labor,
and if it does not, the cy:?t may be. ase.pti~ally
aspirated.
~
 758 SECllON :Vll: DYSTOCiA

The normal des<;:ent .o f the fetus ~through the . common peroneal nerve} is associated with labor
birth c?.nal can be blOCked by the presence of a ~d delivery. 6

cystocele ot a rectt>cele. Proper evacu-ation or

emptying is neceSsary to push them out of the . . "Fei:al Effects
way to cllow no:m-'21 d~scen t of t..he presenting part..
In labor lasting for more than 20 houz-s
Uterine Jilyomas may be found during deleterious effects on-the fetu~. have b een shown.
p r:egnancy and it is believed that in tnos t caSi"....s, Ir....fection nuiy occur .as a consequence of early
there is .&nincrease in" .s ize due' to incr~sed rupture of the membranes.
estrogen sfunu:lation~ Studie.Shaveshcwr.. t)lat the
s~, lOcation and nl)iri."\:)er of the uterine l:r'Jomas A large cap.u t ..s u <;cedarieum fr~q:uently
.determine the effects of the m.yom.a during deyelops .in. th~ dependent :portion of the fetal
pregnancy, labor, and delivery. It has ~,n P:oted~~ he:;tci.. 'Ibis gives .a fal:;e impression of the .d escent .
that in.~e -~ ~iie arid number .of my.oma~ is orth.~ .fetal head anti 1~ to prell'latl,l.r~ a.r..d-.unwise
ass-Ociat~ with higher frequency of ret;aiped attempts at . forceps. dclivecy. Typiqilly. t}).e large
pl~c.e:nta~ .!e.t al malpres.entati"ons an.G. p teterm caput di~ppears within .a few days .a:ft~r :birth.-.
labor. ~w..~t. uterine s~g!Jl:ent myo.xna!> .may As'S()ciat~9- with .~pu.~ formation is molding or. a;.n
abst;ruct. h.~r ~ :as~6iatei:l higher :mcid~nce overlappin'& of tlie oo.nes of the s 4=ull u:o..der
Gf -~,settion.. pressure or the p;t-et.ine c:ontracii.ou.s_ Severe
molding .may cause tentorial te.a.r:s leading -to fataL
. '
O:va.rian. .I).eoplasms may be diagn.os0. befo:~ in~crani.al and Sllbd"Q.t"al .h emm:rhage: How:ever,
. ~eliveryJii \fue..oourse of.t..lie:i:>rima.t~.lJcate 'Ox:<When~ . sucb:"hemoriha:ge.s tnay .oc;ur- spofi:~eousJY in
.. .. th.ere i.i.6ustr.ucted:la~F,',tesa.rean)~\ioni$'ao'P.e non:n:al:vaginal:~~liv.eiie~:witb:out>e'iri.d~nce.:ofibir.tht.1 .
arid removalo f:toe neop1a_ 5.U': ~yi l)e;r:~:uin:d: .. tramna.:< i\::Pimirifiti.p:p.<9f.{).;!S~'(ll'-'So\in~bip~tal"
. . ., . . . . . ~~In3.y.cau$e-i't(i.crebial:mjuiy but.grctiter
Lif~-~ ~ ..:. ' .: degrees-.:of molding :.fu.CI:ease; :t:li'C! .Jiketiho.od of
...... .,;.....q:u.: _.. ~JUJ,Y'.s
. +-=.-........-ial. - -
m .
A tn~.tit~'at:er-:lqw~l:Yiilg'placenta:may.~:prev~nt'. .
non:nal fe~- d~nt~:d1.i.riiig::fub0r;\:orworst;. may.,. Sl..1il iracture-is o~casio~y eru;ountered ::
even ghleti~ to abno-rmal bleepirig:Jhat~~ e~l?.~S~Y "witP.. ~f~:t~9le ~~:tmp~~ ~t q_~l~v.ecy:.
'seCtion t ed.
m.s . be -.~
..........,~-~-Y-- ........ :sliallow~ve .-'.ftaeture..;~hi.ll..'inv9lv.6t.2Pll.~e. __:..
,~emal .bO'g_~.:'fLTJ!.~.5~:A9X.Y..&&Jl~e..r:PJJ~ . .: ~~ .
. spon ~;ha_ped ?.~:piession which .ca.u:res a:Jsc a
.-f racture .ro~.Y Jead: to 'n e()riata1 ~~1:4-.as it "is- more
extensive Wi.th itmer sprfa:ce projections:that:cause
. . de.leteri6\l:S pre~sl:lre. oil the b.r.a:ui. 9 Subsequent
fu)ton~ .l!ibor is coiiUiion ~ p'atient~ Wi:th degree-oftrau~ :is relative . to the d egree. pi fetal
dy~toq.~ ;i\s :a.:_ ro.nseqJ1.ettcCc, eat~y -~emb:rime skull:]:><>ire -OSS:Ji~t:lon- ~th. w.fkr b:~ds v;;..hich
~P.b+i:e :c:urs with: predispos~tit>n. to ;~ecti~n readily molds;
:fur::lugh''l?S.cteiia:i;h~ta~nd,~ froqt!t.heva'gmaanc!
gains -~c~ess to t_h e a -m niotic fluid, amnion~ CHANGINGco.NC.E:Pl'S
and
horion,. !lecidu<).;.. chorionic v.essls.~ Not 9 Dly
4ocs "baeter ia d~velQp.:but abnoqnal. ~g of Feta1"1lelv.ic pide:?r
the loWer ut-erine .segment ca:J;ries .d an.ger:: Of
rupture: Excessive pressure ofthe presentihg_part The term c~ph;:4tlpelvi~ dispropprlion -h'as been
to the s idewaUs or prolo):lged second stage used to describe a dispa;rity between the size of
compromises circulation and necrosis may :r esult th~ m aternal pelv}s ..and the fetal head that
with the app,earance of ;v,esic.o vaginal, pr.eclu.;:l.es vaginal de livery.
vesicocervical or r~tovaginal fistulas. If de.livery
is diffi9114 ~e pelvic flooris :stretchedqy:Q.ir.e ct Ja,g~; et aP re<;om~ettd~d."abando:nihg~the
comp_res'siqnfiom the fetal h ead thatI"Iiay :leaO. to term cephalo~lvic di sproportion: in favor of
urinary and .anal.lri~n:tirtence .to .Pelvic org~ fetop.elviq di~proportion. Morgan; et al.9 explored:
prola.p~e. Reeently, neurological 'injury or footcirop a. novel standarcmed method to discov~r fetope~vic
(.injury of the lumbosacral root, plexus, .sciatic or Q.isproportion by .. comp aring feta l head and

Snanned fy: C
 CHAPTER 49: DYSTOCIA DUE TO ABNORMAUTJES OF THE BONY AND SOFT PARTS PASSAGES "' 759

abdominal cir.c umferences with the respective
maternal inlet a nd midpelvic circumferences. They
termed this as the
fetal-pelvic index.
To deten:nine the fetopel-vic index, the fetal
.head diameter is measured by sonography and
the tnatern'al pelvis- is measured by x-ray
pelvimetry or MRI atJ studied by Spotti.10 Based
on 4~ircumfer.ence differences between the fetus
and maternal pelvis {fetal head-maternal pelVic
inlet~ fetal head-maternal m:id'p-elvis. "fetal
abdomen-matern.a l pelvic inlet, and -r~tal
abdomen-maternal midpelvisj, a fetal-pelvic
number was derived.
lf.the index is positive, the fetal head diameters
are greater .than the maternal pelvic diameters
thus the likelibood. of cesarean delivel'y is high. u . _p revious c_e sarean sectio.n and with cephalic
Accotdin,g to F ergrrson, the o verall positive
_p redictive v.al~e of this inde~ was '90 i>ercent;i2
'{ .
whether patients could h~_ve measurements taken
after delivery to avoid rad.iati6n. The ~l.Jthor~ found
that there was m"inimal to no difference in
pelvimetry measurements (MRI) taken in the late
third trimester compared with 3 days and 3
months after delivery. Over tim~. that ti!Chnique
have gr;1dually evolved from radiograph or
computed tomograpl)y to Magnet~c .Resonance
Imag~ng (MRI). MRI allow~ _imaging in multiple
planes wi~out niovirig the patient. The limiting
factor to this scanrung tecr..nique .is its cost.
()ne of the arguments against the use of
pelvi.meh'.fhas ~eil that it is notacc1,1r.at~ en<:>ugh
to be able to predict outcomes With certamty. The
utility that x~ray pelvimetrY .decreases maternal,
fetal morbidity and mortalit)r in women without
pr;esentations is not supported by clinical
. triats, JS.I6 ,_ . .

J, The clirilcal usefulness of.the fetal-pelvic index
.jf has been-;dmonstrated. by randomized studies in
f
.~
e-valpatL>'lgpatients with previous ce:;arean section
1
.from ,c ephalopelvic .dispmpottiori .and possible
& vagi.na1:>bi1th aft~r ces_a-real} .~ection (VBAC)
~ -, . candidates .in subseq\l:en t pregnancies, .
"1 pregttanci~-a complicated by macrosomia ..and
'k abi;lc>"r.~al~flabor p.at.terns :requiring labor
l augillen.tatibri~ Fox, et ai.J3 believes that imaging
i. techm.qq.es to~ predictive of qelivery outcome, it
1 li'l,.U-.at..:e,cco.un..t. foLb:o.th .:fetal. ...and maternal
dimensions~
l{~l~ of bnaging Te:chniques
T:he potential for pelvimetry and related
techn.iql.'les to assist obstetricians has been an
areawi:tn mucl.1 controversy. The use of pelvimetry
hasdeclined from the 1960's due to L'le hazards
of the ionizing radiation. Enochia:n, et al. 14 in th0ir
stUdy "c hose to a ttempt to an~wer the question ef
The force of uterine contrac~Qr}iPI>taqijyity,
matemal weight, parity, age, vagir~;;:ll: an4JJ~lvic _
soft tissue resistanc:e. epiqural u~~~i;m?l~l?llity .
of the .fetal head, and degr/ee of malposttion and
asynclitism ar~ {actors that affect . prQbability of
fetal-pelvic disposition tt:at pr.eclu(;\5 the ability
of radiographic;pelvimetry. to :pt.edlctcau$es: of
dystocia leading to cesarean deliveny,e:.-:. :ii0:<>t.;.~ ..
Further res.e arch shorild be done towards
d6f~ing.-whether- L'1er~--ar~-instances--~f~breech .
presentations or fF0LA.e)Trial of La:bor after
Cesarean S:'!ction V~ginal Birth . after Cesarea~
Section (VBAC)m which x-ray pelvimetry or-other
predictors and indicators can be shown to be of
value. Newer methods :or pelvimetry like the
Modified Digital Radiographic Pelvimetry and MRI
which should be S\.lbjected to rando~d trials
to as:?ess their value. A prospective investigation
of the use of the .MRI to measure pelvic capacity
remains investigational. 17

POINTS TO REMEMBER

The complex interaction of 3 factors: powers, passenger and the passages will determine the
capabinty of the fetus to pass through the pelvis during labor and delivery.
. . .
To.assess the size and 'shape of the pelvis, clinical pelvimetry is the method. currently utilized. Such
clinical measurements will calculate the pelvic .inlet, midcavity and oullet through which the fetus
will pass through for a vaginal delivery.

Scanned 8y: ~
 .760 SECTION VII: D YSTOCIA :
..,

The pas~~ge 9oes ~of fnclud.e on_

ly :tlie bony' pelvis (pubis, niu~. ischium : and the sacnJmfbuf a(sc
_bythe resistance provideq by th'e sofUissues ( cervix, uterus, vagina, pelvic floor or:even .pelviC.
tumors or low. lying 'pl~icenta).
. .

Pr6long~d ia~r is C:Qmmori jn P?tient,s with dystocia which prod~es effects that'in.de~se fetal-
maternal morbidity and m ortality. (chorioamnionitis, fisttt!a, incontinen~e , intrac.ra;:Jfal and subdu ral
h~morrhages and skull.
frc3c:ture). . . . . . . . . . .. . . .

The'term cephalop41v~ j:irspr~~rtiqn has bee~ used to descrihe.a d!sparity betwee'n the' size.of thei
.I
maternal pelvls.and the. tetal h~a<j that_precluQes -.:ag)nal delivery. Jagani, et al_
. has reeommended I
toabandon this tmn .i(1 favo(of fetopelvic disprof'Prtion. . : . .. .
. .
Fetoi pelvic r~dex in~.~sures fetal' he~d d~~~ter by sonogr:aphy ,and m~t~Oi~l. .pelvis' by, ~;~y ;or
M~l. ':rhe :clipica.r:'usefulne5s of..thfs index' is for patients w1t11 previous cs for .ceph_~lopelvic .
dispropoi:tibn and po;;sibleVaginal birth .aftercesarean section (VBAC)-or pr~nancies complicated
by macrosorpi~. . . .

The utility of .x-~yp~lvi;.,etiy. to ~redict.qtftcomes '!.1th ~e(~i-nty .!s net supPorted ~Y clinical-trials.
..The.:useof MR1 to measure ~iv:.c 93paclty remai'ns investigatior.a.L . . . . . .. . . >
. .. ...
' =', ,,,,,a.,, .. - ' , :. .. , . : l
. .. . . ...
.:

.
:. .

..
. .

. . . .. .

12. F<:rgus;an JEll, et.-81. Canfetal,pelVic,disptbpPrtion be.

.. ~s. Villaouc;a;outi~~~.R. ~lk:_-[jy-;l~ia primiuy .f~ :
.. ~bnorm.B.litid qf'the -~hy auih.ortpai-!::P;isSagcs: Iri:
Sumpa1coWS, et a.L (~d.s):'je,ftboo~ <ir :Obst~tri<:S. -~tid
~d. Quezon City: AsSocfu~on..of Writers of Rhilippine
. 'ratb<x>!cs of'Oi)stetrics and Qynec~logy, 2002'; 503
510. . . .
lumbosacral
t). Wong.CA., d -al. Incidence of postpartu;n
spine and lower extremity ri erve injuries. Obstet
Gyhecii2003; 101: 279~ . ..
prcdic~td7'.~l.i.ri..'Qqstet:G)'ite~l200Q; 43:.247-264 . .
. .
13. Fox LK,. et al. :rhe. Illagnetit: rcsonanc~_ m:;_aging-based .
fetal..pelvic inaex: A p ilotstudy.'in .the community
hospital. Am J Obstet Gync col 2004; 190: 1679-
1688. .
14. Hucrti-En oc\"lian GS, et al. Magnetic re~o~ancc-based
s erial pelvimetry: Do maternal pelvic dimension s
change d_uring.pr~gl)~cy? Am J Obs,tet Gynecol2006;
. 194: 1689- 1695.. .

7 . whitl;>y EH, Grifliiths PD, et -al. Frequency and maternal 15. Pattinson RC, Farrell E. Pelvimetry foi fetal cephalic
history o[ subdural ;h~orrhage.s ip. qab~s .3IJ.d relation presentations at or -n ear term. Thc.Cochranc Database.
to obstetric fa ctors:.Lancet:2004; 363:' 846 .. . ofSyster_natic'Reviey.os, 2007; t1-. : . .
. ..
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~-- CHAPTER 4~: DYS.TOCIA DUE TO ABNORMALiiiES OF TI-iE BONY AND SOFf PARTS PASSAGES 761

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~ 16. Ainericah College of Obstetri.cians and Gynec.ologists. 17. American Colleg<: of Obstetricians and Gynecologists.
:. Dystocia and the a'.lgmentaqon of la bor. AC09 Dystocia and, augmentation of labor. ACOG Practice
... . . Teclullcal-BuUetin.2.18. Washington, DC: f\COG, 1996; Bulletin 49. Washington, DC: ACOG, 2004; 85: 3 15-
53:73 -80. . . . 324.

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 50

BREECH DELIVERY

ERNESTO S. UICHANCO, MD

Classification of Breech Presentation

Vaginal Delivery Versus Cesarean Section

Management of Labor and Deliverf

Spontaneous Breech Delivery

Assisted Breech Delivery

: ...

Delivery of the-Shoulder and Arms

Delivery of the Head
Mauiiceau-Smellie-Voit Maneuver
Pi~!"s Forceps Appiica~on

Complete Breech ExtraCtion

Cesarean Section -.

Difficulties In Vaginal Breech Delivery

Nuchal Arm
Cervical Entrapm ent of the Head
Malposition of the Head

External Cephalic Version

. Symphysiotomy

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766 .::

The mar..agement of breech presentation
. represents an excellent e~ampl~ of a group of
. d.irficult and uncertain therapeutic;.choi~s facing
the oHstetrician in current p;a~tice: For. many
de,cadCs, the vaginal delivery of a breech
pr~~Iifug fetus was regarded.as an obstetric art.
The skill of an obstetrician ~Uld be judgEd by the
el~e;e and efficiency in the conduct of such
de)i~eries. During the last 100 yee..rs,- the
.frian~ge.ment of breech presentation has been
-up.dergoing -~atic: cha.I+g~; and will probably
: continue: to i~m.aih so in the b.;ext half century.
. CLAS$tY.ICATION
' .. ~. - - -~ -
' ' . .
' . OF .BREECE
.. : . . P~ENTATION
'. .
..:.-.Breech presentation occurs in 3.5 to 4.0
peo~ent .of a:il singletons in labor- When multiple
' .:pr~~sJrre included, the incic!:en9e of breech
p~_tlition rises. to 4.4_ to 5 :2%. The earliei" in
.g~thion, the higher is its illcid'ence. 'f'he great
'til;k:jcirlty tho.:Ugh, convertin.g to cephalic
pr~ta~on~by.'fue-.34th.week..
?me: risk 9t.ROurrerit breech presentat,ion.is
.inre:,tlian ilifeefol~;.. .resU:~ting. in a ,~ o to-' 12%
'iJ:i~?en~ in term pregnancies after prior breech
:Q.e}JVery.
rn~;tire th...:.:ee majpr.types bfbreeth pr'esentation ;<~;-bdoaiinal d~}iv;eiT. ~~~:II_lG~e..popular ~th the. ..
. . :(f.i~:$0.1) .
a:.: 'Fiil.iik breech: Hips are fl.eX:~d ori t.heabd.omci1 w'i4e,spre;~4 .. }ha...t. some
- ~ ~,.filia-hees-aree:.ttended,
2:. ~O,m:plete breech: llips and kne~s are flexed
anA :fue butt,ocks and knees are at. the same
level.
.3~ 'I:n.c omplete breech: One or both hips are
~p.ded so that ohe or bOth feet and/ or knees
.: .ar~ 'below the levd of the b11ttocks. FQOtling
:brech is .include.d here.
The most conunon type is the frank bree~lf~
.~!":
altho].lgh the footling breech is seen relatively more
, freque*tly in mul~Raras and in association with
premature iabor:
Jn the majority of breech presentations, nG
etiologic factors are identified. The following are
faCtQrs reportediy associated with thi's
malpresentation: '"'"
1. :premaP,uiJy
. 2; .UteriO.e ano.tiialies
3.. Abn~r:rri.af'a.imiotic fluid vohime
4~ .lAulti.Pk ge;ta:tion.
5 .. ,Pl~cen'ta..pfe.iia
6. Contract~d pelvis
7. Pelvic tumor.s
8. Fetal abnormalities
.
VAGlliAL DELIVER.~ VS C~AR.EAN SECTION
.
Prior to the l9Sb's, ,most -br:~eth fctl.lses were
de!ive:red::by1the :V~.al.~~,~ te~Jv!ate~ai. S'Jiety ~- . .
the m~ conl?ern ~~~:US!! .at that time modem.
antiqiotic, bi'Ood.".:6a.nki'ng'.,a,..."'l4 Saf~. ~~sthesia were...
not r.e.adily a~.ai.1able~ ...B;y " ~he inid'-1950 1s, .
pro'ci~imed ,puri:>ps'~ '.of: mi'iu.PiiZin,g "perinatal.. ~-... .
mortality' ap:d. ~br~idity..''This. attituck becan:J.~?: So. :
practitioners
iridlsenmicateiy.. ?.d~a:C.atc_d_.#_~~WJ. *~t.!.Qri5-'for~.:
alt. .hr.~ech. p'r.esep.ta.tipns,.. r:ega:r.dless. o f .th_e ..
circumstances . A!; .a r:e:..s.u1t; rp. a ny yo~ng
obstetricians wer.enqttrairied to do.vagmal breech :
deliveries and .dJ.d .no t feel Gi)mpet~nt :tO manage,
them, espcc,ially in ernergen:cie.s. Althou~ .the
petjnatal rp.o:ctal;ty-..rc~.te .assoda.ted"with btce~h: : .
presentation has decreased sln.ce the ""idespread '

. . .

. ; .

Complete B ree~li. In com p 1ete B ree ell Fr.ank J? re ech

Fi~ue 50.1. Types of breech presentations.

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_., -----~~~~-:--=-::::--:-------
~- CHAPTER SO: BREECH Dt:UVERY
-. -4pplication of ~bdominal delivery, there are
,;_:. concomitant ~n~ms about the maternal risks
of cesarean section like infectious morbidities and
the danger or uterine rupture in subsequent
pregnancies.
One alternative to abdominal delivery is
se.lective trial of labor for breech fetuses. Recent
controlled studies have . &hown that fo.r the
appropriately selected patient with a breech
presentation, whose delivery is ~rformed . by a
skille~ operator , in . the absence of
contrllindication~~ vaginal delivery of at .lea~ the
frank breech is as safe as cesarean section.
ln the 1990's, meta-ana,.lysis and registry
$tudies, together with multi-center researches
beca'l'ite very popular. . Secause some of their
findings were. _r>U.blished or became available
internationally, they had $lgfibant impact on ~- Contraindications for Vi'l,ginat. delivery include
attitUde.s to.w ardq ,ru;td . management of. breech '. those .who.. -do.. not .zp.eet :the .criteria listed in .the .
pres~ntation. One of the more. popularly sited
publication,s is the Term BreechT~ {TBTj. It was
~ i.n.temaii"9ri.al,prospective trlallhat randomized
J;Jlore than 2000 pteg!lant 'woihen with breech
pre.s entatiqn at..term :t o e~thet planned vaginal
delivery ()i planned cesarean section. The study
~~g,~e higbet perinatal. morbidity and
::nortalit)r'Jn i;b.e vaginal delivery group and
recommended universal elective cesarean delivery
for l)rc;ech presentation at renn. Mos t obstetricians
~~;~~%1t1~~;~~71~~~~~~~:~r-i~~-
pr.acti~
.of vaginal be<:h delivery.
"l'be Euto,pe .an .Obstetricians, on the other
ha nd, \ere div,ided by dissenting opinion
regatdihg the interpretation of the Term Bre~ch
Trial.. Criticis~ revolved atoun(l the issue t."IJ;at
nepnatai .-outcome notne.ce.s $arily being related
c to the mode of delivery arid on the question of
external validity. .The t;rial!s conclusions may not
apply to centets with above-aver.age skills available
an~ inwpmen with below.- average -ris~. Those
unconvince4, . mairtly .. from B.rit~in, France,
Denmark, No rway and Israel .concluded that
vagina,! bree~h delivery .at term is still accep~ble .
as long ~s ce~ .rules ate followed and constant
vigilance is o.bserved and their .approach remaind
indi'lid:ua.JJzed based on sensible obstetric practice
and -sound science.
The authors of the T.e rm Breech Trial recently
recognized that "the benefits of a policy of planned
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767
~~-~-
cesaTe~ section ... appeared to be due to bo.th the
avoidance -pf labor and the avoidance of vaginal
bre~ch birth" .. Thus, in many studies that showed
a favorable effect of cesarean deliyery, including
the Term Breech Trial, the avoidance of labor m<J,Y
have. been the major contributor to a better
ou~come, as well as elimination ()f risk of fetal
death whil~ waiting for onset of labor after 38
weeks.
Although the controversy continues, it is
. unlikely that a study as large as the Term Breech
Trial can ever be undertaken again partly due to
medicolegalconcer:ns and to the resultantcba.nge
in attitudes and operative ~~s..
At the very least, management needs to be
inc!ividua:lized- adhering to strict selection criteria
and .s ecuring the patient's . consent.
table below, significant m~dical complicati9P~~(~f'.
moderate to severe hY:Pert~nsive disci>rd~~-~ !?-Vd
severe heart disease). history of difficqlti deij,~:~fY.
damaged or extremely high risk infant, fuld/o{'p~[~.:.
labor ruptu-re ofmembranes.
Gl,iidelines for Ya~al <ielivery of the b~~chj!)f~L .
~ , ~. I
: ... ' '
..
A. Sonographic (or xray) confrrm~tion.,of
1.- .~!":!Y'!!c l?.r:~e.ch
2 . . FkKed .attitucie
3 . No nuchal arms
4 . Estimated fetal weight of~ lQSO and~ 3750
grams
5. Estimated gestational age of 36.-42 weeks
6. Immature fet"\.l.S {< 24 weeks or < 599
grams) .
7. Intrauterine fetal death
B . Clinical evaluation for
l. Adequate pelvis
2 . . Progress of labor (Friedman curve)
3. Absence of fetal distress
C. Second twin
Personnel critical to the safe,.k\ginal
delivery in breech presentation includi.l) an
ob.stetrician skilled in the proced\u:e. an<;l
. techniques; 2) an assis tant tosupport the fetus
as the aftercoming head delivered and to
~
76a SECllON Vlll: OPERATN'E OBSTE'rRlCS

provide suprapubic pressure on the fetal head A. Spontaneous Breech Delivery

to Pl.airttain flexion when needed; 3) . a
pediatrician to resuscitate the neonate; :4} an in this typ~ of.br.e ech delivery, the only
anesthesiologist to pro~ide pain .relief .and function ofthe obstetr;ician is to .support the body
uterine relaxation when neciled; 5) .a ppropriate nfthe fetu's. It is descri~d fir.st to help thereader
nursing support; and 6) operating room understand the mecha:ni$ms of br:eech delivery.
. personnel ready for imm~dia:te eesarean Mechanisms of treechl~bor and delivery are more
secti0n. compiicated'thrut in:.cephalic prcGI!ntation and the
e.ssociated risks are higher:. ~--
MANAGEMENT OF LABOR A..~ DELIVERY
The postctior'buttoc~ of the infant is born frrst
. Durll:rg labor, it i~ ~sseatial that matemal. and by lateral flexion of the .body after wbich the
f~ vren:..tnmg is ~ozlitcred ~cause cf knoWn. . anterior buttock follows. (Figure 50.2)
increased maternal e.ri:d fC:tal risks. Cerv:i:cal
.dila:t,ation ap.d descent ~f th~ :pres~nting :part
should be progrt~?Sing in a no~al ~te using t~e
Friedman eurv.~. the US {)f -ozytOcin to a11gtr).ent
u teri::ile contta.ctions i'~ . tt:lii ~l:>iitr.ov~tsi:il..
Electronic.:fetaJ heart ~:te rnonit:i;>riilg is :itrteq);ret!!d:
with th~ same,crit.enoila;S in.. eepltaJ:icptesentatk>n
during- fetal!mofi!toiing, Membranes are not
su:rgicall.Y r.u:pt-u;red ~use of the. riSk Of =sbrd
prrilap$':2l'td\.'becal:ise-:iheyi?act, 'M'a gocd:dilafu1J~,,... "
wedge..:. .

. Adequate ~oxygentttion ~q. o.pt,ifutu:n 'bloo.d

perf~~ion :.at:~ .p.ef:ded. 'as .. ;in:. ~Y. ohsteirical
procedtir.e;, 'rbu~l:inor;e..~o: ~because.: With breech . .
px;eseptip.gt!etu~:D;.~~!;d.tecio_r.ate,.m(!re?:ra:_pi~ ...,. ~.t.SO:Z .- D:cliv~:.:of.~ct:antenox::Outt:OCbhy:latera!i.
than thefr. ~phal:ic ooun:teJ:parts. . . fl~n. . . . . ..

.A!~~~~~ .:~~i_i~ia -~Jiin~:n:ec~s:aq: }~~ As -l1ie~ !ih.Oul<re-r--::eilf2~ lli-e ~1V1c "iruet. Uie
ct>ntroP,ed !Jlaneu_v.~.i::~nvill nitriimize='bil:.th tl.<iUi:x;ia. sacrum-rP'iate:S 4,5-Q:.~eri~iij:-i.eUedE:lg-the
The sam ho1~s true when ~:terin:e "m~:P'91ation . bisacron:tial 'Ciamfe'r entering t h'! inl~t in th'e
heco.fnes 'n~ :ana: uteririe:r-e'iaxatioii can 1>e ob1iqu~ diameter. {Fi~e 50.3) T.he shoulder s
~chiev:<1 .b)r :~attio~ hothan:e. Spina:t.';~esia/ gener-aJly dese~nd ~trgb. tP.e IDldPelvis in the
aneSthesia :is rarely uSed duringva,gjna.l.d;eliV;ery ol;>lique diameter., . and -as i$:ey .reach.the perineal
because-i t infl;yinterfere'with the'Pftl~ss'oL4Jx>r. fl<XIt .rot~tion o~urs ;so that tl:i'e .biSac:to'rtlial
'EpidUral ane$thesia gi:.ren dv.iing the actiVe phase 4ianleie'r is ant~~opo:sterio't .~d erte:nally the
does not irit~rfete . m:m
its progr~$s :ind enables mf34fssacruti?- is transv.erse. {Figui-e $0.4)
the mother to push effectively duiing the sec:Ond
sta~e. . I . :, The a nterior shq'ulder impinogi!s Pil the
syniphys~ p.uili~ .and ,t:he postenc>r :,sh0ulder and
Ther.e are vari.o us metl}.ods of .delivery for arin.deliv~r firSt, ag;lln byJ.ateral.flexion 9f'the ~Y
breech \vhich includes the follqw:in g: followed-:~y the :antedor :slibuld~ and inn. .

1. Spontaneous delivery During fhe deliveey:, :the fundus of. the ut~tus
is dose1y'.a_pplied to the .head, ma4J.taining !ts
2. Assisted b reech delivery or partial breech flexion, TJ;re head :eng~ges 'With the Jetal biparietal
extraction diameter in the -oblique 'Qr. :tranSverse diameter of
theinle~, usually with 09Cipufanterior: The weight
3. Total or COIJ?.plete breech extraction of the infa.J;lt assists. further descent ~rough the
m'idpelvis. The flexed head, face and forehead fill
4. Cesarean section the ?aCral curve as
rotation OCCurS to the OCC~put

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 CHAPTER 50: BREECI:J DELIVERY 769

anterior position. Spontaneous delivery of the

head occurs by flexion with the nape,of the neck
as the -fulcrum under the symphysis pubis. The
face is born frrst, followed by the forehead and the
occiput.

Figure 50.5. Delivery of the head by flexion.

trunk up . to the level of the sho.u ld:ers the or

scapula. Delivery of the head then follows. (Flgure
50.5) .
':.'- -~ ..,. .. ::. :...,: ';.
'..

... As the .fetal buttocks distend th.e'' perinetilfi:.

Figure 50.3. Shoulders entering the inlet in the oblique
position. an episiotomy i$ usually done to pr>event und;Ue
d.elay and maternal perineal lacerations. As ~the
. - ~.: .. feta,l :b.ody delivers to. the umbiliCus~ the
!>bstetricia,n:suppor.ts, but does :notpl~<XLt:J:aetion
on, the J6tal .torso . .With addit.lonai :ute.iirte .
contra:ction s, ilie
fetal ann~ and $b.o\ilei.e~$~a;re .
delivered. ..... .

.Jt. -is-impoFtant to alloW"s~ffieienttlme for

spontaneousdelivery;remembering'"however;that
once the body i$ delivered to the $ capula, the
umbilical cord becomes compr.essed between -the
he~d and the bony pelvis.

In modern hospital -obstetrics, spontaneous

breech delivery rar~ly occurs, but should be fully .
und.e rstood by a-nyone performing a breech .
delivery. By following the mechani~ms .of normal
spontaneous breech deliv~ry, the operator can
m.iriimize maneuvers and les~n risks during an
assisted delivery or a total breech extraction.
Fi,gure soA. shotiiQers atilie.outlet ~- the a:nrero!>Qs terior .
diap1eter:
Assisted Breech Delivery

.Part-ial breech extraction involves. the

. In .the normal process ~f breeCh delivery, .birth spontaneous delivery of the fetus UP ..~t2 the
of the fetal bo.dy occurs quickly ()nee the bre.e ch umoilicus and the employment of ,O;~e.tric
has -emerged through the pel\ric.- outlet and the maneuvers ther~ter for delivery of th,~.,w.pper .
trunk llas begun to ro:t ate. WJth :adequate uterine. torso; :shoulders,.. 'a rms and.;: afterco~ing;....head.
contractions, not more. than <>ne or two Although it is :tempting to interfere earlier, i~ is
contractions are required for the d elivery of the . wise to "keep your hands off'.

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77Q . SECTION Vl\1: OPER:I\TlVE OBSTETRICS

Manipulative procedures have evolved through

the decades as .;t r-esult of extensive application in
everyday practice. With the fetus delivered up .to
the umbilicus, the obstetrjcian places both hands
atound h~e fetal thighs with boLl-t thumbs ovet the
sacrum :md parallel to the fetal lumbar spine.
(Figure 50. 6) Ste<;'l.d:f, .gentle, sharp .dGwnw.~d .
tractioD. is applied together with a.~ terine
contniction until the scap:ulae are oytside the
vulva. The cb~tetridan shou.ld be .careful to avoid
birth injuries ~~riPed to t...l).is prPe<;lur:e-: su~'h as
cru.s hing injuries to th~ f'tal .trius~:ulature, .l<'i.gure S.! l. 7. Pi.l'lard m.aneuver.
lacerations to . th.e liver . or ~t'ple;eit, . adr.enai.
hemorrhage ~-1d :rractur:es of long 'OO.nes.

Delivery m1,1-st be gen'tle - undue :rUshing

invites' fetal tra:uma. Cloct< watching frpm time of
.<telivei:j of the ~bilicus may be uiefill, .because
up to '4 rntnutesun~.cpi,n;pl~te rlelly~ry i'~$ bten
:associated with S;m:Lrlitt~ .A;pgar scqres Of 7 G.i"
hlgher. . . .

Continupus t:racfi'v n on ~he Jehis is often

foll&wedbytP:~ unitnpeocll.a'ei.iyety of t;h~ s~ottider
girdle .and ann~. AltemS;tive maneuvers have
.. evolved 'to a~ist. the delivezy.ofthe ~noulders and
fil1lls..

. (Aassic .rn_ethoii~. ~pnasiz~ fr!,~ .fact that_ there

is iii(jr-tYoom15o~teti.or:!Ym"'ffi"e ,spa~ P?<>Yiae<roy
ilie sa-crum: tli<ili.ii!iteri0iiy-.uilafrtp.e :s"YillP'iisis~
Some :piiJii.p}e~ pt thi$ approach are ~ 'follows:
1) ~tti.pn'.of the o f th~ .arm, is best carried out
in :( he .s pace ptonde;d l:)y .t,b.e ~ctu; ~.l tile right
ann:pf.the :fetus ~~uld be ,~4c~ed v..iih, the right
hand Qffue .ppe~ator :~d :'thc left. a:rm by the
'?.Pta.:tpr's 'Je~ 3) th'e :~ '~~G>Jild be brought out
in :front of.tli..e {ett).s . ~~ ':jl:ever ..behi.r).d the body;
and 4J any pressur~ e.X~tte& o~ .the arm m ust be
dlli<:ted against a j oint, l)su~y ~t the elboy;.

Assuniihg that the right s houlder of the fetus

is post~no,f, ~e'legs ot. ~e..fetus.:aregrasped With
If the legs do not deliver sp()ntaneou:sly ~ce the le'ft hand of the obstetrician and lifted up to
the umbilicus is d elivered, their delivery can be rest on the ,r ight inguinat.:ar.e a of the mother.. The
a:'?sisted:using the Pinard. maneuver. {F.igtJ.fe :50. 7) index a,n~ n;lidd~e fingers o.f the right hand are
A :f lnger is .Placed on the medial. aspect of, and in~rted .into :tht:. :v.a'gina:o:ver the p,erineum so 'as
pa.tallel1:o.~ tb:e infan,t's femur. Th~ f~mur is ,rotated to .follow the
.sho:Ulder:,,~d U:pper .ar:m. and .J;'e ach .
.laterally:on the i,n:fa:nfs abdom~n .s o thatth~ knee .out.fbrth'e. elboW. joi.nt of.the right ~a.r'n;l. With.
>;Vill ~d;.and the foot will.fqll ?-.gain:s:t;Ute backof p~~P.Ild~tni<;tion oiJ, theJO~t, thei.rril is swept
the ope.ratoi:'s .h:~rnd,' .where t:he a;nl<le -can .be .out under the body. Wit;h the :tiiht ann: delivered,
graspd :~.nd the leg exte;nded . . the fet,al;legs
.
..~re grasped now
,. . . .
With the'riiht. hand

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 CHAPTER 50: BREECH DELIVERY 771

.nd brought with a broad 270 downward sVfing

o the opposite inguinal atea of the mother.
Figures 50.8 & 50.9) Now the left index and middle
ingers are introduced into the vag=.na, sweeping
lUt the left ann of the fetus in the same manner.

Figure 50;9. Downward traCtion todellver the !Ul~Or anii ,

and shoulder.

. i ~ _.; . : ~ "! !',

Fipn":so i', ;:upward t.-:action to deliver the p.osterior

shoulder and~. . . _/. - -

More recent teachin'g s ..allow either shoulder

to .be deliver.e\1 first. For delivery of .the posterior
~. the infant's bp<ly is lifted up and toward the
opposite xhatemcl groin .(fle:l{ed laterally): Fox: the
anterior sho~lder, the infant .is laterally .flexed
. toward tbe nOQr. Care must be taken not to .stretch
the brachia). plexus during the lateral flexion.

If either arm is nuchal or raised above the

head, rotation of the infant towar:d the direction
of the fetal hand allows the resistance of the birth
canal tissues to push the .hartd so it will .move
anteriorly, where it can be released. Occa sionally,
.to release a nuchal arm, the infant ha s to be
pushed upward into the uterus. The operator's
hand is inserted into the uterine cavity to splint
the humerus while rotating the arms aeros.s the
head. As .. tbe arm des c.e nds; the operator exerts
.......
pressure on.the.antecubit;al space, which will }\elp
:.*-
. . . t'iilt~ .
Jlex the elbow. The h and- should drop down and Figure 50.10. Rotation of the: body towqrd .the fetal }land
can be grasped and gently extracted. (Figure 50.10) to release a nuchal arm. .

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772 SECTION VIII: OPERATIVE OBSTETRICS

..
~
\(.I
'i!
/-
Flgu~ SO.iJ. GxjpljicdemoMtration- displacing and flexing a raised fetal ann.

The delivery o:f th~ ~a.r#ls having heen

com,pletcd, that ofthe h,dtO.}ollpws. --
.~

~liucry .onhe Hea4

j\8sisting the dIivery of tl;le . head: is aimcist
routin~ required iri. most ca~s:of br~h deliv~cy.
Several m~tliodsare avaihibl~ arid are probably
equ~ ~tisfactti.ry :in.e;rpexicmced hand$. These .
maneuvel"$:'inllnedialdy fol1.ow the emmction of
tbe a nns.

Piper'sForce,psAppli~or~:J~f!.ttt~ 50, 12) .

Instead ofroanuif .e.xtraction like in the

M.auric~u..,Smdlie-Viet' manuever, .Piper';s Io~ps
may be applied to the atterecJ;lli.11.g :h ead.. These
.fotteps .are .so 'desigried (to pr-ven.t mJury to.fhe Figure SO.l2. Piper$ forceps .applie(i and W~t:~ body
fetal neck, to d~rease C9#1Pt<!ssio'tl pf the head, supported by a towel for extraction of the head. .
wd to .give the needed . a?Q,s,tiacU~il.

' aerore applying the' Jo:r&p$. ~ll;l;e. had
pelvis C!.ll~ tb.~r~ . shou14:Jj~" fl:dequate
be in the
anesthesia. The fetal b94Y 't:i:iu~t. h .hld by an
assi~tant with some ' de:gr~e 9f eXien~ion at the
neck. The feet are eleviited:Upward a~~e .t he.plane
of the .abdotnen and the i;ltm.S ar:e held behirtd the
back of the fetus by the assistant's other hand or
with the use of.a towel. Soine doctors prefer to be
in the kne.eling position as the left blade is
introduced firs't in an upward and diagonal
dir.ection across the . irttroitus along. the mento-
occipiuu 4iameter of the fet;;U head. Irisertion of
the .other blade !ollows and ~ter. Ule insertion of
th~ right blade, befot:e locking the blades, it i~
important to check that the blades are inserted
should deep enough to have 4 good .g rasp of the feW hefl_d.
Traction is appliedfu .a downward curve a,nd in a
continuous :mariner until the ch;in appears. After
which, traction is t hen directed upward ;:J.rid . the
handles of the blade are elevated so that delivery
is byflexion of'ilie head. ~
Bracht Manuever
The breach is allowed to .deliver sponta.n,eously
to the navel . .thefet~bodyisheld but not pressed
against the .maternal syiP.phy.sis~ This, cpupled
with uterine contractions and . ~uprapubic'
pressure by an assistant often results in delivery.
This technique is Used mostly for small babies.

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 CHAPTER 50: BREECH DELIVERY . 773

In the Mauriceau-Smellie~Viet maneuver,

(Figure 50.13) the infant's body is supported by
the . assistant with a towel and held slightly
elevated above the outlet. Alternatively; the body
of ~e fetU:ll i" rested .upon th~ foreattn of the
obstetrician~ Two .fingers of this supporting hand,
usually the inde~ and third, are placed on the
malar ate as of the fetu-s ; or. as origi.rially described,
one inserted into the mouth. The purpose o f this
is not to exert .t raction, but flexion of the fetal head
in order to permit pelvic :passage With the mdst
favomble h~d diameter. lfthehead is not in L'le
::nidlirte. it ~.n- be rotated using the same fl.ngers.
T he other ann of tb~..Ppetator holds the.shouider-S
of .the fetus with the it14ex and f<>'!.lrth fingers Fig-!Ue 50.13. The Mauriccau-Smellie"Viet maneuver for
surroundi..,g the neck. The third finger .may be delivery tl),e head.
pressed against the occiput to aid in flexion and
.acts as a . splint fo.r tbe . neck,.prey.e ntir.g
hyperextension -and}>otential cerVical sphle injury.
TraGtion is exerted .only l:Jy this. upper hand and
in a doWnward directi~>n clong the rud.s.of the .fetai
spinal column . FleXion ufthe fetal head is .careiully
m8.i..."'ltaiiled throughout the traction.

As the . ftal . occciput is feh to clear the

resistali~~~ogfthe -s.YJllphysis,- : the . ditci:~on of the
pull is ~goo ~dqauy until, in the course .of
the do-wnward tr;;tctiol); the ttQ$e; forehead and
craniu.m ate .~n1 over -t he perl.Peum.

Prague .Maneuver

.ShoUld the shoulders be born with back

posterior, theo~iput; :posterior;andwith the chin
facing the. symphy$is pubis. there. ar.e two .opti<ms.
First. the operator .q m rotate the body externally
while simultaneously internally rotating .the head.
If the head cannot be rotated with the .body, the
second option is.ta..'<en. With the operator puttit?g
.o tje fmger iii Ll)e .infant's mouth; the fingers df the
o ther hand are placed on the. .infant's shoulders, Figure 50.14. The Prague maneu ver to deliver the head
the baby is pulled down pq~ter:iQrly, . towards the when the occiput is posterior.
floor causing:descent ofthe h ead to the perineum
until the chin is under. the jnferior rim of the
symphysis pubis. The .c hin now acts as a fulcrum Cbmplete Breech .Extraction
l;).gainst the symphysis. With cor1tinued ~boulder
traction, and raising the infant's .body anteriorly In this technique 'of delivery. no part of the
on to the maternal abdor:nen. tl~e rieck is .flexed to fetal body oth~r than the lower leg is dtllvered.
~low the -h ead to . deliver qy flexion (the Pragu,e sponta,ne ously. .Complete breech
. .extrad.
~
wn i s
ll)aneuver). \Figure :so. l4) assoCiated with significant hypoXic and. tra\imatk

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 -~-- ------- - --- ----

77-4 SECTlON VIII: -O-PERATI~ OBSTETRIC$

fetal inj.ury and should only -be attempted when
fetal survival is in danger and cesarean delivery
is not immediately available. Indications for
~mplete breech extraction -i n obstetiic practice
'today incfude the .delivery .of'"the second -o f twin
with fetal distress or :as -part of the prxedure of
version and extraction. It is rarely indicated .in a
s ingleton !:;reed~ deli~ery -except when th_ere is
prolapsedcprd.o'i fetal .distre~ w::ith.a .fully dilated
cetvi.x wher~ cesarean .section might not be
-accomplished in time or may be more .haiardous.
Procedures .used -for eX:tr.attion -of the iower
extremt.ies .iie~d op. whethe'r the pres(:nt:t-Qon
ls frank, c~>r~plete :)r in-eomplet6. Adequate
analge~aj~esthesia is ~ssentiaL ln ~-double
footling, both -feet -should be _g rasp;:;d and brought
do'wn. :With a fta':rl.k breech, th~ Pinard maneuver
is performed fir~t. Th~ legs are deli:ered by. gentle
traction .after- which. the fetal. thlghs ate ltra:sped. .
:next as fu::: Par-tiil breeeh extia:ction, and the rest
.ofthe -fetal trunk, shoU].ders; .arms.-rmd head are
delivered. as.desctibe~:h.~:. :... . _-
DIFFICULTIES lli VAGINAL BREECH DEUVERY
Nuchal Ann
In fuis significant complication of breech
delivery, one or both fetal arms are po-sitioncl
abov~ the shoulders ;:1Pd behind. the nuchal area.
This cOuld l~d to difficulty in-delivering the arms.
i
To a, lar_ge degre~, it may .be -prevente<:! by avoiding I
rapid extraction' ofthe fetal body. l
rr nuChal-arnis are 'present, ihe fetus is~. I
or l<W.rerecfin the diredlo~ oppositc to t:Venuchal I
arm arid flXcii -ov.er.'the opposite groin or buttocks I
of the mother. Th~ o:peratbr's finger is then
inserted along the h umerus to the elbow, avoiding I
ho0king the fetal ann, and using the fingers as .a
splint, s-Weep .Uie _arin do'wnward-through ~the
I
vuiva. The trun'k is then -rotated so tlia:t the
opposite Iiucha_larm is s:w~pt olong the .t.l).est wall
and the spliljting inaneuvei- rep~ated .. The
I
pnncipk of dclivering the left arm with the left I
fui.ri:d--art<hth'e:right:-a_.-m_ .with right~hand.alsoholds;;:~. ..
tree..

~rvical EJ;ltrapm.ent ofthe Hee.d

Abdo~ _delivecy.:p::;.arbea plat;med<mode of
delivery.ev_eri'-l>efo.r ;ffie.;-onset: of.la:1X>ror-as .an:: 'If fue c er:\iix"has- trapp<:d -the"'hea d and' the:.: .
em~r.&e:nty-~-after18;boi~has---.;~cmm~:c:-ce_d :~d 'irifaht-~is :'~i'..:.er !D'uhnrt~~:md sions ~may be
C"irclimstiilites '<Ut4t.et'"an-- ettfeFgeqe '~elivery ~or pedOi:nied-to.faciJi~~~--deli'{ery~ {F~e :~o. ';l.~l: ,61tcr
d iffiulti::s .:in-~vn~h deli.vecy .aie imticipated. -adequate Visi4iliza:tl.Qn., r.hi.g':fbtceps-ate bes~ .tiserl
- -~ ---- -- .. . . .. ..., .. t<i .grasp--m-e-c~iVDC. -ancCpulf'i'fcfowri-- s~ghtly.
smce .m'fuiy .ms:-urmouii1a])Ie-duficl}1Ues m:a.y tn:2is1ons<?:i:i til'!:: ;:elYiX arellia4e With SciSro-n-to
arise during laoor' :e.rid attempt at v?J,gfu3,..1"br~ech tlie depth .o f 1 to 2 ems a:t the 10 and 2 o'clock
d'i:ivecy, it i~J~esttiie4,.un:der do.uble set-ifp or positions a.11d a third ,one if necessary at the-6
wh~re j.mmeqsate .ceSc.rean ~ction 'i s :poss{ble. o'-clpck area~ C~nnp"lications -are avoided -by
. Al:ieom.inal'r.esd;J.e.; r~prese~~ ~ l.asto:dik,h.:effort a deqmite "visb:afu;ati6n and- gentle-.tr'a~onoft:be
to sa.v e -the fetus wlie.n extrac'tion oJ the head. After delj:ve.cy,, the-incisions -are rCpaircd
aftercoming h .e ad or uppe~- bo~y ~ppe~rs u s-i ng :mteii:\ij)tei:l chromic suture~.
itnjx>ssible without . potenti~lJy" .dcih.gerqu:s !~tal
injury. lt may offer a better chance for -fetal M.all>osltion :ofthe 'Head
salvage than eHht!r symphy ~i'o to my -or .
perseverance with. vagiqal extraction. beyond the -Malposition :can occur when th~re have been
poiht of- no return. mu ltiple rota ticns of the-- .body .d1;1ring delivery
. m a neuvers,.. when the;;-.head wa s. initially.
Cesar.ean section does no~ eliminate _all ri~ks malr.pta,ted in utero, or when desce11t oci:urre.d
an.d pOSsible trauma. Althdug.Q. .t4ese are far less \vith the saCr;llm.posteribr. When the head is stuck
for the fetus, there .tan b.e a significant increase -. and the qac_k.is anterior, ~diagnosis can be I?ade
in maternal morbidity and mortality. T h e by inserting a -h?-rtd alpn gside the fetal .head to
abdoniinal breech -deliver:y.is.'conduc~d-as:a: total determine the-location of the chinjface:Ifcaught :
breech .e.Xtt-action follo~g the
.sa.memaneuv~rs :. .urtderthesymphysis pubis , upward 'dislcx:l.gemcnt' ~
as for a vaginal .delivery. _ will free it-, and:rotalion of the c4in poste.riotly can

Scanned 8y: ~
 CHAPlER 50: BRE~H OEUVERY
be accomplished by gentle pressure of the
operator's internal hand "a gainst the face ~r chin
ot by a fmger in the infant's mouth.
FJ.pre $0.1"$. l)ulm;sen .i ncision at 10 and 2 o'clock to
.reJM; e!lt;rllJ)ped aft~om:i.ng h,ead.
. ~~AL CEPHALlC ~RSIO:N
One alternative foreesareansecticmis ~mal
ceph~c\~rsion. It has-~ecei~ed ~ewed interest.
Thev?~~~~or~~ v~~f.~~_:l;ij1tt.Q: -
1. Correct the breech presentation to a vertex
2. Lower.the incidence of :b reeeh presentation in
labor
3. Decreare the cesarean section rate, and
4 . Decrease the perinatal morbidity that may be
assoc~ated with a breech :vaginal delivery
H~..!l\J:!;l,~ pf the .higher r:i~k :g., compljcation s
during the birth bf breech presentation
irrespective of the route of delivery, prevention -of
breech presentation must be considered. In s killed
hands , external vers ion c a n effect a 50 to 70
percent reduction in the inciQ.ence of .br.e ech
presentation at term.
The .procedure can be a ttempted at any time
before the occurrence of labotO, bes t wh en the
Scanned 8y:
775
chance of spontaneous rotation is decreasing_and
when, if a comp.Uc;:aQ.on were to, ~ur. fetal lung
maturity is already assured wll.en. emergency
delivery becomes necessary~ Another factor to
consider is the amount of amniotic fluid. The
procedure is best t:iined when t..'le .;mtount of fluid
has not yet decreased to such an eXtent as to make
the manipulation of the intrauterilte fetusd.ifficult.
b:te!ll timing ~aries with different aut;hors, but the
majo.rity place this at between th~ 34th and 36th
week of gestaijgn. It is important to have facilities
for electronic fetal mo:tlitoring," Ultrasound and
easy access to the operating:rooP1.
In performing the version, the patient is
advised to be on NPO for at least -6 hours prior
and the blood indexes avaiiable. Ultraso11ographic
evalU,~~ior. i s done to ascertain adequacy of
amniotic :volume, .confrrm the fetal position, locate
placental attachment and rule mit t4e presence
of a n1,1chal cord. An NST is also done. pq~r. to
confirm fetal well being. The bladd.t'lr<-a.Pd
preferably
.
1he
.
r.ectuin
. .
;::i;h-.
should be ~mpty.. ~ .: ,.. ,..,.
The pa~ient .in he.a d-down Tremlelep~:ilr.g
position _m akes it conducive for djsengage.neD..t
-of t.he ::presenting breech . from...;th~ -:P.~Jvjs ..
Tocoly.s is in t he form . :of : sul>C.l.lt:~~.o.J.J:s .
Terbutaline is s uggested by. so~; b.~1ifn.pt .
required. :spreadiilg .fme talc , powder ~o~eii;Jhe
abdq~i,n~ wall ea:ses the version proce;d.11re.
G~~~~!!_c;_~~l~ ~~~Ati~-- - -- .... _ _ ---
The operator pcisitions himselffherself .t o fac~
the fetus and begins by lifting the breech from
the Pelvis and lifting it as high as :po~st"ble without
undue use .offorce. Theb.teechisthen displaced
towar-ds. the direction -of the fetal back and a way
from the pelvic inlet. At the same time, the
opei-ator~s other hand is u sed to guide the fetal
head forward and downward - a:s if doing a: forward
s omersault. The procedure
. ..)
is discontinued if
contractions, bradycardia, paJn , or re:s istance
occurs. 1'he version should not be forced if it fail s
a fter one or two a ttempts or when a fter what
appears .to have been an accomplished external
ver-sion, there. is repea ted return to its original
pos ition.
An NST is best repeated after the procedure
.a nd the _patient observed for 20 to .30 minutes t o
ta:ke note of pQssible uterine koritraction s. Prior
to sending the p.a tient h ome, s h e is given
ins tructions a nd labor precautions.
~
776 . SECTION Ylll: OPERAnVE OBStETRICS

. t

Figure S0.1"6. External ~phalic version..

.. .:.
~:phy:dQ~tumy
. . .. .. ~, patient feels ready and full . ~ohility slioUJd be
. . accomplished by Pay 10.
,. . .:Alt:hougl):.~an:-:u~l.i~~lY.rp~O:C~UI:e,:~pero~ed.-.~ coNCLUSIONS ....
to deliv.e r..a.~tuc~~iiftereoJlllll'~.:hea~~Ll;D- r,node,m.~ . . .
;oQ~t~tnC$.' ~t~is.:m.e.~ti.6b,ed:.'fr co.tn:pletiom .'(~ne . cesarean-~op: is likyly. to :rem~ the. jnost-.
J:na:j'or ben~fit :\*.:.sf~es ij:nine'ctiatd. :u~liyety.'i~ the frequent.mod.e 'of de live:cy ill b reech :presentation.
peimrui.ent;.~;ge_rn~~:t:~ uf .il;te.ipel'\1s. w4er.e .. . However, .thet.e -i~..a :role for -;raginal dilivezy in
:a~e.s~,:.~~-~~~i~1~J..~..e~ ~s\.a~ pr~bl'~m dti~.' Jo . . _sel~~pa:.!lents. Wh.el_l. 'the..oppqrtunity: lilises~for .
~~~~atei~A~sfunt< 'S<!-F.,'i~s,~.lq.z;~:r~~y's .-1;he. a sel~tive t;ial; of.;liilio17, ::fu~:-.cnstettician,-iiiu3t: .
.c~an.e .. f(>r. ~:v.agi:O,:~l.-<,deHv..e:t{s 'ln fu.:tUl'e: pt>ssess .t he skills nec.essazy to ~ffect vaginal
p~cie'so. :'14 -ho~~er.o; m~y:rei$.ult in .pe~v!c deliV:~, ~thou:t 1m_,inprea:s~ ris~.toth.e..f~tu,~~
- h!:>ne--inst&bllity--am~...;\l;r:ethn.il...tiaurna-.~. Aftea' . T'o,obt.a:in--a-suc&ssful6uti:oni~m-vaginal-bt~
-deiivery:~d~pe~~P~r,th--thighs~~k~pt d elivery; thc--opeqltor:ml;l.st; :adhere ~trictly:to
t.qgejher..,~Q'-the::p~ri~t.i,s ke.p thl th~' lat!!~al pr:esc;n'bed '-criteria, cyefullras.ses.s and manage
p<>sitio.il With :a F((>ley catheter. .for eontin\l,OUS the ,prOg:tess of lab9:r~ u:.t).d.er.;take pi;'oper :plWiri.i:ng
b.Ul:dder dniJnage'f-<;>r 5 &ays. .A.moui~ti!).n w ith .an-d :U:se ..of hospital resour.ce s . 8:nd qu-efully .
a~si~tance .rnay._b~ tr.ie:d' theteaft~r . w}le:n
.
th~ . . coril;iuct the :d$v~-y using pro~r ol;lstetric skills.

- f . / ..
'' \ '' .
.. . .

D~iverf o1-fhe bre.ech .j:m~senling 'fetus .needs ~o -be indivklu?!i.zetl. Contraindications for vaginal
.deliverykro:lud.e .. ti:YQse wh do. not ~eet the criteria listed in the tabl'e below.
.-... .. .....
A. Sonwraph\c (or x-ray) confirmation .of .
1. Ftank breech
2. Flexed. attitude
3. Nonuchal arms
4. Estim9.ted .fetal weight of -~ 1.ZSO and ~ ~750 ~rains
5. Estima.ted.:gestatl.o nal.age of 3642 w~ks
6. lmmatur~ fe.tus .(<; ?4: weeks or< 5.$9 :grams)
7. lntrauteriQe fetal ue~th

Scanned 8y: C
 CHAPTER 50: BREECH DEliVERY 777

B. Clinical ~vah:.i'ation for

1. Adequate :pelvis
2. Progress of labor (friedman curve)
3. Absence of fetal distress

C. Second twin
D. Others: Absence. of-

1. Significant medical complications

.2. History :of difficult defivery .
~:. 3. Damaged or extremely hlgh risk ,infant
4. Pre--labor ruptute of membranes

Aside from the obstetrici;;~n skilled in ti1e procedure .and techniques, the presence of assistants, a
pediatrician; appropriate nursin.g support and operating room personnei ready for immExsiale Ce:sarean
section are critical tO~ the safe vaginal delivery in breech presentation.

tn mOdem hospital obst~trics, spontaneous breech delivery rarely occurs, but should be fully:.t.~.derstood
.by anyone perfotming ~ bteechdelivery.

: :.:Partial breeCh .extraction involves the .spontaneous delivery of the fetus up to the .umbilicus::~md .tJi~t-:
. empk>yment of obstetric maneuvers thereafter for delivery o f the up~r torso, should~rs,,~sar.di~
:aftercoming head. Aithough it istemptihg to interfere earlier, it is wise to "keep your hands off': . : ~~?,

~'' :- ':M~nipulative procedures h<;we ..evolved through. the deCades =as a result of extensive . app.licati.oal .iiri>:.:
. _.. ~j~~ay practice. .wJth the fehis delivered up to the ombilictis, the qbstetriclan l'la~es "both~::naiias;.;:1:;': .
,... :'>around the fetal thigh5 \vith both .thumbs over the sacrum and paraiiel to.the ftal lumb~jt-.~spin..e ' '{;:):.'
Steady, .gentle, sharp downward traction is applied together with a uterine contraction until the ~pulaf!..,;';-- .
are ~\Side the vulva;The obstetrician should be careful to avoid blrtl"l injuries ~scribed -to this proced.ore.-

. As~istingthe delivefYOf-the.headis-.almost (outinely required in

most casesof breech delivery:Methods
like .the Mauriceau~.Smellie-Viet maneuver and Piper's forceps ;;~pplication are aveilable and ar:e probably
equal!y satisfactory in experienced hands.

Complete breech extfl'!ction is associated with significant hypoxic andtraumatic fetal injury and should
on!Y be .attempted when feta! $urvival is iti danger and cesarean delivery is. not immediately available.
It may be indicated in the delivery of the second of twin with fetal distress, ,as part of the procedure of
version and extraction, in prolapsed cord or fetal distress with a fully dilated cervix where cesarean
section might not be accomplished in time or may be more hazardous.

Abdominal delivery in breech presentation may be a planned mode of delivery evenb~fore the onset
cf !abor Oi as an emergency during labor when circumstances dictate an emerger.t delivery or difficulties
in vaginal delivery are anticipated.

. Cesarean section does not eliminate all risk$ and possible trauma. The abdominal breech delivery is
conducted as a total breech extraction.

. .., .
~

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 778 ?E.CtiON Vtl1: OPERATIVE OBSTETRICS

8. Pajntar M. Breech presentation. In: KurjakA (editor in

chief): . Textbook of Perinatal Medicine - A
1. ACOG Committ~ on O'Q.stetric Practice. Mode of term Comprehensive Guide to Modem.C linical Perinatology
singleton breech delivery. In: 2007 Compendium of :!.998; 2: 1791-1803. .
Selected Publications Vol I. Washington, DC: The
American College of Obstetricians and Gynecologists~ 9. Penn"Z. Breech presen tation. In Jaraes, S teer, Weiner
2007:374--376. (editors ); High Ris k Pregn ancy - Management
Options(~ci Ed.~. China: Ha.tc~mrt Brace andCompany;
2 .AJarab M,-~egan C, O' ~onnell\1, t<:earte Ci, O'Herlihy C, 1999; 102S-i049.
Foley M. Smglctoq.v~ bre.e ch.dcl.ivety at te~ Still "
a sal'e optiop. Obstet Gjnecol ~004; 103{3): 407--412. 10. Queenari J. 't~achinginfreque~tlyused skiUs: Vaginal .
beech.deUvery. Ob.stet qyneol 2004; 103~ 405-406.
3. Breech Pr~entation a t;\d .Dclivety. Jn:-Cunninghan F,
l-eveno K, Blooin S., Hauth J, Gilsrrap L liT, Wenstrom 11. SuM, McLepdL, Ross~.Willan~.H~ah W, Hutton
K {e(litcrs); Williams Obstetrics rir?ud Edi~n). New E; et al. Fac.tc>rs as$(?eiate4 wi~ ad\'use perinatal
Yor'.c McGraw-Hill;.2005; 56-5'-"586. outeome:.in fue'.'l'ettn.Breeeh Trial. Am J .Obstet Gynecol
2003;189{3): 740-74-5. . .
4 . Ei;len .a. Fleischer A, S:ch"\:,l.man H, Jagani N; Fe.t al
acld-q.sU aniJ, '!h~ abr..ptm.al feti;l heart rate tiacing: The 12. UoT.ilaJ., Tuimala.R,.$rkinenPA3oodpefiriataloutcome
. tern1.bieh fetus. ()bstcl Gynecol 1:984; 63(2)i:233- in selective b,r~11. delivey.attenn. Acta Obst<;:t Gynecol
23S. . . Scand.200S;.&k:S7;S.5 83. .

- ~- -~~o!J. -e, yn~q~ p, Olot~n. P. Va~ .bre::ch 13. Whei!lerT, G;:~ene K Fetal heart cite ~~p.itorillirdwing ......_
deliv.ery::ilJ it.still ~-l?ption?. Eu J 0bstet:Gynecol Rep breeCh lz.boi!t. 'B!- J Obstet Gz,.'netol l975;'82: 2.0 87214.
-BioL 1112oo;3; 122- i!la.
14. Wcing6ld A. ~e inana:gement of Breech Presentation.
.(?. ijryt; T:8yior,u.:Sr'e~h-0efut6y.tn:: 1fty::~ A;puZ;io J , . : In: 11IY I;,-;eharles.n :(edit~~J;:opc:ci..tiv.ePerinatclogy
V =~ec~':.k{eiiitbrs)f 'o/.P.eta~C: ObStetrics: N~vi;Yorli;!. . ~vasive 9J?s~tr.icTec~que;>. .New York; Mac.m.illan
MCGraw~Hill; Jti.C!-~ ~ 1~2; ~sa--~61 : PU.bli!;bilig
. . CompanY;
. ' . 537~553 .
19B:i:

. 7.. ~pi~_-f:i. ~ w.,

:~~p.e.r ;r.i$o~er:gr,uber. M,
.15. Yasi_..TJ. S, 0'~~~ ~ ~sis~ed:breech cxtr~cti.~.n.In.:.
.: ~ger E;7o/.3Q-LAS81sted,'v8.gii!.a[d~v<:.t:Y.ir~i:$\is..: . P,1auche W,M.om~n J ;.0'Sullivari:M'{edito~: Surgical
~'tion-ut.bte.eh1preseniatio'n:t:A:Ct1t"01:l;>tet'.. . . qbs'tetti_c ;sd'i$adelphUi: .w::B:~a.~cieis; ..-1992;: 32S-
~-~.Qt!s;~::;saa,.s92~~, -. . .. . . . . 34.5 . .

. .~ .. --

! ....

Snanned fy: C
 51

INSTRUMENTAL VAGINAL DELIVERY:

FORCEPS AND VACUUI\1 EXTRACTION
PILAR T. LAGMAN-DY, MD

. .
Forceps and Vaccum Extractor
Comparative Advantages of Forceps and Vacuum
-...... Vacuum and Forceps Mnemonic

.... -F,;orceps Delivery

Types of Forceps
.... Functio!1S of Forceps
Types of Forceps Application
. :
..,.. ~ .., Classification of Forceps Operations
Conditions and Prerequisites in Forceps Application
Indications to Use of Forceps
-
Elec tive tow Forceps-E>elivery: Details- of Application
Contra indications to Use of Forceps
Dangers of Foreeps
Trial of Forceps and Failed Forceps

Vacuum Extraction
Indications
Contra indications
Procedure Using Soft Cup Vacuum Extraction
Complications
Recommendations Regarding
.
Vacuum Delivery
.

Medico-Legal Concerns

Scanned 8y: C
 : .'~:'
: . . ----~------------~~--.,----':---'-------------...,.. : .
78{) . SECTION VIII: OPERATlvE OBSTETRICS . . :. .::. .

. . . nr,l'RODUCTION Forceps an-d Vacuum E;xt.ractors

..
Jn .the early l990s, Hillier and Johnson ihe advantages <>f vacuum extractors -an(l .
-9oP:.duct_ed_ ~. worldwi-de <?Piri!on sU:r;v_!!y -,about - forc~ps are li-~ted in Tab~e 51.2.3--7 A recerit
-.-ms~ent preferences for .vagintil' ddivety illld Cochrane review' found that th.e ri~ks a:pG benefits.:
.. :--found that the forceps are mo.st-popular in o'f the tw6 form-e of ass isted delivery ~re
:~ :-~_glis~speaking" countries, Eastern Europe and cor:::.parabie. Often, the delivery instrument i~ -.
South America. The vacuum is preferred in selected based on .t he training and experience of
:-~!)ithem E'LltQpe,Asia, :Israel, and fue M,id9J_e East. the. individ:u~ physician. ~"'
-I:t; ~p~s 'tbat. j)l_'~ :givt?n..ar~<:J..: .t he ~hoi~e. of.. . . ,.-
:inst:rWilet~J 'ti'Sed dtiting:cr....ia:ti've V.a~ .dC}ivexy F()RCEP.S '

.. - -i;s~
_-_,tb.:~~t_e_np.P.~.~:7.t:_,,_' ::_:':~. Sf~:::. C~:;~!k~~~~; _i~tit~r~.:u~T,
, 1:'- . - . , -. ~~~g ,._ - . .. Y,.
-... _;CQ.ril.i:riittee on .Nz:tio~wide
Sh'tpstics, ~ppm6 is-aniiistiumep.tdesignedforeX:tractionofthefe~- .
b~t:clriealanddyrtet:OlpgicalSociety {POGS)hav-e h ead. While many varieties of forceps h ave beeri: .- ..
'7 _ _-:~~~da.ta -o~.insfrumentai-vaginal delivery (Ai:mual descn"b. :the ba,sic ' de~igr). .anti purpose renllun:-- .
.? . .O;n;~s :2002-2006) (l'ablc sLw.. :
~cha:aged. .. - ..
. ;
..r:... :
.......
: .T-'~-ie.Sld. POGS data on fo~ps del.i,.eries and vacuum extraction.
.,
{ -~ : .. t ' 1003 - . o/., 200:4.. J- W05-- ,v.. .J.OOL-
.. ... . . .-.

. ::t;o.i!il--Peliverles 226;,505 .- 141~68.5 236).60 1'.12.Tl.i _31.~,.564

-~ 177,81 9 1.05,5&3. 116;i.53 :22$,.$0:8 239,-135-
.!_;; ... _..:Pijyite . . 4&,686 '36,IOi '&l;Wf . 67:?94 .7.6,429 ,"';:
i . . :: . '- 1 - ..

._
:-.:_;,~ _:_..f~~~d~- .5,524'. '2 .44.
5,492 2.42-
2;013--. - ~- 1'.43 .
1,936- . 1.40
.5;243' ' 2.22' . 4;h2' : 1.54' . . -.A.SE&' . L-45 .. _-
.5).19- . 41 .f,613 1.58 4,.515 1.43 .- -.. .'
-

. -,:-~Mid ();()~ 't 3 . 0.02

. ....>~~-~~~::~~~.
)2 0.14 J7 .14 .0::01
...

'199 {).07'
...;.-.
. _-_-" ; .Y.,_u:jj_~ .. . 0. 14 633 {).io

_. ..tih~
:
-S i.:2. Com,parative a dvantages ofvacu:cm c:x:tracto::S and fori:eps.
--. ~ .

; - ~~:-extractors For.Ceps

.-'~tirleqrn FeWer n eonatal-injuries, :includil).g cephalohematom.a, retinal

-~- delivefJ hen::.orrnage-ana transient la:tenil rectus_p alsy
~)natenuil geri,.i;te.l trauma Higher .rate -oisuccessf..ll ~ delivery , .:
Le3s maternrudiscbnifort
:F~neonat.al Craniofacial injuries
---~~ ~~;lia required

~~of Forc eps (Figures 5 1.1, 5 1.2, 5 1.3, 5 1.4 & 51.5)
.,.

.
. -
~ ...
. . . . l"

-4~:",.;,";J:J;-~
.. . -. ,.., .; :ii:!. ..~-:::~ . . .
F'i.tUre 51. l. Simpson forceps. The most common type of forceps With a c ephalic and pelvic-cwve. The shank is straight; the:

C
'lOck is of the English variety. , . ..

/. Scanned 8y:
~~~====C=HAP===T=R=_5~1=:=1N=S=TR=U =M E=NT.=_.A~L=V.='A=G=.IN=Al=~.-o=_e=l.J=V.E~R~Y=!~F_o'="_R: -:.C~E~P~S=A=N~D=V.='A~C=U=U=M~EXT~:_RA=-~:-=:c_:r~IO:N===== 7-81

::t,. Table 51.3. Vacuum mnemonic21

?~.

'# A ANAESTHESIA ASSISTANCE adequate painreliever- neonatal support

f B BUDDER bladder empty
c CERVIX fully dilated, membranes ruptured
D DETERMINE position, station and pelvic adequacy- think possible s.houider dystocia
eQUIPMENT inspect vacuum cup, pump and tubing- che<:kpressure
?
F FONTANEUi-E )>os!.tion -t he cup ovet the posterior fontanelle sweep finger around-
cup to dear maternal tissue
G GENTLE TRACTION. lOOmm ~ginitially and between contractions- pull with contractions only
- As ~ntractions begins:
. :. increase pressure to 600:trun Hg
1-- - prompt the woman for good. expulsive e:ltort

- traction in a xis .of birtb canal

H HALT no progress with 3 traction aided .contractions- vacuum cups off 3 times-
no $i~t progress after 20 minute.a of.operative :a~ delivery
l' 1 lNCISION consider episiotomy if laceration is.jmtninent
j r~ove V~CJ!~. V!hep.j~~ is r~Qle .ordi!liv~:8.$S~
.r ~----~~----~~~--------~----~~~~~~--~~--~~~~--~'~,_w-~~~~~~~------
J JAW

~
~
I

-~

f; .A ANAESTfiESIA ASSISTANCE adequate pain reliever- neonatal s11pport

t. ,B
c
-BlADDER
.CERVIX
bladder ~mpty
fully dilat~. menibtanes rupti.U-ed
~--
:j;'
DEI'ER~ pcsitioti, ate,tlc:laild pelVic ad~acy- t.~p0$51'ble should.erdyst~--.
~;, E EQUIPMENT verify quality -a nd functiomility ofequipment ...
t F FORCEPS phantom applkatior.- left blade, left hand, matemalleftside, pencil grip
-~ -- ~~!~.~-~~-:a.~~.~~"~.!~~~.:~$J~~<!~. ~:!'_~f~~~ -
.. ~JJP.~.!I;ruL~1mtimti2n:,pO.:it.eriodontanclle.lcm.abo~e pl:aneor
sha.ri.ks- f~nestration P.O more than a -fm~Q'breadth between it !Uld scalp-
sagittal suture perpendlcular to p!ane of~ with occipital suture 1 em
above respective blades
G GENI'LE TRAC1lCitl appijed wi.th contraction and I or expulsive effort
1-i }if.NDLE EL\'"ATED traction in axis ofbirth canal- donot elevated handle too early
INCISION - . co~llider ~P.isiotomy
J JAW remove forceps when jaw is Teachable or delivery assured

..
. ~:

Figure 5L2. Tucker-McLaneiorceps. The blades are solid and the shank.is narrow.

Scanned By: C
782 sEc110N Vlll: OPERATIVE ossTe-rR1cs .

rtgure 51.3. :Kiellatid for.:eps. The pelvi~ c~~5fllniost no11~tcnt, :making the i.n:stiument ideal for.rotatirinhe Mel
head. The sliding lock m4kes the 1ocldng of the :l;Jlade:i ~- J?elivery can be a t:t;;omplished with the same instrum~t;
rcapplica.qonis:IrotnecesSary~ . . . .

.~ 51.4. ~on'fo~q:ps, Tb.i,$is a.gc;>;odforc~s for.rotation:Ora-~h:transv~ar:rest. The anttrior\>1ade"is~ingw: at

its'junctio.n:to tbe.s:M.nk.allowPig movement th.t-:u 45". The 1>li4in:g lock~~ .th~ blades to be locked even in the pres---..nce
of=~~c;litis;m.

~-~t,s..~f~~-..:.PJ.ej:i.Wr:.t:ei!!.:iiDJtkr-.~:simp~n-'fo~~~islonge'!"and ~.mr~dbwn~ru.-d sotli1.t the

~~.ills! ~..)ri.E:;fu?. nJl;J..;pl.94~-.1(~_a.~dolibl.e..:pclvicciJ,I;ve.t:O-~bi..tA-appliliation tothe afta-<-om.ing head .mPieecli
~tiO!l,S . f
. ... ..~

..

Th~ o'r iginal uses Qf for.c~ps ar e: iradion,

..,"'""""'"-'' e'n.dose tire .h-ead; may be

. . rota:Son..oomP:r~ssiqn, !iilii.tiol)., and leverage. Only .
.fenestrau .d ~r 'solid tract#>rt ~d r.otation .a re a tceptable .in ~odern
obstetrics . Compression. .of the head maybe ari
unavoidabie accompaniment hut. is never a
'SHA..NK: connects the 'ha ndl e . function of Ioreeps.
t and the blade

Traction

The .dir.e ction .of tr~<;tion must be alpng the

pelvic -c~rvamre (Fig~.1.re 5 1. 7); as the station
changesd\Uingdescent S0does the lineofttaction..
The dir~on -of puU should be ~rpencUcular to
the .piane -o f the level .at whiCh .it is being applied.
HANDLE: t o grip th.eforceps
The higher the level is, the m9re posterior the line . /
-Fi~e S 1.6. Sltnpson forcqJs shov.fug variou~ P~-
oftraction_

Scanned 8y: ~
 Jf
' CHAPTER 51: INSTRUMENTAL VAGINAl DELfvERY: FORCEPS AND VACUUM EXTRACTION .
Figure 51.7. Traction with forceps.
Rotation
This is carried -o ut best in the ~dpelvis._ In
,_ .r<>tat.i.JJg the head fro~ posterior or (tansverse
positions, the handles $hould be sv.;u.ng through
:a wide .arc in .o rder to reduce the a,rcof the blades.
This makes the procedure easier and lowers the
inidence and extent ofva:ginallacerations.
,Appllca:tlon o Fo~pa
CephdJic,A.ppli~fl .
nus appliq.~.tion is .made to fit the baby's head
(I:f'igUre 51J~); pr:es$\t'te em the ha(:l cau$CS the
leastd araage; An~idea:l" cephalic a;pplicatioll-ifr
occipit~reriot _ position is_oi.panetat; " along~ me
oecipitomentrJ. diameter. The fenestra a,nd the tip
of the foreps lie ov~r the face, With the convex
edges toWaz-d the -face.
Figure 51.8. Cephalic ap-plication.
Scanned 8y:
783
1'
P:E LVIC APPLICATION
this application is made to fit the maternal
pelvis regardless of how the forceps .g rip the fetal
head "(F!gu:-e 51.9). The best pelvic application is
achieved when: -
The left blade ls -next to the left -s ideo fthe pelvis
The right blade is on the right side of.the pelvis
The concave margin .is near the symphysis
p:ubis
The. CO'nvex margin is in the hollow of the
sacrum ~:
'rhe-dianreter ofthe forceps is in the t:nl.rtsverse
- diat:p.eter of the pelVis
Perfect Application: -_
;... _...
Th-is a:pplication"-1~-'a~bk~ed---when:both;_:tlte
c.ophalic:an~d--p~tvl:C--T~q-mf.eni~nt"$" .haV'e':tfeelr
fulfilled -(Fi-gur,e :SLJO). .Whe.Q the qc:Cjput has
rotated t!nc!er the sy:I;i.phy$js pubis and dt.s agittal
suture ism thtnl~te~pQ.s~rior :d.iatnetet. an ideal
application i$ :po:ssib1e.
FitrJre 51.10. Penect application.
r-..
~
784 SECTiON VIII: OPERATIVE OBSTETRICS

Classification of Forceps Operations 1998. In 2000, the American Colle!e of

Obstetricians and Gynecologists (ACOG) reaffirmed
The mcstappropriate and current classification the 1991 Modified Classification of Forceps
offorceps operations is that proposed originally in Deliveries. 11 12 13

Table 51.5. Classificaticn of forceps delivery according to station and rotation 10

Description

OTJrLET FORCEPS Scalp is 'visil>le a,t the introitus without separating the labia
Fetal skull hast.eaabed the pelvic floor
Fetal head is at or: on ~rineuill
Sagittal sut)t!"e is b the anteropc~terior diarnet.!r or :ight or left occiput anterior
or.posterior position
Rotation does not: exceed 45 degrees
'
Leading portion of the fetal skull is at station +2 or below, but not on the pelvic
W!VFORCEPS
floor
Rotation is.45. degrees or less (left or rigil.t -o cciput anterior to occiput anterior, or
left or right occip"\it posterior to occiput .posterior
:Rotation is gt~~e"t than 45. degrees
.., ~~

MII)FQ~ Station :above. +2 QD. Q\it hea~l is e_~ged

HIGHFOKCEJ'S'-... NO:t
: .. fuCfudedin
: . -cla.S;wcati<m
. '
, . .

':-' 2. Th~ . m~m~rap.es shoUld be .rupture.d

- 7. SOtneform of-anesthesia~ general, re.g ionalor
..
Fi~r~ St..li ~ Gl~~s-fficatlon .of fo~ce~~ a~piications
accotdingto sta.tion.9
co'ndltlons and Pr.er.f;lqlJ;isUes in Forc.e p.s
Application
The following requirements . must be present
before obstetric forceps ~nay_ .be used:
1. :I'he cer0,x mustbe fully di.l ated and retracted
3 ; Vertex presentation
4. Th~ fetid .beaq $\lst be eng~ed , .
!?.Acctu:at..~osi~ . of .position: and statiOn is
essenti~
6. A.Y} adequate pelvis with no dispro-portion
loCal . (pudendal blook)- shoulq :be -used, .T his
achieves bOth.relaxation and telief pairi of
s : the bladder must be emptied by usi.Og a
straight rubber catheter before the forceps are
applied. Art empty bladder occup1es less space
ai}d ~s less .liable to injury
9 . The r~ctum should be empty. This HJ"usually
already accomplished ~y an enema_~lier ~- .
labor
10. The patient is placed on a good delivery table,
with her legs in stirrups and her buttocks well
down and a little pas~ the end ofthe.table
11. The operaUon is petformed under strict aseptic
conditions
12. Cesarean section capability
13. Experienced operator
14. Patient consent

Scanned 8y: C
 CHAPTER 51: INSTRUMENTAL VAGINAL DELIVERY: FORCEPS ANO VACUUM EXTRACTION 785.

IndicaUons to the Use of Forceps 14

Fetal indications
Non-reassuring fetal heart rate patterns

Maternal indications
Prolonged second -s tage (more tha..& 3 hours
with .an(l 2 hours without regional analges,ia L11 a
nulliparous woman; more than 2 !lours witll ,an4
1 hour without regional analgesia in a .parou-s
woman)6

Exhaustion
Figure 51.13. Handle of left foroep$ is lowered and the blade
Maternal Disease: cardiac disease, moved up over the ten parietal bone.
tuberculosis, hypertensive condition - .to shorten
the second stage of labor and avoid the need for
prolonged bearing-down efforts by fue patient. .

.E lective Low Forciep3 l>eUv~ry: Details of '

Fc>rcepsAppllcation

Tnis p~ure, describedby nr. Joseph B. De

LeeH in.)9~0. is designedto prevent fe~ ~phyxia
and to r educe injury and needless sufferillg of the
mother. !tis. done in. conjunction with ,eariy
episiotomy. lt$4"\'es-the.mother a period ofbearing- -- ~ ':~~~):~ - ~ .
Gown. Tbe~ction of the baby with outlet forcep~ . ::'
..~ '
is less da.m~gii~g than t3rolonged pounding of the . :,, .... .

h~ on ~e :pepneum.. . . .
.
.
.
. .. . . . -
In~tda-cto~eli:n>ifllsston:oressenuarsteps,
o ne ~.liounr l:ie--fr.alne_~ - to p-ea.orm. -rorc.ei)s
operations witb. a defipite routine in mind. The Figure 5.1 .14. Insertion of right blade between fetal hea d
details of application are illus trated as follows: and right side of the pelvis.
(Figur-es 51.12 -& 51.20)9

. .
. .-..
" '"'-'
-~: -

:<:

Figure 5 1.12. Insertion ofthe left blade between fetal head Figure 51.15. Handle of the right forceps _is lowered and
a'1d left side of the pelvis. the blade moved up
oyer the right parietal bone,

Seanne4 ey: c
 7S6 SECTl.ON Vtit DPERATNE OBSTEtRICS

FJ.pre S1.16. For~~ .,l.;>c~e4 ~ ~~pl:!.alic and .pelvi~

fi:.pplication. .
Figttte 5:1.19. Remov~oftbe right forceps blade.

Flgute ~l.lil'~ ~~.~e cutward and ~totty:Uritil

fue~cf~c~ ~~tl~ thei>yplphysis p:ubis.
.. . ..
lri.g= s 1 ;20. Removal of tlie left fcirceps b~de.

Contraindications to Use of Forc'eps

Absence of a pt.oper 41tlication

Incon:\pletely dilated ce~-.:: .
Marked cepl;laloP,dvic. d~~ptoportion
Unengaged fe~ :head
Lack of ~rience on t!le part of t."le operator

Dangers of Forceps 15

A. Maternal Risks
Lacerations of the vulva,. vagina, cerVix, and'
extension of episiotomy
Uterine rupture . l
Figure 51.18:The direction or traction.is changed to 'outward
and anteriorly to promote extension of fue head. Hemorrhage from lacerations

Scanned 8y: C
 CHAPTER 51: iNSiRUMilNTAL VAGINAL m;:uVERY: FORCE:Ps:ANO VACUUM EXTRACTION 787

Injury to bladder f1,Ild I or rectum demonstrated the u~e of a vacuum extractor, Jn

Infection of genital tract 1848. The modetn apparatus was made by
Atony of bladder leading to urina.ty infection Mabnstrom 17 in 1954., and the modified
instrument, now in ,gen~ml use, was developedffi.
B. Fetal Risks 1957. ln 1964, James Yo~g~ 13 had described the
Cephalhematoma use of a cupping glass on tht fetal scalp to assist
Brain damage and intracrani~ hemorrhage the delivery of the fetal head. In the Philippines,
General depression and asphyxia verJ few institutions use vacuum extraction a~ a
Late neurologic sequelae ... method of delivery.
Skull fracture
Facial paralysis
:srB.Chial palsy
Bruising

.One of the most worrisome a$J)ect;3 of forceps

qellver}r is the q\le~tion of long-term aclverse effects
(i.e.; mtellige.n~ quotient :score$ on the offspring).
Friedman and~~t.e$;6~ in a ~p!e population
.f:rOm. the coliabQratiVe :P erinatal Pri.>j~ . reported
towe"r m:e:an .tnt.~tligence qu()tierit ~cores for
cbildte~ aged 3-7 years who were delivered by
midfor~eps16 compared with tho;;;e 'born via
spo~Wle~1.l;:J vaginal d.eU.Yery.

Trial of 'i 'orcep!l and Fatted Fotceps

1: Trial.ofFo~ps p<;>stulate$ thata l'ter su<;cessfu'l

. !~aJ>pliCation has 1::>een achieved, gerttle traction
j~ rilade. Should the head come down eastly,
the pi.ocedure i.s c:x>ntinued and the baby is
deliv~red. If the o~q;.tor feels tb.at und\le
airi~~tof.f<>.~~. ~~~!~ ~..~ J9.~~.
:lli~. h.~..:!A~ fQ~W! -~~- fr!!i.QY~ .aP.d...CS. is oup'.'With-~ctiOi'dl~dlr.~uid~trap;-vacuum:-"gauge-:attd
carried out, In :<>tder to avoid delay,, all vacliwn.,p ump .(Courte;;yofDepartinent of Obs.tetrics &
preparations for csarean should b~ m a de Gynecology, St. LWce'is Medic,alCenter, quezon Cjty.)
.before the vaginal deliv:ery is attempted.

2. F ailed For~ps. It falls !nto tw.o .categories: ln~Hcations

a. Failure of application. the forceps cannot
be.applied properly t3 t..l).e fetal :hea&:
b. Failure of extraction. The forc.e ps are
appHed, bu~ despite an all.,out effort,
delivery cannot be accomplished, By the
ti'lle the .attempt is stopped, the b aby may
be.irtjured.
The .indications for vacuum assista..~ce in
vaginal delivery have changed over time. The
American College of Obstetricia ns and
Gynecologists' 12 current recommendations state
that the same prerequisites (or forceps must be
met .for vacuum extraction:

Causes of failed forceps include: disproportion, a. The cervix .tnust be completely dila ted
malposition, ce.r.vix. not fUlly dilated, constriction b. Ruptured membranes ruptured
ring, and prematUre interference. c. Engaged feial head .. .
d. The capability of quick cesarean section:ls
VACUUM EXTRACl'lON available '1!'
Saemann and Arnott9 . reported the use of Ma~e.rnal indic~tions include inadequate
vacuum instruments in 1.829. james Y. Simpson10 voluntary effori, soft tissue obstructiqn, and

Seanned 8y: ~
788

elective avoidance of val~va effort in the sect?~d
stage becatis e of pre-exi.sting cardiac or
cerebrovascular disease. So.me degree of
m~presentation o f the -ve~ often coexists 'With
maternal indications for intervention. Fetal
indications include anticipated c:- evident f~tal
intolenmce of:cont.inuet;I labtn. 17
fontanelle. As a practical guide, cup is generally the
placed as far posteriorly as possible (Figure 51.22).
This cup placement maintains flexion o! the fetal
head and avoids traction over the anterior
fontanelle. In positioning the cup, the physician
.Should be, careful to avoid trapping maternal soft
tissue between the cup and the feW head. 1s .

~here are some special cir<:-u mstap.ces in w.hich

vacuum -extraction has unique advantages:

a. (+) occult or over.t cord _.prolap$e in .,_

multj~us patient at c.Qmplete dila.Ul.tiOn .. ..
b. delivery of the s~nd vertex twiil from high.;
station when the centi,.'t ba~ be.en al.re~<l.Y "
traversed b-.f . the fttat - ~ rum.tbere - ~sl$ .
indication .f~r ~tervenijo~. .. : ~ .

COnttanldieaUi,~
. . . .
'llle ~~lla_ti~p., ~f the 'Vatuumd\Uitrg the fit.S.t
st9 :of~.~~,:~)l~di~~--I?l' the -!\nl~ .
CoU~ge 1of"'Ob'#:t~tpei~ita..;;andi""~ecc)Jb'gist$t~:-;" -Fii~=,S1L:.:;r.itPit"Qi:M~:P~~c:ht,,:>r-ei.ccuJ)i~d'iili'Va.cl
Relative con1i~lt):Qleation's' :mliUid~/ feta:1~ :Ji:ttaction; The 'Center of the cixp $bould1be over the sa;gitt...al
prema~t1~. P.~1:- ;~~J;at S<;a}p .-.~~:{frp'n.i:.'bl~ . su~ ~ ~ut ~- CJD._ ii.~ in) U! .ffont of the .~sterior
~pliJ)~:~r-~;iitj~ :~p~eeU,t)4~ijW,~$i. . fonqmclle.1he.-cup u genetally pla()ed as fat postenotiy as
uneng~C'a~f'e~~adi:,incon'lplete~:c~J:Viw:: 'PQS$ib,l~
dntat!Oiffi~tt~~zbJ~~d~-i)~rc,-r;:s~~~tea1z~t~l~. .-; .. ,. .. . . .
.

eo~tio1:J ..'d~f~p~,, su~pec.~~4::tne:ro.sonU.&;; .;

av.~:Jr:ta
A;ft~r ~e e11p is prcqpe_
po~ition:e4. thedy
phyS~ ,places t:he fulg~rs o( Qile ~d agamst
th~- Su."ctfoii~eu.,.., ancr-""1ls-
s :llie-:-Handleor:llie
............. . . . :. .........,.. --~--~---"-:. ... _!!f?____:__ '---- ....... ........ -- .
the arite,ior .bt;ttt.o.dk Of:f.l b.ree.ch- J).te:sef:itation ,bas- inst:tui'ndlt with the other h;md. .Qnce vacuwn is
been de$eril;)ed b~t v~e-uutn appli~tion to the applied. the CllP tohoutd not be twisted. Twisting
s,tt~r<Oming .had-~u:..t(> a :b row:or:face presentati~n thecup may lead to "esokie,.cutt-et or semi-
are deady contraindicated. circumfereptial lac.eration of the fetal . scalp,
. \ althou.gh this is less likely to occur With the soft
Proeedure Using Soft:.Cup Vacuum ~~ct1<>n cup th~: With the metal cup.3
. '
After the patient 'has ernp.tied her -bladder, she The degree ()fi~c\lUJ:h. deter:n:tines the traction
is placed in' the dorsal :lithotomy position ~thout forces {Figl.tre SL23). Effective traction usually
strappil;lg or :taping of her leg,s . Adequate requires ,a 'pressur,e: ofat least -0.6 kg per ctn2 (440
:anesthes~ can beobtained with a:n ep.idunll, spinlil tnm H:g)~ Although-more negative-pressures'reduce
or pudendal block The feW presenta;tion, positk>n the risk:of cup detachment, lowering the pressure
and station ar~ . th~n confirtned. AvoidiPg undue beyond -0:8 k~ percm2 (588 mm Hi)lncrea,ses the
stretch on t.'\e :perineum. the physician appijes the risk of fetal scalp and c~rebrocranial trauin~. 17
. soft cup by spre-ading. the .patie.tit's .labia,
compressing the cup and ihsertin,g it gently by Traction-should be in lin:e .with the pelvic.a.:xis
pressing inward l;l.ild downward with the . inferior and coordinated with matemal :expulsive efforts.
edge -QVer the pasterior fourchette. The :traction can be relieved ~r maintaiped.between
. contractions with .n o difference in maternal or-: fetal
. When contact is ma,de wit_h the fetal' scalp, the outcome. Some authors 17 suggest that conti.hued
center of the cup should be over the sagittal suture moderate traction may aidin maintaining gained
andabout3.cm (1.2 inches) infrontoft.~e posterior prcgress in descent of. the fetal vertex.

Scanned 8y: C
 CHAPTER $1: INSTRUMENTAl VAGINAL O:El;IVERY: FORCEPS AND VACUUM EXTRACTION
Ftgute .S1;23. .Snctioji.gan,ge,,~o.tion should~ gtilq-ated
until the lOng arm points to the ..Q.6 kg .per tm2 '(440 niin
-~~. as shown in tlje 'pict'.l.Te.
. .If fue (;llp .i s.d islodged, it is"re-a pplied only .a fte.r .
caiet\il1nspection of the fetal scalp for injUl'y. 4
..Tmctionis repeated with each con~c.tion until
the hciid i$ :crowned;As the head cleats the pubic
syll).pl;ly~t~~ the vert..exis P uUed:\lpwarii a tWt ~gle
ot 4-5--'degrces .to the fi6or. Once t~e bead is
delivere4, suction i.s released; and the cup is
removed. Pe.livery then.p roceeds asuspal.4
vacuum extractiOn shoilld ,not be ' .afti:!m .t ed
.for m6re fua:ii 20 i:iihiiit.es. T he proee<luf-e sil~uid.
be abandoned if delivery is not achieved .o r the
.labor does not progress. Und,er otdinary
circumstances, the procedure should be
. abandoned after three cup detachments, The
procedure should also be stopPed if there is any
eVidence of fetal .s calp .tra1,1ma.l
Complications
Matemal: Most series 17 repo rtd complication
rates .GQmparabie to.. th~t .see1;1 wi.th ~pontaneo.us
delive,ries. Compared to forceps d~livery, vacuuril
extraction is associated with J~wer vaginal and
perineal lacerations.
Fetal: These are similar to those that occur with
forceps and include: .
A large caput, which disappears by the fourth day.
Scanned 8y:
789
Scalp tr~u:m.a. Abrasions and lacer.a,tions of the
scalP at the s ite of application of tile cup, probably
as a result of the instrUment's being left on too
long or of improper traction. these are treated by
gentle cleansing and antibiotic ointments. The skin
at the site of the suction must be handled.carefully
tO avoid rubbing off oi the friable superficial later.
These areas heal without residual '!Jfects.
Cephalhematoq1as
Subaponeurotic hemorrhage
Retinal hemorthage. 'the lesiotl does not in: itself
appear to be clinically significant in 'term$ of visual
problem for the neonate. 17
Occasional intracranial hemorrhage
RecommeJ.ldations Regarding Vacuum
. . ' "1111 .
-Dellveey- ,
. . . _ . :)~~.:-:.: -~. ..
r ::~ i:~~.c~ :
.. Considering the 19:9 3 F.DA- ~b11c<t~l~!:llth
AdYispry, . the following recommenq~~On87}~
reasonable: .. -. >;
L The claSsification-of vacuum deliveries,sho~
-be the ~atne ..as -that utili:zetl-I~~':Jofe~:PJ~>
deliverie$, including station:. ,.~::.: :.~< Nj,;,.~-~::
2. The same indications and cont:t;aihdicatiohs
ut:ilizcid.for fo~s deiiveries.~ntd~ tippiied
. -to-va:cuUin.:a ssisted-:de'liveties: . , .. .. ' .... ''"' .
3. . Theva-ctmrrr snould- n.ocbe appli~d to an
unengaged vertex' (ie. above _zero station).,
4 . .The individual,perlorming or :B.$Sistitlg -i n the
procedure .should be an experi~ced :Operator
5. The q~rator should' be willing to abaridon the
pr~edure if it uoes not proCeed easily or if the
cup Ppops oH" more than 3 tinies..
MEDICO-l-EGAL CONCERNS
-Befcre forceps or vacuum extraction is
initiated, th~ parents should be given a clear
expl~uiatiotl of-the risks and benefits of the
contt;mplated instrumental vaginal delivery for the
mother and fetu.s. Advisin~g the patien~ that an
attempt at instrumental delivery may nbt'tes ult in
vaginai delivery may avold unrealistic expectations. ,
Avoiding .the 'use of forceps br vacuum extraction ,
when the f etus is hi{t in ~e pelvi~ can .r educe the
risk of complicaiions; . .
r-..
~
 790 SECTION VIII: OPERAnVE
. ~- . OBST.
. . ETR!CS

Follov.)ng forceps or vacuum-assisted delive!Y the. prote9-t1fe,: ~ recard of. the..discusSiori with the.
or an attempted assisted v~ginal d~l~very, patient and a.qet,ailed descrl_ption of the .P~~
documentation s hould include the indication fer itself.:lo . ' . .
. . .. ...

POINTS TO REMEMBER

Forceps are most popular in English-speaking countti.~. Ea~J~tn .. ~uro.pe ~nd _Sou~Ameri~; vacuum .
is preferred in Northern Europe, Asia, Israel, and Middle ~~~ >- ' ':
According to the PhilipPi~e Ob~te~rical.;nd Gyneco~~rWe~, 2ooi~2o~-da~; f~~Ps ~nd' Vciuu~
defiVeries .comprise only 1A3-2.44% and0.07-:0.2<r>k :respeclivety, of'~ginar detive'r\eS: .
The~
..
and beneJitS offQrceps '~fld vacuum ~~eries ~re -~ri1parable, -a~fdi~~- to the +~nt Codlran~ .I .
. . =.. . ' ' . . 'l ,,
revtew.
Vacuum and forceps.mnemonics for easy recall of .the important steps and aspects 'in doing assisted
vaginal deJivery -ar~ !isie<i .tro.-nAto J .
. . -. '. . . . . ._ . .. . . . . : . ......... .
SJmp~1's, Piper's, Kierii;nd's, Bartor1's a~q Tuci<~-Mciane ar~ five of the known forceps used in obstetrics.

fbrCEips:d~Iivety-a~o~ding~to.. statiom.andt:rotatio.n.of the. feial..head .?ire outlet forceps, low .forceps, -and ..
,, . . fuid~~: ~: . . .. . . .. ' . . , . . .

. Th~re'are~veral'co_ndioon's;_-an'di'p;-~requ1$ite.s. that must be met before usil')g tne .obstetJ:ic forceps..

- Non~ring _fetal. l!~art:rate .wnel'!1 is _the. most CX?ffifhon f~ta:J_.' indication .f<?r. theus~:-~t forceps.
. ,P~ed:,~d: ~~--9f ~oo;,;.~~t~aiexhausoon;'and''iriatemaJ-:dlsease-(~.' ~rdiac). :~re'ttie ...
matemai.fin!cirtioqs,tor;t!:le:J:lse.~of.Jor~ps,:>.- . ~ . : .- : . .: . .. .,
rn:gtij:~ to::pr~yent Qn1i~iqrts-: of ~ntl?~ -~eps. the.atte~ing .phy~lcian shql),td .b :tr:ai~ed :to perform
-tbrceps:<opetation~definite.OOtin~dnmind. .. c -
. . . ....:... ____ . . ,, ..... " -- -~ .. . ~ .. - ~ - -
' . .
h'l.CQmpletely dilated Geif-Vi-X and.'Jack of exp~rience on . the part of the' operator an~ some of th~ .
ro9~i~tions, t,q-th~ :~e0f J0rqeps.
.. ~ o'fthe birth panal, uterine rupture and injury to the urinary biadder are some of-the materrial
riSksin~,use of ,~i-ce~. . : . : .. . , . .
. ,
eepbalh~atoma, braln.ci:ama9~ .s~t,JII fracture -and ne!.!r:ologic palsy are some of ~e fetal risks duriog
forcePs. d~~ery_
Ti:ial0f.forceps means-that after su~e$sful applkatioh of forceps, gentle traction is a.ll that is needed to
aq)leve _p_eliverY. if hot, fmceps-are removed and ce$arean .. delivery is done. .
. Failedforcep~ -could b? due to 'failure of application or.failure of extraction.
In the-Philippines. very fewhospitals usevacuum extraction as a method
. ' . ;f ~ssisted Vpgirial delive!')'.
Thesame ~P.rerequisites -for:forcepsdelivery must be met for vacuum extraction.
The vaci:Jum- cup should be .pia~ .over.the sagittal suture and as far posteriorly as possible to maintain
flel(io,n ofthe. fe~l head ai1d ~void '.tractfqn over the-anterior fpntanelle. . . . .
once vatuufri is .appliect'; the suetion ct,Jp should not be twisted-as it may lead to seirii-circumfereritial
laceration of the fetal scarp.

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'
~1

!....:!.
CHAPTER 51: INST~UMENTAL VAGINAL DELIVERY: FORCEPS AND VACUUM EXTRACTION 791

Effective vacuum .tractlon usually requires a pressure of at least ..:0.6kg/cm2 (440mm Hg)
~um-extralrtil;)h should :not be attempted for more than .20 minutes. Under ordinary circumstances,
the procedure should be abandoned after 3 cup detachments.
Compared to forceps delivery, vacuum extraction is associated with iess injuries to the birth canal
Fatal complications secondary to vacuum extraction are similar to those that occur with forceps.
It !t always impOrtant to document everything whenever an assisted vaginal delivery is attempted or
.,..
-~ done: the indication, patienrs infonned consent and detailed description of L'le procedure.
..

REr.ERENcES. 12. American College of Obstetrici;m{' and G,}'DCCOloglsts.

l. Bofill JA, Martin Jr. JN; Morrison JC. The Mississippi
Operative Vas;inal TJ."UU: Lessons l~arned. Contemp
ObstefGynecoll998; 43:60.
2. PbiUppine Obstetrical and.. Gynecological Society,
. ~Mmittee on Nntlonwide Statistics & Annual Reports,
. 2oq~~2006.
3 . American College of Obstetrician.s a nd Gynecoicgists.
1998. Delivery by vacuum extta:::tion. Committee on
.. "_.pt)~fetric Ptactice No. .208.
~ " .~. . . offspring: A m.atched"Pa!r aru;ilysi&..Am J Obstd.Gynec.Or
_., 4 ....BofillJA,.Rust .OA, .SchorrS:J, Brown RC, Martin RW,
' < ".Mii.'"tln JN, e.t ;JLA randoMIZed prospective trial ~f the
obstetric forcep~. vers~s the M-cup va:cuum .extractor.
AmJObstetGyneco1l9:96; 175: 1325-1330.
,
February 1991. Operative vaginal delivery. Teclu'tical
Bulletin No.l52.'
13. ~erican College cf Obstetrician:; and Gynecologists.
. 2000. Operative Yaginal delivery. Practice Builetin No.
17.
14. Yeomans EP, H~ GD. Operative v~ .dc;fut::rt.;in
the 1990s. .Ci.in Obstet.Gynecd 1992; 35::-487. > _.
15. Fri~an EA, Sachtlebem~MUJTay MR;'~ge!:I;>~ .
Neff Rl{. Long~tenn eff~ of la,bor and ddiveiy on .
. '1984; 150: '9 41-945. . .
"'.'~.'._~-. ~~~~j-~~s:r:r.-: " .
16. Hankins GOV. Rowe 'IF. Operative~'~.('(~
2000. Ain J Obstet Gyneco11996; 175: 275.

5. Ross .MG. Vacuum delivery by soft cup extraction. 17. Lucas. MJ. The role .of vacuU!Il e:xtractiotdil ~-odem
conrempOl5i>'tera~ecoTl"'g94; .39: 4~53; obstetrics~ clin: Ob~tet Gyrte~l. l99'4; 37:"194:

6. Towner D, Castro MA,.Eby-Will<ens E, Gilbert WM. Etrect
of mode of delivery in nulijpa!'OUs women on n eonatal
intracranial injury. N Engl.J Med -1999; 341: 17q9-1714.
7 . .Johanson RB, Menon BK. Vacuum extraction: versus
.force~ for asSisted vaginal delivery. Cochrane Database
Syst Rcv'2000; 2: CD000224.
18. Plauche WC. Vacuum extraction. Obstet o,necoll978;
52:289. .
19. BajaPanlillo H, Baltazar FM, Su.mpaico WW.Tcmacruz
JC, Garcia FP.. Textboc;>k of Obstetri~ .(Pathologic
Obs~etrics). lst edition. 1995. AssociationoCPbilippine
Medical Coll~ges pASO.

8. Cunningho.m FG, MacDonald PC, Gant NF, Leveno KJ,
Gilstrap Ill LC. Williams Obstetrics. 19th edition. 1993.
Appleton & Lange. p.SSS.
9. Oxom H. Human Birth and Labor. 4th edition. 1980.
New York: Appleton~Century-Crofts, p . 292
10. Punniilglrarid<!J, Gant NF, o~veno K.J, Gilstrap LC,
Hauth JC, Wenstrom KD. Williams Obstetrics. 21st
edition. 2001: McGraw Hill Co. pAss.
20. Cutting your legal risks with vac14um-assisted delivery.
OBG management. 1999, March, p. 22. Retrieved June
19 , ~000, from the World WideWeb: http:/ 1
wwW.obgmanagement.com/cutriskfvacuumhtml.
2 L The Societies of Obs tetricians and Gynaecologists of
Canada (SOGC). ALARM International. A Program to
Reduce Mateq1al and Neonatal Moratality and Morbidity,
Fourth Edition, pp. 14-15, September 20(17.

11. AmeriCan College of Obstetricians and Gynecologists,

Committee pn Obstetrics, Maternal and Fetal Medicine:
Obstetric Forceps. Technical Bulletin No. 59, February
1988. ' .

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 .;:

Scanned IJy: ~.
 CESAREAN SECTION AND
CESAREAN HYSTERECTOMY
CARMENCITA B. TONGCO, MD

Definition

Indications

Historical Background

Technical Aspects

Preoperative Preparation
Timing
Decision to Delivery lime Interval
Informed Consent
Laboratory Tests
Incision Site
AlllibJotiC-pfOpnYiaxis
Anesttiasia

!ntraoperative Management
Abdominal Incisions
Uterine rnc~sions
Technique

Postoperative Management

Complications
Matemal Mortality
Maternal Morbidity
Intraoperative
Postoperative
Long Term

. Neonatal Morbidity

Scanned 8y:
Incidental Surgice.l Procedures
Tuh~l Ugation
Myomectomy
Appendectomy
J\dnexal Surgery
Hysterectomy

Perim,ort~m ..Cesarean Oelive.ry

\

FutUre oe~~ries After. Ces~rean .- TOLAC and VBAC

CS on Oemand
Cesarean Hysterectomy

'

Scanned 8y: ~
~
 CHAPTER S2: CEsAAEA~ SEcTION AND CESAREAN HY~TEHECTOMY 795
------------~--~--~--------~~------~~--------~--------------------~- ~

'1: ,
DEFINITION (unstable coronary d.is ease, Ma:rfan 's.
syndrome). respiratOry disease {Guillain-
Barre sy.n drome), and conditions
Ce$<lleail dt!livecy is'defu.!ed.. ~~ $he ddiv.e;ry of associated with u1creased intracranial
.a fetu's, th.roagh ~ surgical incision on the pressure.
abdominal and uterine wall.. When hysterectomy
is performed .in conjunction -with cesarean 1.2 Obstructicn of the .maternal pelvis by
delivery, fhe procedure l.s aalled cesarean x;nasses such:.a.s lower segment myomata
hysterectomy. or Qva.rian neoplasm m~y prevent :passage
o!. the pres enting part through. the pelvic
rnl>ICATIO!iS caneJ. Thes e r~sult in a conditio1;1 :cal1ed
tumor. previa~ Women with massive
ln g~~l. cesarean delivery is perfon:::i~ for :: condylomata m~y require :ce~ean.secti.on
two rn.ai."l reasons: 1) w.hen atty fuither delay in . as wen~ .
delivery will seriously c;ompro#se 'the mother, the
fetu~. ~r beth; ana~} whe11 vagm~ delivery cannot 2. Fetal indicatiorts~ tho$e that reay result in
be safely accompli$hed. The fudica.tions for fetal hypoxia and the possible )on.g-~rm eifects
cesarca!l delivery .may. be classified into 3 m~or cif fetahicid6sis l.i.ke cerebtal palSy ifimmediate
categories: Jj matern:al~ 2) re"l;al, and 3) combined deiive:i-y is not; . ~_.rfor(ne(t
mater-nal a nd fetaL These concHtion.s . are ........
-en\lf:littni::ted m: Tabl~ s2. u 2~). Fetal distress is the third most, common
-n~ason for the rise in cesarean. .birth 'over
the -last decade. Thi~ .is .re=adiiy.de!'ected
with the u s e of intrap.artuUL-:-fetal
monit!>ring sp.c.l::l :that PfOtnpt .and fast
delivery g!'events pr.olongatiqn of fetal
Meruc::w . . expo~ure to .the h.yP'ox.i~ en~o.-o..m.ent.
~speci.llf.tardiacdi~:(Ma~~s eyndi-o~~. :un:stable Ilow(!ver, wh~ther -~~ delivecy1 <b.as~
coronary ~IY cf#;ease) . . .r:esulted in' lesser hJ,POJPc msults.-Qb-.itb.e .
Spccifi.c resp~ ~ (.Qui:lliai!.~Barrc syndto.t,ne)
fetus and .red~ced i ncidence -of cerebral
~rur~ep. y.rith.~in~p~ure
ppl$Y, js s~ Qebat;,\ble. .-
- ....
.. . .: ..... ___.. ..... .... __ ; ____ __ .. __,__ ..
.M.-c:.Chanical..---- ... .:.. ........-.. ...... .'.... ..:... . ... . : ., -~ - - ~ ~- ~ '

. Qb.sttu.ctk;n._-of.thcl<>-.vd.uterii:iesegrnen:t{tlitnorn, fibroids) 2.2 .In.conditions -wherethereispotential-h:ahn:

0 bstructio~ of the vulva {condylomata) to the 9al>j .during a traum:;tti.c v.aginaf
delivery, abd.ominru delivery. is:i n:dicated.
:F.etar
.Non-teassuring fetal st<ttus Examples ofthese'are: .1) delivezy of a fetus
:Br~ Qr ;transverse lie in breech pres.entaion beqtus.e :head
Materilal~s entrapment 1s apossibili_ty, ;2) ~c~ssive . .
Congc:imal anomalies . fetal size.or S\J.Spected~osoiPia. {4500g
~'Corlt.ptolapse in rion:.pj.abeti.cs and. 42t?O_g in. d.iabetics).
whkh may1ead .to $oulder dys tocia -and .
Matero.al-fetal
C'epbaloj>elvic disproportion maternal and .fetal .injuries .. (maternai
Placental abruption genita.i tr-act lacerations .and uterine
Placenta p:cvia rupture, neona:h)l intracranialh~mo.rrhage,
E lective cesarean delivery brachia l p lexus. injury and fractures),
3) babies with b'irth defects such as
. h y~i'rocep ha:lus -a:n:d neural tube and
'0
abdomihal wall defects (omphalocde and
1. Mate.mal indications are 'Classified as medical gastroschisis) ... .
or mechanicaL . . . .
!~
..,..:. .
. . . 2.3 When there is risk of transmis'tbn of
1.1 SQme mediCal illnesses that may beco!lle . "infection when the ba:by ,passes trfrough
aggravated as a result of the stressoflabor th e birth c anal, .as in ,maternal herpes
or its prolongation are c3:rdiac disease infection, 9-bdominal delive.ry is preb::red.

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 SECTION Vlll: OPERATIVE OBSTEmtCS
3. Majority of cesarean deliveries are done for
.both maternal and fetal indications.
3.1 Placenta previa arid placental abruption.
3.2 Dystocia ar..d cephalopelVic disproportion
(C?D) present a .risk for both direct fetal
and matema.:l trauma. Fetal distress,
infection, and coinprpinised fetal
oJcygenatitm leading:to metaboliC 'acidbsis
may ensue as :a result vf.prcilo{fged labor.
Tr_anma to the mpth~r may irlv.olve the:
ge.q.ital tract (utt!rine t:uptu-re, atony
lacerations, hematomas, peivio hoorinju._ey
leading to. pelvic ~tion}, urin_azy tract
'{bladdti- a~o:ny. -l1rh"i~ iilcontirience, anci.
fistula~)~-and. recfuiri (fist\+la:s, iacerations,
a~'a fecal incontinencej . in. -addiiio:ll,
.-mc:.terrial. d.ehy~tion arid. exhaustion may
arise.
3;.3 Oth}-reiatiY.e 1 fri<!llci=<Jiioh~for' cesar.ea:n
'deliveryfudu<;ie'ny:pertensive;disord~rs.~
prci:tnt~ur-e :ru:Ptu;re~ 9;f".-me~brancs,
malpo~itions: {brow ;:fac~~ p~rs'isten't
O<!cipu~ (pcistetioi:); "{L'"l~ mUi,tiple births.
.. . . .
Elective tesar:~air de1iv.eiy also kndWp. as
"~;stio:I.J.on dem~<P -has.em~rgcd as a
widcl:y debj;\t. 'top5c :~ 9.9~t~m~ Q.v~x: ~ft. p ast
sev:era} years. Fe1dm,an a,rid:~Fi-'enn~ 1n Hf8's. fu:st
Q!Qi)~d elective--~;;~~ ~delivry-1n~on:fer to
p_revent f~W ~ro~dity and. -tii"~t.Y--~s"S&:iatcti
With lntrapattrun..e:Ven~. although =finhe pre~p.t
time . benHidai e':ffects on.. the mother are
-Mbiita:.bie: .Rlsksandl:>enefits a:Ssodated with
decti~~ ces~ -d~livery are
o~tUne.d iri Table
52-~ 2, the M:i~ii~-i~. C0llg~ dHYt?-st~tiidans and
oyJ;t~~ogists':(AcO.q,) "in L~~ y~ar-200B, :everttuhliy
B::6knowled~ea.tn:at ip cettain ca'.ses., etectiv.r
cesarean: d.d.lvery Illight b~ :petfbmied provided
that upan tho~-qgh evaluation ofthe obstet..---idan,
it' .appearsthat the-procedU;'re would . promote the
overall health and welfare of the woman and her
fehis. 2
HISTORICAL :BA<iKGROuND
Cesarean delivery has evolved from being a
.postmortem practice' to a vital live saving process
fo:t both -mother and 'retus.
. In the anderit times, the pritriary purpose w .a s
primarily ~o retriev~ the infant from a dead or
Scanned 8y:
. ':;"
Table 52.2. Risks and benefits of elective ce~ dclivery
Potential Benefits
ReducPori in ;><;rinatal morbidity.and morU!liJ:y ,
Elii:DiiiatiOn. Ofmtriipartuin'zyents assOciated~ p6inatal
asphyXia
Reduction-in trawnatic birth injuries
Reduction in $tillbirth beyond 30 weeks~gestfttion
Possible protective effect against .pelvic floor clysfunction
Potential Ri:>ks
In~ased ~hort-tetm, morbidity
Increased endometritis, transfusion, venous thrombosis
rates
Incr~-leri(ili of stay imd longer recovery time
Incr:a.Sedlongt~.tnorbidity ...
Increased~sk for.pfu.centa accreta and hysterectomy in:
subsequept ceSar-ean deliveries .
'
a:gfng mvther a.rrd n.o.t.~o pr~enje the ~ther's
life. This was conduct_ed in _the :wpe.cjsdvirig-
~ baby's .life or> a reqtiirement vy religious
lawS;. so:the:!tif~tmigMbe~bu.iied ~po.r-iaezy-;,, .
Jrorr.t tr..e .m:otfier_; rinil.p- the Roman. law. (Le:c .
~are), during the time of Julius Caesar;,
~ b.u'rials_for tli.? .dead rnpther and. her
fetus-~e ordete~- th+tsnece,ssitdting surgU;cl .
I;edwiJO.l.oft11E-fetus-3 . .. .
the poSSibility of sewing {>oth mother- aTulfetus
.. carl{e ii!ithin the grasp ofth:e inetlicalj;-r'rJjf$Sicn
tOwQJ'i:ts~tlfe-}.f!hc~ntarg. wrtJttne~oo~-fn:
iiied~Cirf'{iTiiproveii:aJie$tlies1a; asep$is~
ahti-bioti.cs, blpod 'b arikir:tg. ar:z_d. surgjcal
t echirique.S} and technology, cesarean delii>ery
has..bi!come more corrtinorzplaee yet vital in
obstetncs t>ecause -ojthe :many. f1icitemqi a.n4
neonatal.livl?S tlwt mwebetm savdfrom the
perilS_ of infection, hemorrhage. and other co-
mor.l)id m~dica! an~ surgiCal compliccitions
aceompanying p regnancy.
TEC~CAL kSPECTS
L Preoperative Preparation
1.1 Timing of Planned Cesarean Delivery
Planned .cesarean delivery should be.-.carried.
out when thereisno doubt that the pregnancy
has reached ter:m. An ultrasound do:qe early
ingestatlori: i$ verj helpful in es~bll~P.ing the
exact age of .the pregnancy.
~
~
.wr:
'"' CHAPtER '52: CESAREAN 'SECTION AND CESAREAN HYSTERECTOMY
1. 2 Decision-to-de!ivety Interval for Emergency
Cesarean delivery
In the face oftnatemal or fett'\1 compromise,
emergency cesarean deliv~ry should be
accomplished as quickly as possible, while
taking care not todo harm because of rapid
surgecy.
1.3 The Informed Consent
An informed consent is secured from the
patie~t after proViding her with evidence-
oa-s~d information that respects her
dignity., privacy. views and culture while
taking into consideration the clinical
situation. Inf!)imatiori on the following
.Piust be discussed and presented~ l) the
risks and benefits of cesarean delivery as
compared ~, vaginal birth, 2) the type of
..anesthesia and .the risks involved, 3} the
~ cype of abdominal and uterir.e incision, .
,. .. A) :tlie duration of operation, and 5). the
postoperative .c o\lrse and the possible
.C omplications at this stage.
Preparation of the skin is performed in
order to reduce the risk of wound infection
byd~smg the amount -of skin flora and
.:.<ntamfuilnt$-at ..the-.incision :site.~This . is
done- ~y- removing- h:a,ir- -and applying a
aurgical antiseptic scrub.
1.-5 Antii;Jiotic Prophylaxis
The single most important risk factor for
p(>stparlum maternal i.nfection is cesarean
delivery. Prophylactic antibiotic.s ate of
clear benefit in reducing the frequency of
wound infection and postcesarean
endbm.yometrl'tis by 66-7 5%, as shown in
the comprehensive Cochrane Revjew of
2002. The preferred agents for pnophylaxis
ate. :t;~,-mpidllin . and first generation
cephalospm:ihs (cefazolin or cefotetan).
Sin;gle-,dose therapy given following cord
clamping is just as effective as rnultidose
therapy. However, iliere is still a need to
determine the optimum timing of antibiotic
administration.~
Scanned By:
1. 6 Laboratory Test
In women with no known m~dical
problems, a preoperative hemoglol;>in and
hlc>Qd typing assessment may be the only
tests needed prior to surgery, primarily to
identify those who .h ave anemia. BlOod loss .
of more than lOQOxnl occurs in 4-S'.percent
Qf cesarean deliveries .a nd may be ~ serious
. complication that needs prompt blood
(eplacement.
1. 7 A~thesia
The types .of ~nesthesia employed for
. cesarean deUv<!l:y. are regional (spmal or
,epidural) and gerietru ~esthe,sia. There is
no evid~nce from the Coclri-ane. ~ew of
.~006 involving .16 RCI's (l5S6 :patiep.ts),
. to show that one type is 3upui& ~ the
Other in terms of major thai~rnal or
neonatal ontcomes. The;.:2()_(),~;,:NICE
.. Guidelines on Cesarea:n i j:$k'6'tion.
recommend regia~ anes$~~i~,.~~ause
it is safe and has less . maternal 'and
.neonatal morbidity than . general
anesth~sia (Grade A reC()nrirlendation}
. ,_
;5
' ..
2.1 Abdominal Incisions
-
T-he sui'geon has a choice of a vertical or
transverse skin incision. The types of
incisions are shown and illustra ted in
Table 52.3a:nd Figure 52.1. Factors that
influence the choice of indsion include the
urgency of the delivery; prior incision type,
optimum access to surgical field and the
potential need to explore the upper
abdomen for non-obstetric pathology.
T able 523 . 'fypes o( abdominal incisions fo r cesare an .
deliver)'.
Vertical Transverse
Midline Pfannensteil
Paramedian Maylard
Chemey : .;'~-
. . ~~
Mouch~l '~ ..
.~.'!:- - .
Joel-9ohen''
~
798 SECTION VIII: OPERAT!YE OBSTETRICS

The lower .a bdominal transvene Jnclsloa is

adequate for the vast majority of -cesarean
operations. It is cosmetically pleasing, less prone
to <lehiscence and incisional hernia, and less
postoperative pain. It is the incision of choice in
obes~ individuals because it avoids cutting
through a thick pad of !at aswhat woUld usually
happen with a vertical incision. ijowever, more
dissection is involved, and therefore, more blood
loss. The risk for su:p rafascial hematom.a is
increased due to interruption of t.'le perfora~
capillaries. Sensory .nerves are disrupted in the
.pfOCess of disse'ction _leading to prolonged
numbness of the skin arou11d the incision. When
be~er a ccess is need~d. thts incision may be quite
difficult to extend. This is the preferred incision
_e ver tl1e vertic~ . inci~ic;m according .to the NICE
Guidelines 2004 and giv.e s it a (J~de B
recommendation.

The traditional lower abdon,Unal incision for

. Ji'lpre 5:2.l.:Tht ~b~tetrici.an JiiostC9tnm:PnlY' .uses one of
three -ab.domibai -mcisiofis: ."{A) ..midiin<;;. :(B) -:-Mf1;yla.--d, or
(C) Pfannenstiel liatche4lines indicate possfol~me-':}siori.
Downloaded -'fi-om: O.bstetrid: . Nbrm:a1 and.Problem
Pregn~iiclea 2()07.
TraditicmaUy.:; verttcal incls.iQns wer e the
.c hoice ror ~esarean dellvecy bee.a use ofit:s many
~dv~~~e,s.
caesarean delivery is the in-cision des<;:ribed in
19.00::~y.:Prannenatlel. Tltis:incfSidniS'l~ttd two
fmgen..b~dth above the pUbic . S'%,iphy~ - He1e
the skin .js entered via a : low transverse incision .
that curves gently upward, p}aced in.a mtural !old
of skin (the 'smile' or bikini inGision), 15 tn long. .
When .expos~re with a Pfapnenitiel inciSion
.~~ nQ.!:~q_ough__~mt~.<l@tW.~ -~pace..iu"riqili.~ for
the dclW.et)'..of.the:::pab)!', th~May~d. Cherney, or
Moucbel Jllodifiea.t ion .m ay be u sed. i.
~.2 Uterine Incisions

In the: iO!dllne v~rtl~al ip.i$ion, the skin is Incisions on the t,tterine ';nusculat\ue are
~cl~C:Un ule ,Dlidiine betwe.e n the uznbUicu~ M:d class'ified .2.13 transver-s~ (Kerr incision) or
th~ .p Ut# symp_~ysilS and eattie:d ;down to .t he vert:icru (Kron1g and class ical hlcisions). See
peritoheuJn. This inci$ioh has tbe presumed Fi~re 52.2.
aQ.vanta,ge of speed of abdominal .entry and less
bleedipg. lt may be e~ended .u pwards_j,f inQt:e A tra.n svcr:s e inci ~ion . ~m the tower uterine
spa~e :i s req~ for access: The disadva.ri~ges . .0f segment, 2. c:m above the ):>ladder margin, is
a vertical midlble incision include the greater risk performed in 90 percent of cesarean deliveries. It
of postoperative wound dehiscence and is also called by the names: low tran:;verse, low
develo.p ment of. incisional hernia. The scar is transverse curvilin:eilr, and Kerr incision. It is
cosmetically less pleasing. preferred b~eause - l.t - d oes not compromise -the
l,lpper uterine segment, i s easier to perform and
In th,e paramedian- inc~sion, the skin incision . repair and is ass ocia:ted with less ble<x.lloss. This
is made to one side of the midline (usually right). incisio.n :proviqes an option for subsequent trial
Th~ pa.ramedi3.n incision is reportedly s tronger . of labor becaus~ the rate of subsequen~ rupttire
than the midline sca r but has no cosmetic is lowe r than with vertical in cisions that
a.dvanUi,ge. incorporate the upper uterine segment.

Scanned 8y: C
f
~--
..,..
CHAPTER 52: CESAREAN SECTION AND. CESAREAN HYSTERECTOMY 799
-------~------------~......:.-----------------.. ~---

.- - .. ~ .: .. .., .

. , ~ ~- ~
: .

:p
.
. e
' ' . ~020071o.dlll~ .. ~c;;~~
.. '

52.2. t,Jterinc:iDdsions foreesaiean & LOW~ inci ; lb..~

' Fi
-~-~ deJiv ..~JC;----~-
---~-9Y . -~-~Qtk .
'is r-e~ dOWliW'ilrt! and the incision is m~M i!! tb:~J~W.g_'L_terine -~~~~~- ~g
gentry ~':f!ilie~~ent isJ)riY developed, the incision can also curve Sharply
upward ateac:)t. end toavoid extending jntothe a,Scending brar.ches of the uterine-arteries.
a. LoW verti~ inciSion; The incision is made vertically in the lower uterine segmQ1fafter
refiecting the bladder, avoiding extension into the bladder b~-low, lf more iwm'is needed,
the incision can be. ended upward into the upper uterine seiment. C, Ctassic mcision.
The incision is entirely Within the upper uterine segment and can be at the.level shown or
inthe fu.ridus. D, J lndsion. lfmore room is needec;l when an initialtrnnsverseinCision has
bCeh ma4e. either end of the incision can be extended :upward into the upper uterine '
~g~p,en~and ~ t9 t}}e aSc.erid4)gbr1ui(:hvftb'e uterine artery. -~. T inciSion.. More
rodm can
be Qbta.ined jn a tran$Ver-..e incision by an upward midline extension intO the
upper uterine $egl;!ien.t . Do~oaded from: Obstetrics: .Normal-and Problem Pre~cies
-2.oo1
.
(on29
. . . .
Augu'sl200?}.
., -~

.... ... : ) ' 0 ,.

A vertical in~is.ion. on the uppe! segm~nt. is to more bleeding,. As such; Uiis incision~=,ca::nllot
called a classical ihdsion. Wh~n performed over stand ~h.e. str~'ss .of
~~~or ..and is ther.~_re a
the lower uterlne segment,. it is called a Kronig contramdtcatlon to tnal of labor. Th~te are
incision. The upper segment is a thick, muscular however, ce~in .~s.tance.s .when perf~~g- this
area and any iri~ision that inv'oives that ~ea fs incision becomes inevitable. .
more difficult to repair, heals poorly and is prone

Scanned 8y: ~
 800 SECTlON VUl: OPERATIVE OBSTE'rnlCS
t.a

Table 52.5. POtential. indications .for vertical uterine incision. 2.3 'The Technique

The technique of cesarean delivery is sti,ll

Undetdeveloped lower uterine.:segment.
Difficult access to the U.wer 1.1.terine =gment due to:
Varicosfties, Lower .segment anterior myoma
B~ or transverse liewith.undcvelop~d lower uterine
segment
Inability ~ develop bladi:ledlap 'bec<mse ~f adhesiQlls .!With
re~~ddivery
.
Antenor p~ta_p..-ev.ia
Neglected tran~tae:li~
When thereh needw.~iri.cision.in~otmacrosoicia.
hydrocephalus, fetaltnoi)ll~.that will require a
bi~inc:lsion to'.fucilitate deliVery.
evolving.~ search .for a technique that has .speed
and good exposure, without sacrificing hiood loss,
postoperative pain, ~ealing, scar integnty, cost
and overall maternal and neonatal welfare
cqntinues. Evidente~oased, go"ad. quality
re~Q.Jnmendatio:n,s o.n ~"Ppr()pri;i.t:e surgical
~e~hniq1les are currently . tin4~r U\'?'estigation.
.i The standaTd technfque of' low segment
cesar~~ delivery is ~hpwn 'iii. Fietires 52.4-52.10.
A detailedjllu~tratior::. nf th.e closure of the low
segment a:nd the cl~s~ical uterine incisions is
shown in Figures 52.il~52.12.

~.52A~~,~~~~:~clSi~~Mi~e~,fu#n:a~\ls-~.~diy~::a; Thesaoe
Iriidlin:evemaJ,;lidm&~ ~tii !lf1e.G,~""~scllr-tin<t:fiorotic tissue is rem9Ved1&r:bett~ beru.ii:lg'-a.iid ~er repafr
=to~~~~t~tl~~). :< . . , . .,. .

...

. :Ftiuris:;z;S. Ah'do:o:rina.ill\dsion:ia toritintiedin.~y~.. A. <;>pening{)fthe.~~.Liyerby.knife or. ~~n}: B/Ih.~.

perltQneuin ~ lifted. m~cirt"g ~e t.hB.:t .~-~enttii laceration to th.e bowel~ -~~ avoided. _'C,.. The p eritqneum.. h
incised tb$se thepecritoile<il :cont6nts: ~ar.e 'is taken to avqid .injutj to me urinary bladder as the.inosi6_n is
carried in[eiiorly, . .. '

Scanned 8y: ~
 ..
P
~
.

:.
.

CHAPIER.52: CESAR~ SECTJON AND CESAREAN HYSTERECTOMY ' .801

"i!-

52~6. 'transverse is-made I )Ver tlle lower uterine ~egment.. A, The towttvterli.e
segme;rtt is ~s. It is thi.D.ned out in tim;:patient but $-he previous uter:ine scar.i s inwet. B, The loose vi.scerai
~tone\un -qr uterine. serosa is incised and,a-hladderflap is c:reated to eilSU-re that the urinaty is~ away

l
I
from the area of incision. C,-1heufmls:b ~fl.illy :nd&ed flOOUt 1 em .below the ~ritoneA} ~n. using
a~~~ and.111aking sur!! that the p:'Caentins [.tart ;fs nnt~te4.

Figu.re.S2.8- A. T.he b.aby"~ t$bouldet3 .axe deliv.er:ed wiUl ~entle .traction-and thc:~~t-Ohthc:.t)Ody.foUows .Wi.th
ease. The urnpilical cotd ~s ciampd. a. Oxytocin is <~.dnlinistered to facilitate. Sqjaration of the placeta by
efih$ncing Uterine (:Ontraction~. Th~ placenta is SpontanePusly separated. The Cochrane waew.favo~s
method over manual separationoQs i tls aSsociated with 1ess~l6od loss and lesSe-riisk ofendomeqitis. <;~Jhe
neonate is brought to the p ediatric team_for the initial resusdtativt; prqcedures. ::-

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802 SECTION VIII: OPERATIVE OBSTETRICS

. .

FleuR sa,g,.A. ln~situ~~'ofthc uterltte edgesis performed ustng delayed absorbable sutllfl!s.1'hen is no
.add~: mt>ttildity to the t!lotherwhen the uterus is drieriorii:ed during the repair: It may facilitate~ but
tPe:e ia -~~ufflcient evidetiee to support routine ~eri~~ for rej,alr. Th~ uterlr.e inc;:Wcn is closed via a
single }!eyer or d~ouble layer closure. The ~est ob~tional study to date ~y Bujold, et G.L ill 2()()2,:found a
fourfol4 increase in risk of uterine .rupture am>ng patient$ with previous 1 layer closure compared to a two
layer closure. B, Completion ofutenne closure. The viscer-d.l perito:newn or bladder flap is su~d-bhclc. There
i:! limi~ed data to support thi_s practice. No-n-closure may be assotiated with less opera tive time, lesa cystitis,
-~~Jl~~for~ge~,vo~t,:5\U;tb'~ (;:;:.'ib~~o~ M4.fallopian-tu~~~ ~spected prior to ~osur.-: qftbe
- ~~~ - ; -. - . .- . , , : .. . '._-. , .... ... . .. . . .
......
' : .,

inf!~_l)t\!1. ~d :with les~ need tor posto~tive . . 'l'Pe re<:t\Jil -(~ is :C.lQ~ . witb
dtherc:ontinuQus ru,nning ot:i:nterr-upte(l tec,hnique with 4e1ayed ab~rbable, mono(lla,ment s\1~ SUtw-__s
should be placed at.leastl .Scm aWay from the margin oi the inciSion to prevent cu.tting ~ugh Utefasciathat
will te.$ult in wound d isruption a rid Jncis ional hernias. For ca$es ~t risk fc;>t woUI}d dehiscence, tlle -~Cad
JoJle3 (ftrr~*-ea.r~ .oea,r-far placemel.lt .r;>,f ~t'M~s)i{l f'e90pllllen4~. Th~ .SU'l>cu~eo:u~ tissp~ :is ck>~~_ if:~ fat.
tbi~~:.2 _cixJ,jh,orderto!al;illta:te.~~~~;:C., $kjntlo.lf.m:Witb~~ticUWsutlireis~~
..pl~g cotilpa'ted t()' $taples and i:Ujus~t&liliith le-s11pa:bi. :
_. . . ... .. -

Fi~ s2.11. Cti>$:eoito..v~~~tscd,nci~-~ The first

layer i:4Q be.e;ilier interrupted -or contiri,ii}ius. ~ c;ontinuous
lo.c ldttg sl,ltur.e js -l es.s desira ple,__ desp.ite . ~~ reputf.d
hem.os#l~ abiliti~~.;l:>_<;cau~e.i t!..P.l.!iY~t.ei'f~~ incision
va~tute a:nd,:hence, with healing and tear fOnria tion. B,
A seco~d inverted' layer c~ated b.Yusi,ng a c:Qntinuous
Lembett's or CUsrungs stitch .i s :tustottiacy"but is really
needed only when _a;ppdsition .is .unsatisfil,ctory after
application of the fu-st layet. Inclusion ohoo much tissue
produces a bulky mass that :may--delay ~volution ' and
interfere with. :healing. c, T~1'e bladder peritoneum is
reattached to .t he- utedne peritoneum with fme suture.
Downloaded from: Obstetrics: Normal .a nd Problem
P regnancies 2007 (on 29 August 2007).

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 CHAPTER 52: CESAREAN SECTION AND CESAREAN HYSTERECTOMY
...........,....... - 3.5 Catheter Remov:al .
Figure 52.12. Repair of a classical"incisicn. Three-layer
closure ofa classic incision, including inversion ofthe serosal
layer to discourage adhesion formation. The kriot at the
superior end o( the incision of the secoru,lla,yer can be buried
by med,ial to lateral placement of the suture from within the
depth -ofthe~on andSl!bJseque:it la~ to ~edi.at r~try
.on:the oppo!>i.ng side with resultant !mot placement within
.the inciSion. Downloaded fro1n: Obstetrics: Normal and
Froblem:Pre(':nan'cies (on 29 August 2007).
3. .P()stoperative Management
. ....:.
. 3-.Uwmed.iate Post-op
After surgery, w0men. should be observed
.by . a properly trained health personnel
until th~y haye regained airway-conqol and
caraio-~resp~_a.t~ry: ~la.blHt,y;~~- ru.-eable
to
communicate. After recovery from
anesthesia, observations (respiratory rate,
heart rate, blood pressure, pain and
sedation) should be continued until the
mother is stable.
3 .2 Pain Relief
Relief of pain after surgery could be
accomplished via intrathecal/ epidural
morphine, opioid analge,si cs or
nqnste.:roi~~l - anti-in,Q~mmatory ~hugs.
3.3 Ambulation .
Early ambulation a fter surgery has many
advantages. It enhances p\llmonary
rdnflation of collapsed ,alveoli from
prQlonged immobilization and promotes
return of urinary and bow~lfunction. Eight
to twelve hours followin g an
uncomplicated
Scanned By:
803
surgery, the patient can be all~.Jo sit
up. Ambulaticin can be started within the
first day after operation.
3.4 Early Feeding
The evidence from the Cochrane revie1..
does not justify wit..lilioldirig food and drink '
after uncomplic~ted surgery. In the
absence of bowel manipulation during
s~rgery, e~rly feeding is recommended
because it may speed up bowel recovery.
Women having cesarean deLivery with
regional anesthesia require an indwelling
urina.-ry catheter t:o prevent over-distension
of .t he bladder because the anesthetic block
interferes ~~ normal bladder function .
Removal of 'the urinary bladder catheter
within 12 to : 24 hours :; follow.i ng
.uncomplica,t,ed surgery. is saie:~:c \ ;>~ :'.kt..
-~ . \~
. ~ ': :--. .. ' i :~ -~..:.~-~:~
. 3.6 Wound Care ;..,, ' I
The -operative.wound -is . in~~~~d;,and
cleaned on ..the second.. d.Ct.y .~ ,:S~ery.
TenQ.erness, redness. and ::.4i~~P.,argc
indicate wound infection.. . . ;. .. ;
3. 7 Breas_tf'e.e.ding
Breastfeeduig. is not contram~ted after
ceSarean d elivery. Many women-who have
had a cesarean.delivery need tnan:.support
on this, as they are less lik.eJ.y 'to start
breastfeeding in the first few bouts after
birth . . However, once breastfeeding is
es..tabli~hed, they are as likely to continue
as those who had a vaginal de~. (NICE
Guidelines 2004, Grade A recommen-
dation)5
3.8 Hospital S tay
Length of hospital s tay is likely robe longer
after a cesarean delivery {an a?aage of 3-
4 days) than after a vaginal birth (average
1-2 days). However, wome.;a .~o are
recovering well, are afebrile, ~.c;Cdo not
h ave ~omplic;3.tiqns may. '.b e offet~d early
discharge (after 24 hours post qelivery)
from the hos pital and followed up at h ome.
C
804
..
~:-t
This~ practice
is .n ot associated :with more
infant or maternal read.mis:;)~ons. (NICE.
guidelines 2'064, Grade A recommen-
dation)
COMPLICATiONS
1. Mat~rnal :M~rta.iity
COmpared with Va_gip:81.deliv:ery, the Il1atemal
mqrtality and moibidicy ru:e iQ.creased with
ces8.r.ean'de!ivel)', fton;dour to nine -fuld, eve n
when preexisting medical co:np~cation~ are
e.xclud. The. risk is :f4ct.e aSed. i;n .emergency
.e:o.m pared With elective cesare~n cases.
Materi:laldeaths due to cesarean delivery as
repo-r:~ irlliteratu,re ln the "United States and
.Unltf!(f'Kthgdoi:ilf.tbmi980to-2000, railgefrom
:6 t().2!2'-pef 100:000~67
2:: Nebn.it;Mor:b"icUty
. .. : . ~ ;-.:. ' .. ~' . . .
.Th~-riS~:if;&:. e~~,~v.ecy'"to~O'il.eonate~ .
indude:'l~tr.qge_nic >:.p rematUrity:; :-'i ncreaseO:=
r~spif.ator-f . w(irbi~t:y ~{re.ipj.:f.atpr:y~,di~tr.ess
syn4,{Qine~ tr.,_:q,sie'P :t . t~C:hy.pn,ea or the
.newb.dfu;.i neohitatdj~'ssion' .i 'rbm<g~ner-al . ' .
;anesQI.es!a}f~~.s~t~ ''4eHiyid<=:'A~ttr6togi~!
. a~'Prii.tl~~ and ~t.tdayea;',esta~li~liertt,:of .
b~tf~.. La,pqr: m<:h:t~~s :th'e r.~lMsa of
~~tal...~l_e.Ghl_~~~:s. )~t..~~agl15!i~l~h...~P:~
~pJ!Lcphrl;Jl.e..nece~Ji'P.:.I.l~ilit~:aqgJi~t:i<?.p..
tO ~~eli,fe.. rru~ process .is :~ppar-e~tly
. laClObg:~ym~1et:tive:~sar~!ielivery.
11l~se 'ti'skS p.~i!e ~e J,}<it~n:tihl t;o .prolon-g
hosp'if.~.I:stay, u8e:t.~tUtiO'nal.ir).tetv.en:tion, and
in:ci:..A~e the' cbs t ~Of'-rreona'~ cte.
. Ce~ deliyety-di:>es-not.~ntke~y protect the
:feh). s.{t'ot~l1;1itth: ~rauma; lx1 .ar.eport by
'Alexahder a11d kverro iii 2o'o6, o'f 3711.0
cesa:re.an Q.di~ eries fr. 6m 1'9~.9 .. 2000, 418
(1.1%) had fe~ ~jUries, :most .of which were
d.ue to slqq. la~eratio:p_s 'il}.C\ltred .d uril1g
inci~ion -of the uterus. M{;>st injuries were
d eliveries
associated wlth fast .. . .8
3." I ntraoperative Co.mpllcatio.p.s
3.1 Anesthesia-relate.<:!: mortality~ has been
sil.hs.taritj.~lly .rt;,dtiCed qec~:use of the
preference for regional anesthesia. Deaths
related to generaf.a:nesthe~ia. are due' to
airway m<'\Ilageinent probleins , aspiration,
Scanned 8y:
intubation errors, inadequate ventilation
and respiratory ~ailure. Deaths _d ue to .
regi9nal anesthesia.:r:esult from anyithetic
toxicity or: inadvertent high ~pihal or
~pidur-a.l blocks.
3.21ntraoperative sii.rgical .compficalif:m-s
dq.ri;ng; cesarean delivery it~elf'.,in.ciucte
hemorr:hag~ :an4 injury to. .p.eivi~ : 3.nd
adJacent organs (bowel, bladder,:.uretet"S)-.
T:he key is to t.ecognize. and. 'define the
~en~ cf these ir,juries and to promptly
institute repair.
. Uterine La~erations
Lac~rations of. the uterine incision most
commonly Tnvolv~ extension of a low
~sv~e incision to-llowfug pr610l1.geP,l.c:!.-bor,
low ~tatioi;t af the :p~e:sen~g pa,ri:;,.:or with
deliv~ oC:a lru;ge fetus. Most lacerations are
myometrial' qensions and ca:n be clo~ with
.a nh'lning-lodring
.
.. suni-re
. ...~ ...:,....-.. :. .,.
B!adP.er Injury .
Injury to ~e blad:der may happen; in the .
:. followmg:in.stan.ces:: J.:rwitli'vigorous:re~ction ..
by.the .~ssista:nt, ;2).'when dense adhesions are
pr(!s,e~t l?anicu}a,rly Wifu multiple.repeat
~~~fion:!!:3:-"19:..9t. ~her:"".w~.-~J.~mr-.!lj:gjp~
!.Vall J~. '~~vet~-~GlU:t.,~d. :.~PJ:Ltn.e .:blftoder is
a <il':lerent to tl\e pre'vi(?us c~sar.(!a.il sear. In
these in~ta.nces, i t may be ad-viS able to. proce~d
with:a v.eiticaf :ute;riq.'~ilicision to aV:oid bladder
disruption .. :Enadd~r dome likenitions are
.geneta)ly 1-epairea in 2 layers. Continuous
Fotey drainage !ihould be accomplished for
s evefal days following repair of a bladder
. injury.
Uretercil. Injury
Ure~eral injury.1s uncommon in cesarean
delivezies:--T-he .freq1,:1e~cj
of injury increases
with cesarean h ysterectomy. Most injuries
follow attempts to eontiol bleeding fro.m lateral
ext~nsi<:m~ of the ut~rine ir).cision into the
broad .ligament.
. Gastrbintestinal Tr~ct Injury
Bowel injury during cesarean ~ection fs
rare. Most cases involve incidentallaceratio ns
 CHAPTER 52: CESAREAN $ECT10N AND CESAREAN HYSTERECTOMY
on entering the abdomen for a repeat
laparotomy which can be repaired with
interrupted sutures. Long la~rations on the
small bowd or colon generally require referral
to a surgeon. Broad-spectrum antibiotic
coverage is recommended for such cases.
4. Immediate Postoperative Morbidity
The principal -c auses of morbidity related to
cesareQ\ section durlr..g th~ puerperium are
infectious and thromboem'bolic ~sease.
4.1 Endomyometritis
Post--cesarean endomyo~tljti~ is stj_il the
JD,ost common coPlp~c~'ijol:J. of cesarear.
delivery despite its r~du.eed frequ~ncy
-- b.~~ause --of prophyhictic .' .. antibiotic
regimens. In the pa~t. without
"'! " a.dm.inistration :-o f prophylaxis, .p rimary
cesarean delivery with labor was
associated' with an average rate of
endo~et:ritis of 30-40 .pen::ept, as well as
pelvic abscess necessi~-. hysteredomy
- P!'_;m,l~rlmposetf -sept;ic-tlui;ltnoophlebitis. -
-~ ... - -Lqng - 'labor, prolonged -ru-pture of
. membranes, and lower -soCioeconomic
stati1~ appear to be the -~ ~~t most
~\!~n~!fi.~_.rn!~_gf~thl~L~;~:1~.RIL~li..9.!1.
The majority of cases of endomyometritis
are ascending infec-tions f.rom the cervix
and vagina. These may extend to the
uterine musculature, produce perit<?nitis,
abscess, and septic phlebitis ~ The
. diagnosis of endomyqmetritis in a
postoperative patient is -su.$pected ii). the
presence of fever, uterine tenderness, foul
lochia, and leukocytosis, With a history of
chorioa mnionitis, prolq11ged labor, and
_ ruptured membranes.. ~ndometiialc,::ulture
__js C!i..Ufl:lJte,P value o$g. to contamination
with vaginal flora. Parenteral artti\;>iotics
directed against' pos~ible anaerobic
infection are the preferred therapeutic
agents. These include Clindamycin and an
aminoglycoside such a.s gentamicin or a
single-agent .p~lactam. For wo~en who fail
Scanned 8y:
805
to respond to antibiotic therapy OY,~J. 2 to
3 days, an alternative source for fever the-
such as a wound infection, deep abscess,
hematoma, septic pelvic thrombophlebitis,
or mastitis should be considered
4.2 Wound Infection
Wound infection complicates approxi-
mately 1 to 5 percent of c.esare.an de&.:eries .
.In approximately 90 hospitals locally, the
reported rate is less than 1% (POGS from
2003--2006). 9 The diagnosis '(lf wound
infection i~ _usually straightforward when
tenderness, erythema, or diScharge are
present. In the ftrst 2 days after surgery,
wound infection is often du.e to
s treptococcal infection, whereas later,
infectiqn i~ g~neraUy cau$ed.by overgro~
of staphylo'coccus or a tnbce_d ae_robic/
.. anae_rol!ic -infection. If 'Ql)treated,' this. can
lead to wound disruption or :dehiscence.
Extre.m~ : w.ou.nd .discoloratJo~~-oJ,..tbe
surrounding tissue, particu"4iiiy~ft:'the
patient is verj ill with.markedleukOCYt9~s.
should .prompt consideration.ofnect'Otizing
.fasci,iiis.' 11Us,has been :i1:~~ :in .,_l .in
.. 2,500 ~of- wotlleri undergplil&i:P-rfina cy.
cesarean deliv.ery; - ' ' -- -~- : '
. ::~.!il.~'~' ~-~~;~~~ '
L:-_, .' Y. .f'
WQun,~ disc;)large. WQOlild . b.e ~~nt for
. -~4l!YrJt.J!ti..9._L!Q __tbern,py.~_Th~~_lq{~~te:9.
_ .. por:tmn~:OLthe. .wound ~ho.Uld_be_ :open~d.
inspected, irrigated, and debrided a s
necessaiy and the wound is left to close
by secondaty intentic:m. Ahbbiotic co_vera ge
should be insptuted promptly !or advanced
seriou~ wound disruptions . .
4.3 Thromboembolic Disease
The risk of deep venous thrombosis iDVT)
is elevated dudng pregnancy due to higher
levels of clotting-rad:o:ia and venous stasis.
OtheJ;" factors that .pr.edls.p ose to this
condition are the puerperal period ,
cesarean delivery, ihlmobility, obesity,
advanced age, a11d parity. Wor}dwide
incidence iS 0.11% 1n women undergoing
cesarean birth, while_locally, this .\%:,0.01%
(I'OGS 2003-2006) .-~ Untreati'Cldeep
;~
r-..
~
006 SECTioN VIII: OPtRATtVE ~ICS
venous t hrombosis can progress to life-
. threateriing pulmonary embolism in up to
25 percent of cases. Prompt treatn'lent with
antico8:gulation r.educe-s thi's risk
substantially.
Symptoms .of DVf are unilatersl leg pain
and swelling. ao.man's sign (pain with 1uot
dors~o-n.) is often observed if the talf is
involVed. Many ,c ase$ of DVT present as
pulmonacy tinbolu, (PE), particularly in
the postQperativ.e patient, manifesting 9:s
tachypnea, dy$:pnea. tachycardia, and
pleuritic 'p ain. ana
cough. ooppler studies,
impedance . plethy-stn<>graphy, and
Vei'l9~iatn are u~e:ful to t$tabHsh the
diagJlosis.
4.4-~ptic Pclvie 11ui:>lllbO.p lUebitls
. S~J).t,l':! pql\ric thrombophlebitis is niost
.. :'"41!\eP .a .diagni:>-sis.O.f.exl~~ion. i.'l those
be . ..,_..,t~.~........... d""
~otrl"'~ti.. 'a nd not
. _; ~- . ,Ul$~1:"'.~ . qi:.~"""'~ . .,.pl.,!- . ,: ~~ ,.., ..
. .. ,. . . . .
.re~panding t():'f;teatnient. s~td:oms .are .
spikiil"lioetur:n:arf$et.pnd ehills. A pelvic
er~.:mq.aid-itt~e~r;Us_.~though
. ,Jhe..:.$.~n:siUvity . @r;i ..,$peetncity ..of. thi.s
.. :,~q~tt~ ,cl~fy. 41Uficnn'::t o:.establish.
.~Jli pril.ctlct:. v,.. !l;bpleLp.a tient/ who has ..
unde~nc eesatean'. ~elivefY.artd : fails.to
tesppnd:.~~ ~B.P,pJ:o:ptht.te .broa..dtoverage
. $tloi&tic.~~py.;to.t"-.$\lSpe~leCl-~ter.ine
. --infe.G~O.Q:-is;~~:a.- on-;fuU'-'dose. ,heparin
th~rO.:py whi~ll :1$ .':corifu11led Jot s everal
Gay$ foliO~ a :CiUnieal te~~~se. When
there- l$ .ji-o te$.J>o.lil~ tp a:g:t;icQagulatioxi
. th~py, .~m~gi?g $tmiie~ i,n.ohuling pelvic
cr w~ ~dicat~ :to. ntle out an abscess or
he~atoma Refractory .cases may require
laparotomy -1\tld :})y:.;ter~t;>my.
5 .. Long Term f>.os~pe.rative Morbidity
Pri~r.~~area,n delivery 'increases the risk in
.subseqUei).t ptegna_n.clS of Uterine de.h iscence
!iOd t'\lptUt~. and multiple placental
abnormalities . s~ch as a~M1P~io placenta,
. plac~nta pre\ti~ and -abno:rmal adherent
.placenui.tion (placentf;l a ccreta, increta, a..pd
pettreta). tlie$4! conditi()ns in turn; increase
the possibility ofmtrapart\lJn hemorrhage and
periPartuin hysterectorily, 'blood transfusi<5ri,
puerperal infe.ction.,_pretetn'l births,~d infant
death.10
Snanned &y:
INClOENTAL SURGlCAL PROCEDURES
1. Tubal Sterilizati~n
Women with tncltiple .c esarean deliverie:s who
do not desire ru.rther chUdbrearing may be
offered tul;>al sterilization at the completion of
.closure of the utt:~e incision. The procedure
for ~bat ligation {Modified Pomeroy, Irving,
Uichida techniques) is the same as that which
is ~rfonnEd in the interval or postpartum
period .followi:r)._g a vaginal deli:vet-y.
2. Myomectomy
The prevalen.ce ofleiomyoma during pre.gnancy
.is abb\lt 2%: Pali~.n.ts often request
siJ:Ilill~~Ut :~q~ect9my during <:~sarean
<1<$v~ry! it wa~ preVioU'sly thought that it
would be ptudenttp a..v()id thispractice, except
~orpedun~.ub~ou~.myom.as, ~use
'oi the<riiS'k:,G~jnti'f;lOper.atlve,.,bl~edin:g and
. .sub~~qu~t need: (or 'blood transfusion .
.Morto'li.et;- niy>:tnas. often det:rea:>e in size'
:dUrlll,g:tht:puti.rium..B-u.t n<~w,"many reports
.ot~~;on:1nyottte<;:tb.my-<lurlng:ce~ean
: ,4divezy; "ilfQC:it:~.:in siZe~ : ~how Ulat th.e
procd'i.i:.'"'e: le ~~ ~ven -Withthe=intra,mural
~~~ . ::Q.Jl~. is .tlot as~~~at~~ ~~ .. adverse
QU~lJke PQ.s.topera.thte. morb1dities, need
1'6t"hY~te~y~ ~JI10'te~b1txx1'1os~s- a:ncttortger
liospnat$lay.
3. Ovaiian 'Sl.u:g~r,y
An ,ov:ar.ilmne.Qp4lsrti f ound .during ceS<~.rean
d.eJ.ly.ery ~y -~ ma:J.l.~ged by oopho.r:ecystec-
torny or .()Qpbo~oxp.y as in the non-pregnant
state . ..
4, Appendec~my
Thete. are no .. ~t\J(i.ies..:t o ;pt;ove U;tat d;9ing an
elective ~ppend~tomy is completely safe and
.should.. b. ~mmended .
. 5. Hysterectomy
Hysterectomy durfng a cesarean delivery is
called a c esarean hysterectomy. It is discussed
in detail in the next section.
C
B'
~
-~~ ~..;...
- - - - -.....
C_H,....AP....,.T'=E:c-R-5-:2:~C:::E:::S-:A7:'R.EA::- . T:::IO-:-:N-::-A::-:N:::D:-C::::E:-:S:-:A'::-R-=EA:-:N::-:-:HY~S=TE==R-=ec:::T=-:O:::M7V:-------
:-:-N~S::-:t::-:C::::: 807

:i: pJ!;RIMORTEM CESAREAN DELIVERY 2. Candidates for TOL-VBAC ;

i
The followmg are sekction criteria s uggested
To save the .viable fetu.s of a dying pregnant by ACOG (2004) foridentitYing candidates for
woman, periciottem ce~~~- de!iveiy may be VBAC tc) ensure a safe outcome:2
performed. In the fa~ of metabolic:detangements
in the dying patient, prompt delivery il:l of 2.1 One previous low-transverse cesarean
parainOunt iniportance in order.for fetal autcome . deliv~ry .
to be good. When delivery is accomplished way 2.2 No ceph~opeh-'ic disproportion
.after the a,rrest, neurologic sta.tus of the baby "is 2.3 .Nc other uterine s--..:..ars.or previous rupture
comprox:pised. The recommeqda,tipn by ACO.G (itl 2 .4 Physicians immediate~y avaii'able
19~8) isto do the ~e8arean delivery within 4 to 5 througho-u"t active labor capable of
minutes <>f beginnin,g CPR. !t has been -~und tha.t monitoring labor art~ perfor.ning an
98 pe~nt of inf~t!l. born witllm thi$ t:i,me .bav:e emergency cesarea,n <;lelivery
their neurologic functi<>ns U:ltact. Legal liability
from the operation "is minimaL- .3. Success Rates for ve.Ae-. .'
The overall success rate for VBAC ranges -from
FlJ'nlRE D&LIY'lt;;u:.f~ .ArtER ~ ~~,A:..~: 70 ~80% according to published -reports .
Va:~ {VJlA.C) v~~'QS Al>do~ Route . R9weve~, there is no reliabl~ and consistent
niethO<;l to-:predi~t- the ~uc~ss .o f a tot and
1~'-'The di*tum that -~Once a cesarean. always a vaAC for every 'pregnant womari. ;Cet;t.a in
-,ce~"by Cr~ in 1916does:nothold t,ro.1e matetruil characteristics may preqic~~s~ss
at the present time.'J;.hat s~teroent ~made ofVBAC
.
{seeTable
.
52..4).13 .. . ... ..-.;:,.:;.:;
.-.. -.
wh~ thevertital~sSicalincision, the~er :-:::~\}~-:..

t,: . '~FV{a.s the nortn. However. in 19,2 1, whc:n.

~ ........ 'Kerriiittoduced tbeben.efitso!a'lmvtransverse .
~2.4. su~ss rates for trial of labor {ri::?L}':tiller
[ ;-c'ces~ u1cisioil.- many cam~tu:, chal}erige iabto ce!!ar~ delivery. .:' ;~~~,;
if :: CnU,ghl'*a p!,'Onoun~ment.ln l978; Merill .~d :', . . t ~ -.:

Gibb!l from the Universi-ty of Texas reported \'BAC Succe8s (%J;:t:.'''-'

t:tr~ AAf~tY of vaginal bir$ after ces~en.
n.rt:J.A.C.' ~""JiS.-: - t -"'
."f.._"".-; ts whQ ~---
lt-d a I?rlor Indication
,~ '~--"... pe.rce_n -~Q---~---
t~FP1FI"P" 63.5
preVious..low ..segment .cesarean deliv.ery__and .NRliWB . 72;6
were allowed a trial of labor (TOL). This paved Mai_prese:atation 83,8
the way Jor a renewed iri.terest in VBAC arid it
became .an. effective strat~gy in c-grbing :the Prior Vaginal Delivery
Yell
rising cesarean d6livery ra.te~. ~e:praeticesaw 8Q.6
its peak -in 1996 but only to .dedineih~er No 60.9
as a result of repox:t13 .o f ca~stropbic uterine Labor Type
ruptures which a lso led .to more m~pni.ctice lliductlon 67.4
suits. A more conservative stance has been Ai,.tgmented 73.9
adopted by its support~rs and VBAC Spontaneou~ . 80.6
recemmendation$ are -conliiluou.$1y . being
updated. 11 At present, the latest practice CPO, cephalopelvi:: disproportion; FTP, failure .to progress;
NRFW.B., non-reassuring fetal well-bei.tig:
bulletin {2004) by the AGOG: on-Vi3AC states Adapted .from Landon MB, Leindecker S, Spong CY, et al.
that most women with -.o ne previous .c esarean Factors .affecting thesuccess:of tri8.l of labor following prior
delivery with a low-transverse incision are cesarean delivery. Atn J Obstet Gynecol2005; 193;101 6.
candidates for VBAC ba~d on certa,in.selection
criteria, -and should be counseled about VBAC
and offered a TOL. 2 In a ~tudy by Gonen in 4. Risks of VBAC
2006, the ris\c -ror uterine rupture can be
m arkedly reduced to a rate of J.2 per 1,000 Vaginal delivery is generally associai~d with
when the Candidates are properly _:s.creened: I~ . lower morbidity an'd mottality ratls than

Scanned By: ~
~
8,08 SECTION V!H: :OP.ERATlVE. 'OBS..TETRlCS

. cesarean delivery {'i'able'52.S):H However, with
VBAC-TOL, a very significant risk for
. ma:ternal.:r uid fetalxp.orbi<;lity...and mortality is
,uterine :ruptUre ~cause ofa!Hts att~n.dant
complicatitms .(like perinatal dea th, hypoxic-
ischem,ic .ence.phalopathy, and hysterec-
. . tomy). (Tal:?le 52.6).' 1 ~
Uterine rupture is de:fined .as a thfough-and-
tlrrough djsruption:l'>f alluteiin:6 l~yers, v;.it.~
the dll:e .Cons~quen~es of hetn0,rr:lu;ge, fetal
-di~tre33, :;tillbi.rth ahd sig:nific~t :nlatemai
rrbidity, arid .the -pOtential roi:.mcrt,hlity. Thi~
should be qiff-er-entiate'd from : uterine
dehisc.epce, wl+ich is sep~ation of the pre~ous
cesarean scar with tP.e. serosa of the uterus
intact, a.nf;l hei;non:hage is-absent.
Ut::~rii:l~ tu:p ture rate,~, _.-as seet)._in 10
-0b,~i"Vp:tjuru3.i_. stUdi~ 'OU ~ymptqrriat;ic "!Upture
. . witb..-$0L~ -railge .frcm Qfl,_ooo tc 7:8/I,ooo
:WJ.ih::'ii-:ii)QOloo":ritte~'o(3 ;a: ~rce:nt per1 ,oo o
..-t::tlli!S::oi~tab6r.:
. i
' .- .- . .. -
Risk .factors for uteri~e rupture include: type
of uterine scar, number of prior -Cesarean
deliveries. prior vagina}. delivezy, interdelivery
interv-al, uterin-e closure tecb,nique, and
induction and the use of oxytocin
augn:u:1;1:ts.tion. .
Type -o f Uterine .ScaT
The rate oftJ:terine rupture depends on both
the type-and~n. of-the, previous J.li-{?iin:e incision
(fc:Lble 52. 7). :tltrine ruptUre r.ates are lo~t With
the low -.tri:msver-se- incision a.itd hig~st with a
p~ class~ :tlr T-shaPed ~n. .
.Nuril.ber of Prior CeSarean DeZiwries .
women With mo;-e than :One prior cesarean
detiv&.y ~ a 1:i;igher-likel.i1U?od ofUkiine -rupture .
as shoWn dm.Si$tent'ly itt_r;iq:ny .stuaies.. this led to
the ACOO. r~mmendci.tio'n .(2(.)04) that a TOL for
thost:!'Uiitl:L,tu.:IO prior'cesarean del~- 'be limited
t.o<tfw'se:tvith;:C!-i'r.J$to.rydf.prio'r~(ae1i-vay,- --

~ , .
~

ri~-~~~- : 124_(0..1} o ,
H~..on;ty 4 1 '(0.-2) 47"{()~) . 0;77 :(0.'511:17}
~~bolic,d.ieease ...7.~{0"04) ~1e.t<>;:lJ- - 'o:6210::2~r:-"62r
~srg_sw~- _: __. ~OA{1.7.) r58-{1-~0f- 1:7qr::t1.;2:oar
Enllometiitis 517 (2.9) 2a5.{liS) LQ2:{L40-;1.'.87)
~t~-:d~th 3 (-0.02) :7 {0~04} o.3a:(Ll0-1.46J
On~ pr---more of the above 978 (!5.5) 563(3.~) 1:56 (1A-l-l.74j

A.cbwted.~:Lanu9n_,MB, :Hauth.JC1 Leve11o IQ, et ~ for.the Nati~al -lnstitule ofiChild Ji~th and Hup:!an 'IkvelOp:mc:nt
Ma~ern~iF4a). M~e, Units NtwOJ:k:-Matemal B.l)d .perina.tal out~me;S.as_sOCi!l-bi With .a tri.U ofla:bor:after p;riorce.sarean
~on. NEngtJ Med 26b4; 3 51: 2581.

Table 52.6. Perinatal outcomes after. uterine

. rupture
.
.in t = prym~<;ies.
' . ..
Outco~e Term pre~cie_s With uterine rupture
(n- 1.14)
.. ... .
Inttapartllp:l stillbirth Q
HY.P.O~c=ischern,ic em::ephal0pathy 7.(6;2)
Neonatal death . . . 2 (L8.)
Admission to -t he neonatal intensive care unit 4Q -(40:4)
5-nUilUte Apgar. score.~ 5 16 (14~:0) ..
Umbilical-ii,-tery blooP.-pH :: 7.0 23 :(33~3-)

A(iapted ~m: ~don MB~ Hauth, JC, Leveno K.J, et al. for .the Nati;o~ In;;titute of Ouid
'Herutl;i.:.and Hum~ :Oevo;:lopment Maternal-FeW Me~cine Units Netwpdc Mat~rruti an_d
perinatal outcomes associated with a trial of labor after prior ceSal'ean section; N.:Engl J Med
2004; 351: 258 1. . .

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 CHAPTER 52: CESAREAN SECTION AND CESAREAN HYSTERECTOMY .809 .
--.:~

Table 52.7. Risk of uterine rupture with trial oflabor (fOL). compared to thpse with longerinterdeliuery_~al.
Whether this is associated with incomplete healing
Prior Incision Type Rupture ~ate {%) of the uterine incision site remains to be prover..
Low. Transverse 0.5-1.0
Low Vertical . 0.8--l.l Uterine Closure Technique
ClassicorT 4-9
Unknown type 0.5 Closure ofthe uterine incision using the single
layer technique appears to be associated with a.four-
Downloaded from: Ob~tetrics: Normal and Prpblem
Pregnancies (on 29 August 2.0 07). 1
. fold increaSe in uterine rupture rate following TOL
compared with the standard double---layer closure.

Jnduction-a.>id.the Use of.OxytodnAugm,entation

. .,
Pi"Wr V.qginal Delivery .,...R eportsontheeifectoflaborinduciiont,uiththe
. . . use ofprostaglandins or oxytocin ~n uterine rupture
A prior vaginal delivery seems to jaJ~orably . are conflictin!J. Until conclusions are established,_
decr~e the risk of uterine .rupture following TOL. the current approach, as has Pe.e n set by~ AGOG,
is tp-:d f$coura,ge the useoflaborin.du.ction in t,OC)in~
Interdelivery Interval attempting TOL-V8AC., 'l1le ~ C(;lP,_ be stli:d for
labor aug:r..entatit;m 'With oxytocin. .
~Itii.Jiis- observed that the .slwrt~t the inten.ial . .: . ~ .
be~wee~'-a .previous .c esarean d..elivery,-.and. the Overall, most of the. excess. adv~~--~~~nts... ..
cwr.en-t.p'refi!Ulncy, the greater tJ:e r isk for uterine accompanying a .TOL-VBAC are .
attdb;,te~,:~.q:: .
rupturewith a trial of:la.bor.Fcr:inst:ance, in,women those who failed the tii.al of la.OO.r and who ,wo,u ld
t(JithaninterdelivenJ interual ofles:S than 18 months, have to undergo.a repeat.cesarean operation {Tab~e
the risk for ruptur:e was 3 times more likely 52.8). 1 ~
7.: . ........ .
. .
-'!~.-.: . :.. .... ~ - : -
. ~-a -::;~".~;~;;;~::..-;-"'~ :' ~;_ . .

. i-, . .
Table52:-8. Mat~al complications according to the outcome of a trial ofla~Y.>r fl'OL). ~ oi-H )ol ,,.,~~ ~.. ,u.......

~'p~n Failed '1!;3AC Successful VBAC Odds Ratio ~vWUe

o ''R'"- c:; -- ,, O o .. ... J~-~--4{~~ii~L . ... _(n_:- !~!~~?.L . -.~?~~~~<::IL.. .. . .. i ' ' ' - ---- ......
Uterine rupture 11!)~(2.3j HTO.l) 22._rs (12.7<1-38.72) <0.001

Uterine dehiscence 100 (2.1) 19 (0.1) 14..82 (9.06-.24.23) . <0.001

Hysterectomy 22 {0.5) 19 (0.1) 3.21 (1.73-5.93) . <0.001

Tlu:-omboembolic djsease* 4 (0.1) 3 (0.02) . 3:69 {0.83-16.51) 0 ;09

'

Transf\t~on 152 (3.2) 152 (1.2) 2 .Q2 (2.2S-3.54) <0.001

Endometritis 365 (7.7) 152 (1.2) 7.10 (;) . 86 ~8 . 60) <0.001

Maternal dea th 2 (0.04 ) 1 (0.01) 5 .5 2 {0.50-6 0 .92) 0 .17

Other adverse event~t 63 (1.3) 1 (0.01) 176 .24 (24.44-1,271.05) . <0.001

One or .more of above 669 (14.1) 309 (2.4) 6.8 1 (5.93~7 .83) <0.001

* Thromboembolic .disease includes -d~ep venous thrombosis -or .pulmonary embolism. : .

Otheradver,;e .~ven_ts incl~de. br.oadligarnent hematoma, cystotomy, bowel injury, and ureteral injury.
'$-
Cl; confidence interval. _:ltft.- .

Adapt~d from Landon MB, HauthJC, leveno KJ, et al. for the Nati<,m al Insti~te of Child. Health and Human Deve}.S'pinent
Maternal-Fetal Medicine Units Network: Maternal and perinatal outcoil}es.associa_ted with a trial oflaborafterprlorcesarean
sec tion. N 'Engl J Med 2004; 351:258 1.

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810 SECTION VIII: OPERATIVE OBSTETRICS

S. Management of VBAC-TOL are: 1) patient comfort and avoidance of the

inconvenience of labor, 2) delivery ean be .
The ma.n~gement of labor in women .s cheduled at a time convenient for the patient.
undergoing trial of labor "is based on expert 3) lessening Ihorbidity on the baby thai: can arise
opinion. Careful screening, counseling, and during labor, e.nd 4) avoidance of pelvic fioor
cautious monitoring are important to ensure damage that can lead to uterine prolapse~ bowel
that the risk of uterine rupture and its and biadder incontinence. The last argument was
attenqant oonsequences are avoided. found to have no basis during the US Natiohai'
Institute~ of Heaith .State-of-the-Science
Ctose' momtbring for signs and sympto'm$ Conference in March 2006.15,16,17
of uterine rupture is warranted. These include:
Stic:U:len ~vere abdominal pain, a sensation of When a physician is faced with this situation,
tearing on the area of the u~ne incision, it is proper that Ll}e patient is thoroughly educc:tted
vaginal bleeqing~ mo.-t~rntt! hypo-t ension, of the risks and b enefits of thi$ prr:>cedure.
tachycardia.and pallor. regression of the fetal Physicians should not promot~ elective primary
heaf;HD.'il higher station. fetalparts niOre-~ly Ce$ifean delivery rior accede to the patient's
palpable abdo1'71ina:lly when these are extruded request without thoughtful and extensive
out' of th~ uterus, an.4: feto.l ~ti.chyear.dip, discussion. If after the discussion the patient still
subse.qtW'ttly -leading to b'tadyc(irdiq.. This ins~sts~ and after an h"'lformed consent is seeured:
implies the need f-or exmtmuo.UJ$ fetal monf.toring the patient becomes a can!lldate for the procedure.
be~the eaili~ sign.of a rupture might b.e If a physician is unwilling to perform such delivery,
a fdnJ.:hl!!ni:rate:cibrt.o1"!1lillity.. .then a refertal to another provider .i li appropriate.
.. . :.. .

. '-;~;4'$Si$ted."..\Jiaginal::deUverg riuitft'forceps .-.o r" . Many-standard. teJctbooks;in Obstetrii::s.define .. .

.'IXlCt4im'extraction..to.o shortefl.~the,seoo.nd;<'.Sta.ge,:. .? cesarlU1 .::l~;y~terec.~omy.. as.. ~~e- rerpov.a lof..the,
-and les$tnbeating down.e jfoits by the mother
-i s prejeTted. . . . . . . .
..... ..
Riiitbtii inspection of the uterine caVity to
check for uterine dehiscence is not generally
-Tecommended b:e cause ,asymptomatic scar
~~- usuaUy heal very welL Hor.uever,
in the~~ oJ.e$Ci:esSive bleeding or maternal .
hypotensio~, m.an.d.atory eva!uation 'tJf it he
. utcfin.e ca:uwj is done, 'n ot just for dehis.c ente
' :IJ.ut more SQ to detect uteri:'l.e rupture.
CESAREAN DEL~R ON DEMAND
uterus at the time of a planned or unplan:ned
ce~atettn delivex1r. It falls. under the . g~P.eral
ciitegocyorPosfPiiifiiili7Penpartiiin hysterectomy,
W:Flcii Tfictudes i-emt>Vw ithe uterus: folloWing
vaginal delivery. 18
Incidence
. The i.pcid~nce in Wt>rld literature of cesarean
hysterectomy is 5-8 .per 1000 cesarean deliveries.-
LOq:ll data from -the POGS show an incidence of
4-11 per 1000 cesarean deliveries from 2003-
2006;9

Also called '"Pati6nt C_hoice Cesarean Indications

Delivery", this policy_has come into fore with the
increasing-aWareness of a patient's autonomy in
cq.oosing the proc~dure tha t s he would want to
h~vefor l)er body. This concept is still in the mic;lst
6f a ragingcontroversy and has not been ,accepted.
in many institutions;
. Alth-o\lgh pot well-s~bstanti~t~d. the
arguments in ravor.o f cesarean d_elivery on demand
Mpst cesarean hysterectomies are emergency
procedures petformed to control hemorrhagewhen
conservative meas ures have failed . These
conditions include: placenta accreta_,uterine
atony, and uterine ruptute {Table.52.9). The t nost ,
common reason for postpartutn hysterectomy
following a vaginal birth is uteiine l'l.tony whic~ i~:
'.unresp<>n sive to meqical management.. .. . . ;~: .
.;

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 . CHAPTER 52: CESAREAN SECTION AND CESAREAN HYSTERECTOMY '811

Table 52.9. Indi~tions for cesarean hysterectomy.'

CLARK STANCO ZELOP SHEUHAAS

(1978-82) (1985-90) (1983-91) (1999-2001)
NO. % NO. % NO. % NO. %

Placenta accma 21 30 55 45 75 64 69 37
Plac::en~ pci'a~~ 6 5
-U~SV)e !il'ony ~30 43 25 20 25 21 65 35
BlCciling . 19 16
Ut~e rv.pture 9 .13 14 11 10 9 10 5
Fibroids with bleeding 3 4 3 2 2 2 9 5
Uterln~ infectiPn . 1 1 3 3
Sca,.r ~n}other 7 10 2 2 2 10

Dowilloa~ from: Obstetrics: Nonnal and Problem Pregnancies (on 29 August 2007).

Placenta. acc.r eta is reportedly the mo$t in1868 by Horatio Robinson Storer of Bc>sto:n ;n a
frequent . indic(!tion for p .o stcesatean woman With a dead f~tus and tumtlr prev.ill.whk:h
hyste,recrotny~ Nearly three-fourths ofthes..;;,were . prevented fetal destructive. proced'Qte$, The
. ~b.y:(!.(epw~artarw1elivery..T11e patient sut:vived'\Ultil.the.third .day afterope,nJ.tion . .
. '' >inci(J.ence .ofcesarean. hysterec;tomy appears to and died.- ..1:.- .:: ,, ..;; '."".;:,; '. . . , .
be a TeS!!1t :af iru:teasih{}frequencg ~f'c:eSarean :. ... ..: ) ~ .
b~ iiiffieh in itself is a ri$k:/actorforpliu:.fmta Sorne clinicians refer t<><~~;:~~~ean
hysteri!cto~y as the "'Porro operation:'-'.f ~iil
aeareta.. Mor:e 'recently; a hi':;tf'ty :Of prior
cesar:ean se'cticm..i $pr:e$etd in 51 to 67 p~ recognition. of .t~e .first succ~ssfu:t cesarean.. ,
of w omen :unde(giJi)l.g 4 pt!ripcirt:i.m hysterectomy reponed 'by Eduarq() Pom;dn .1876. .
. . .~ hyst.eredom!f. P,lac.ent1 .pt.cvia and :p.rior .Since, then;
:modifieations :to the.::p~tw.ere
--cesarecm. delivery are risks for placenta ~a. .m ade. By the 1970s, mortality an.d~~mtJ.teb,l..d,.i,ty .
With ini::teasing cesarean deliveries and an figures had improved. "'' '
~ting placenta previa, the f'.sk for ~an ,
~~edofnJI r~ SO pe_~TlJ..:
. ..
-.-
. Occa$ion:a lly. cesarean h~$terectomy is Cesarean hystere~tomy may be total or
plan~ed in advance for the treatni'e rit of a subtotal de'p enditig o n ~ecllnical circumstances.
gynecologic pathology like cervical an.d .ov:ari.a n A total hysterectomy '( removal of the uterine
cancer .pr l~rge .m yomata, tha:t can be corpus and cervix} is more often performed but a
actbrilpli~hed at the fune ofcesate~ del~veiy and subtotal hysterectomy (only the uterine ~rpus is
thU,s
. . . t;l() away.wj.th
. ,.
a secOnd s~rgery~wjo
. ..
: removed) is prefeJ;able. wh~Jl faster surgery is
requird, es~cially in unstabi~ 'patients or when
. A retrospective study cy WhjteQran, et al. jn dissection of the cervix is difficult. Total
t:4e us in 2006, show~d .Ul.at vaginal. birth after hyste.recto.~ is preferred in.cases of placenta
cesareaJ1, prfraa.ry and re~t i:esat~ deliVeries, previa/ acreta becau.s e lower uterine segment
and multiple births are in4:pend~ntly ass<>iated bleeding with these conditions often requires a
with an increased risk for peri~m hysterectomy. total hysterectomy to control hemorrhage.

.HISTORY The operative technique for cesarean

hysterectomy follows the . sa.me general
Cesarean hysterectomy was perf9rmed in the hysterectomy principles and steps a~r in the
18th Certtury to make it possible for women to nonpregnant patient. Care is taken t~avoid
survive a cesarean delivery. Ce.sarean d~Uveries bladder and ureteral injury, which api:>eif.to be
then were almost alw.a ys fatal because o( relatiVely common with pexipartum hystet~~tomy . .
hemorrhage and infect.ion. T'he earliest After the delivery of the placenta, the uterine
. documented ces!l-rean hysterectomy 'Was . done incision is closed temporarily to .Contr.ol bleeding

Scanned 8y: ~
812 $ECT10N VHI: OPERATIVE OBStETRICS

from the uterine edges and the surgeon proceeds

with the hysterectomy. In most cases, the normal
ovaries are not removed. The technique. of
cesarean hysterectomy is shown in detail in
Figures 52.15 to 52.23.

pERJOPERATlVE -M.'...NAGEMENT

The pr.eop:erative and postoperative

x:nanagement for uncomplicated cases is siinilar
to that of cesarean delivery.

COMPL!CA'i'IQNS

The m~jor complkati:ons of cesarean

h_y$terectomy are urplpgic injury and hemorrhage.
'the average blood lo_s svan:e$, f rom 5001,000 ml
: more thari ,M'l>Utine cesirean deliv:ety. the n$k of
oo~tsu:r;gical '::bleeding..is incr:e,a:s~d .following
:.... ...,.~ -b~_,.re.ct.om
"""..-.. ~ ""'""'
. .. -u~..._.. . of-t:hefriabillty_0, r
_veeea
~
' ~
Figure -52.16. ~ the -ascen~g b:raricQes of the uterine
.
peMc,,tJ.~sU~; iifs well :A$ e oagulQpathy which-tnS,.y: artety ate dam~. ~t.::~M!i a. suture is :-placed just below
be hap_i)eri. 'With sYeted:>lee<Ung -and -a btU.ptio -the up
-~rthe ~p and imlnediately ne::rtto the uterine
ptaeen.t~~ Febrile :t~:o.t'b:idity-i$";i}S'O-cp'lp.m'Ori~.... .:wa;;,b Ctp~~P~ :P.gb!l)\".al,Opt~ Jatefalr.aspect.of
p.articul~t:ly. with :an urtplann~d - . c~sarea:n., . t.he-,\1~.!\': ,to:.~ m)'~ to the \Iteter. and :heatoma-
t,ysterectomy1 vi:itb infeetlon tate;i .Qf 25:-a()%' formation. ~. After mnQ~glhe'clam.p, the su~ ll! tied,
thus~g~e v~pefore they ate -C\1t. C, The pedicle
d~$pite ::pro.phylacti.~ ~tipiotic aAt:n.it'.ist:nttion, A .is 1~j)ed;j}i$t above 'the tie apd then .d oubly ug~ted. At
list <>frilP.tbiditi~s~ated with .this ,p roeedure . tl\iS~U}.t tb.e-Q~Qn:is often made.wqethcrto prpceed
is ~hi>w ..fu1'a.ble:$2~l'Ot . . :. . witit:subtot111 >t~etotarli~terectomy. .

Figllrc 52. iS. ~&:;~.rean hyster:ecto~y. A, After .e xtending

the :t>~dde~ flap, ea.$ round ligament is cut .and ligated.
Tlie -~r1afofihe'brolid ligamentcan be opened for a
sho:rtdistance, t*in.g.care to indse.ollly:the surface layer.
The avascUlar !~beneath the utero-ovarian llgalllent may
be:opened .t>y.-blunt fmgq-~;4is"Sectio:n to.-isOlate;ihe~adn~ .: Figure:S2.l7.c$ubtotalbysterectomy. A, The cerviX is incised
pedicle. B>.A Cree .tie U~sed 'thr()u~'the avascuiar .~pace just below the level of the ligated- pedk les of the uterine
-~d f!mtJ1 ped, The a.dvanUtge of $is -ti~ is to secur.e the arteries, amp\l,ta.~g 't he uterine' co.rpus from its cervical
ve$seb WitPm the pei:licl~ be(ore itls <:ut
(rlgbt). The
a:dpexal -stump. .a; The ~ervicat stump may be dosed with' several
:pedicle i$ doubly clamped a nd cut. In addition, a transfiXing interrUpted figure-of~eight sutures; r eperitonealization is
.eutu.--e will then be placed around the pedicle. then aq::oinplished as in a total hysterectomy.

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 CHAPTER 52: CESAREAN SECTION AND CESAREAN HYSTERECTOMY 813

Figure:52.18,'to~ Hyster.:cto~y. The~ li&iunents Fi~ 52.20.The vagiila-i$ circumferentia.Uy;lil~11t its

are clamped at their.pointqf jn~ CU.~lU)d singl,y ligated. ce:vicel attaclunent
. .
and .grasped
.
w1thfour.crnm. ~
. .,:.: ---.. :- . .:. :: .
.. < : ; .
~~!.!' ~-~~:.._::-~~

~se these -structures ~<Ut h~ ~ b;tes -~~~ ,}:~- : : :,~~--;~~~:.: .

Jnay be neees3ary. Some physicians ~p. C\lt.. ~d ligate
the uterosacralligaments separately.

,;, ..
. >..... :; . .;. .

lbld~~'JI.*':V-~

~1/Jttlt::~'LE/.J~W

Figure 52.19. Because the <:eh'ix is elongated, i t may be
useful to insert a."l indeX finger through the cervical canal to
demarcate the vaginal ini;.i{>ion and to .ensure complete
r emoval o{ the cervlx. and avoid unnecessary rt nwval or
vaginallength.
Figure 52.21. The angles of the Vl;lginal cuff are cl.osed with
. sutures to inclu.d e .t he cardinal and
uter;osacral ligaments,
thu-s providing fascial support to the vaginal vau.It. A simple
loop suture is co=only u sed at this locatio!l to reduce the.
likelihood of breakage duripg the .s.t ate of postoperative
edema.

Seanned 8y: C
 814 SECTIONVIll: OPERATIVE OBSTETRICS

Fig are 52:.Z~~~~ a-.n~~t' !:lfi:p.eth~s:bf 0~g the : . . .. . . .

vanal ciliC.i!IIi:Stb:t:edis.~ tWfr:la.Yer clOsu.re.The.~er. .. . Fi(UI~ S2.'2_3.:~ blad~&pJsclOsed~.a:continuQu.s .
t;l~'the Yagina:~ap.dfu:e: secOit:d.:fuy~:~~'thechdSJPelvic- .. ;;~~..r.e ~,f$.~:P.<:jliq~.:of~ ~~~J~~~and
fasc:ia. Many.o~'P#a;:toJeav6.fue.cUJI:;op"n~py.using: ..... a9-ri.t;xae~ .~otc~~~ia~.!tt'eshave:D<>t heouu:tedled
on~: continuous. sutu.re -t.hat-circ'ks the cuff,.appt9ximafulg.: to thcr vaginal ~.:if.
th~ .c:ut edge:;<> its sUriounq.ing fascia.

. CJarK,..:.,.~t':iu:.- . . . stariC:O; ~t" ;J._ : ~b.~~ et :ei

., . :.. ',\t~Z~~tR .: (1985-~.0) H~200J.l ..
-N0~ , : %
... . - ..... ---~ - . -
NO. % N6.
.. __'%
__.,.:.......
~~ -,..- ,.. :~-~-

PrPCid~.. - .:. ...: :'10~-:.. , .. 123 Il7 Tmr

SUbt9tal. .. 38 '$ 4% 65 53% 25 21% .. . 6:?. ~%
- Ope~1iine (!neaD.) ~3 . 1 h NA 3 . 0-b. 2.8h
'
.l<>Od.LO.:is\m~) . 3.; 57Sinl 3,000ml 3,0Qnml..
Hern~e . "' ,102 87
Transfu~ )?atknt.S 102 83 lO:,t. 87 ~t; .
.Rq~~e<i . .. > 3 1 . 7 3:B<ih
"Iri.fc;;ct ~otbiilltf . 53 sO
Feb:ile 35 NA ..39. 33 .. ..2 1 11%
un ' .. '~ ...
NA .7 6 :6 . 3.2",:0
Wo~d-lp,fection 8 12: 11 9 4 6 2 . L1%
U:rologic InJ\liy . 3 4 4 3 10 9
"Cystotomy 0 l-2t 9 8" 18 9 .7%
Uteteral 3 4 .. 3 j 0
Maiernal'Death 1t 1 . 0 0 3 1.6%

*M~dianva,lue SO% >3,000ml ~d:s<Wo. <3,000I1'll. .

t .Intentional ~tol:!lies for ureteral stent passage.
tCai4i~c ~Secondary to a.in.I:llotic'Ouid.embolus.
~~ :~-tractinfection.- : ....
Downloaded from: ObstetriC.: Normal and Problem Bregn~cies (on: 2~ August 2007).

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'f CHAPTER "52: CESAREAN SECTION AND CEsAREAN HYSTERECTOMY 815

I
I
POtNTS TO REMEMBER

Cesarean deliyery is defined as the delivery of a fetus, through a surgical incision on the abdominal and
j uti:lrin~ -~.~U.. Whe'n .hyster~my is performed in conjunction with cesarean de!!veiY, the .proc.,"'dure
i Is called cesarean hysterectomy.
I
: Cesarean delivery ls performed for two main reasons: 1) when any further delay In delivery wilt
serlously compromise the mother, the fetus, or both, ana 2) when vaginal delivery cannot be safely
accomplished. Majority of cesarean deliveries are done for both maternal and fetal indications.

CesareM section is safe when the patient undergoes a careful and thorough preoperative assessment,
c;nd '#hen .good lntraqp~~tive and postopemtive ~re are observed.

lhe.JowtransverSe lnclsionorlthe uterus is most preferred and ,utilized for cesare<:ln-delivef)'. because
it Jess bloody, ea$ier to perform and repclir, and heats well such that it provides an optiot1 for subsequent
i
trial of labqr, .
i
i . Post~sarean el'ldorr.~.~~metritis is stllllhe most common .posto~t.ative cam
plication - of -cesc;~rean
li delivecy. :Fever, uterine tendeme$s, f(>ul lOchia, and .leukocytosis; with a history of .ctiorioamnionitls,
..prolonged lclbor. and ruptured membranes.:strengthens the diagnosis. 'i~---~..;,.? . . ... :.'":i: . - ~ ..
,. ., ~. _ ~ .Ji ~::~": :~ :t~...z ~
Compared. with vaginal <!sliver(, the matem:al mortali!Y and morbidUy ar.e incr.eased -W,_th. ~r~-n ~
.delivery, from fo.ur to nine.,folct, even When preexisting medical compliCations are exclud~i- ~
: ;rfs'K1~
.increased !nemergency compared with elective cesarean cases.
- j
l
;
...,:p;;or cesarean delivery increases the :risk in subsequent pregnancies of ut~rine dehiscen~' ancff:i:jpttrre~'-
.
!
I
., :and multiple -placen~l ~bnormalities like abruptio placenta, placenta previa and abno$ar acfh'et:~'nt
placentation (placenta acereta, jncreta, and percreta).
l. :ksafe-VBAS-<:ar'l"be-achlevectby-foltowing as$lectlorrcntefia WhiCh include: 1) Oti'e :previo'us toW-
traJTSVe'rse ~_s~rean -delivery;2rtto:cepnaiGi.pelvfc dis.pfo-poffion, :3) No other uteiine or previous scar$
rupture, and 4) Physicians immed!ately avc;~i!able throughout ;;3c~ive labor capable of monitoring tabor
and performing an emergency csarean <ielivery. -

Uterine rupll,lre., which is the most significant morbidity in VBAC, is defined as a through-and.through
disruption of all uterin~ tay~rs; with the dire consequences of hemorrhage, fetal distress, stillbirth .and
significant maternal morbidity, and the potential for mortality.

The use of oxytocin for labor induction and augmentation during TOL-VBAC is discouraged because it
may increase the risk of.uterine rupture.

Placenta accreta is reported to be the most frequ ent indication {or postcesarean hysterectomy while
dtetine atony is the most common reason for hysterectomy after a vaginal delivery.

A subtotal hysterectomy (only the uterine corpus is removed) is preferable over total hysterectomy
when faster surgery is required, especially in unstable patients or When dissection of the cervix is
difficuiL

Seanned 8y:
~
~
81"-6 SECTIQN VIII: OPEP.AnvE: OBSTETRICs

11: Cahill AG and Ma.cones GA. Va.&lnal birtb.a.ftc:r cesai'Call.

delivery: Evi.d~nce-based practice. Clin ObStet Cynecol
1. Obstet:ric:s Normal ~dProbl= ~gnancies: Cesarean 2007; 50{2).
Deliver;Y Sth edition, ~00.7..ChurChill Li\ingstone/
Elsevier, 'inc. 12. G?n~.R Results of.a mil-defined protocol fora trial of
labor after pHor~ de1ivery:'Obstet.Gynecol2006;
2. AC.OO Practice Bulletim Vaginal Birth After Previous 107; 240~245.
~Delivery. Number 54, July 2004.
13. Landon MB; Leip;decker S, ,$pong CY, r;tal. Factors .
3. Lurie 'S ~ Gl~~ M. The ~l9IY ef ee~ aife~ting the sii~ss of trial of labor following prior
technlque.AmJ 'Obstet.byneCol2003; 189} 1803..:1806. cesarean delivery.. Am. J o 'bstet 'Gyr.ecoi 2005; 193:
1016. .
4~ Co<:hrane DaW>ase of~y.stemat:ic Review32006 & 2007
Issue3, Jcim'W"uey&:Sons, Ud.' . 14. Landc;~n }-.$, HauthJC, Levena KJ, et al Fer. the Natian'aJ.
Institute of Child H;~alth and Hum.~ 'Development
?- ~ .~ CUD.it;al 'Guid.efuie A.pril'2004. Na.t:i.onal . 'M;atemal-Fetal Medicllia O:nits Netv!orlC .Mata:nl!111nd
. . ColW>omting~ forWomen'j and Cmidren'sHealth perinatal emtcom.es associated With a trial oflabor after
. ~~iioit~ by the'NationAI. ~"instttu:te for .-clliUcal pr:Hir cesarean sectio~ N Eng! J :tvj:ed 2004; 351: 258l.
' ~~ (NICE). Royal College of Obstetrici.ims and
15. Weber AM. Elective cesarean d elivery: T!J.e pelvic
~
perspective. Clin Obstet Gynecol'2007; SO !2J.
6. .,MatfuJ~ HaitiiJ.fOJl.:BE :uen:aclikerF .ct:aL.:~-~:-;.;... 6 ~
' .. ...... ~~-J
... " ., ., : .
birt~ .fc; '2p!:l4.
. .... _, . - ', .
Health ~Stat3. Natio.nal :Certter' for ~-~6. W~er M. Choosing cesarean ~o~ Lancet 20oo;
~thSts.~ .. 356: 16'7:7-.1680. .
. ,
17~ : Cc.Sareaivdcliveiy en aei:nahd. Cli:-..ieal .Qbstetrics =ti
7. ~h'}he: ~"~sa.G?. ~~JM,'Oibl>oJ:llil'L,. Jacqqefio~
~.-~l 'E:.:~ sectiori I!li:.es ahd:n1atemal'and
Gyn~ol6zy:.:2004; '47:.(2).
n:eili~:mb~i#:ww... :m~~ ..~4hi~ineom~
~&ies::an ttQ~o.gicil.l study. Bii=tli:2000; 33{4)':".27.0- 1'8,..C~Sa!ea:n delivery.. and -p.eripartum. hys terectomy.
ZfJ:. . . Williatris Ot stetrics. 2'2nd edition: 2005, McGraw-Rill
.. CompafU~s. :Ih~~ . .
8. A kxander J. 'Fetal 'injury- associated .with. ce ;,ru:ean.
d.dfik:::obfuiGYP.~i2006; 1o3~ ieS=.aoo: _: . -: i9~ ~ery-'CM-..~ed_vs,em.~ent~h~y.
. . _...> . ~..~ 0?~t~t..Gyi:teCol200;7; .lQ?: 154:-el-lS4 .eS.
9~ Obstetrical~ Gy,newlogl.~
..:PhilipPine S9cieti {.fOGS): .
t~~-<rn Ji?..thLn..l'Gd..e. .g!!~!!{l.A!it111.:.~ ~~i:t:
20.

Vlhi~ 1i, Ih\;id~n:ceand det;:iminarits ofpai.partWn
.b:ys'tel"'!tt:bmy:-0!!stt.t'Gy:tretql2ooo~108: H86:t492:

:IO.~tah. Previo~ -c~sar~an. delivery and :risk~ of

. 'p1-acenta preVia a:;ictpla~W $Upt:i.On.:Obst'et Gynecol
200?; 'lQ:J:; 771-778.

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.. . . .. ...... . . \
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 53 ..
...."T...

ABNOIW~ITIES OF THE TIDRD

STAGE OF LABOR
FLORDELIZA M. BALTAZAR, MD

Definitions
. .
Signifi~nce and Incidence

Etiolt-'2Y
Prognosis
Signs and Symptoms
Managef:nent
Generai .Measure~ .
Atony otthe Uteius
Bleeding from .B irth Canal Injury
: <Vulyovaginal Hematomas
. . .. ~ . . . ,;: .. ,; . . -
Third StageB ieeding
Technique of Manqal Removal of the P_la~nta
Hemorrhage from Retained Placental Fragments
Abnormal Adhe.rence of the PlaCnta
Placenta Accreta
Pl~centa hiereta
Placenta Percreta
Uterine Inversion
Complete Uterine Inversion
Incomplete Uterine Inversion
Coagulopathies
late Postpartum Hemorrhage
Summary . ':.il ..

Algorith m

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 .. _ .., ...
.. .. .
~

; . . a~o . .
-~
SECTION IX: ABNORMALITIES Of THE PUERPERlUM
--------~----~------------~----~
.,.~
. ------------~--~--------~~
~ ..
-:.. -
. .DE:FmiTIONS ETIOLOGY . ,.

._,.. . . P ostpartum hemo~rhag-e (PPH) 'has _been It is helpful to thlnk of-the causes of PPH1n
terms c!' the four T's: ' . . .
.trafiitionally'defined as blood loss greater than
;'qOO.,inL in a -va ginal deliw;ryand, gr~ater than Torie .- ute.r me atony
:i,O:OO mL in a cesarean deliver )< 1 However, Trauma. -uterine, cervical, or vagmalinjw}" .
:s~ul:l:ies have rev ealed that uncomplicated Tissue - r~t:e.!.ned placenta or clot$ .
de4v~ry results in .blood loss of 500 mL without Thrombin -pre--:~xisting o:; acquired coagu.ld~
. any-"comprQmise of the motbe:r!s _.condithm. ~...
'T~. e:_ ~.nd~~~-~-. :t,~s.\tlt~d in -~d?J>.tio.~ of .a . Ofd~~sdt;tetoh;e~Grr~e, thelarge~.gro1,1p
. b.foad~r "d~furlfi~ :er;PPfl;:, -;Any _blt;e"ding tl_ui.t . . due lc postpartuii h~mor-i:ha:ge is utt...r.iu!.t$ny:
_;: ,r.e:s.1l:lts ....J~.: ,$.jgP.,_r... : ~-ri4 ..~. -~:y~potoq:l:s .._ :. ~f- ~'_is~~-t~J.~~:bif;Ji~.~cl~q~~Ptw:~ _
.. ' Jli~in:~dj;J;r~mic :_iitstab.ili't,y-'"if .U)ltt~:at~-d~ -is . ::~f.tlre ut~~ ; -~.-~z;nlno:ii ateretenti.oo o! the ..: .
~f:Oit."sidet~- P.P.i!.:;(. :aeerease :ili..pcrstp:~him. ; . p1acenk. :P'laaiiti:.acreta;mversi0n-6r-iheu1~ .
.. . ."lr~:m~t()c'rlt' :iev~l - :gt.e:at~t th:a-n .1Do/o o-r th~ arid: -.,er.yiafel.i .coaihl~tit>ifdisor.der-s: .' ,.. '
_; I?~natai value can. pe con-sidere~ PPH. 1 . . ..
; ~- .: oo: Tfte etiologies of late postpartum hem.Oirbige'
.-':': .
.- Th~ differing ca,pacities of individual patients are .r:etained .'plaC'.en~ element~, 1:;uccen~t~, ._
. ..fu..i:Ope with 1)1()()d loss is another consideratipn. lobe-, ~.ateril.ai"infe<tien~ placental site invo}:\ltfun;: .: .
. .Alietilthy WOitlah ha-s .a 3-0 -S{J prcent~ncrease in aud hereditary coagulopathy. J~ - .

' Dibo~Vv:olu.riercmd is -much mor.e to!erc:u1t of blood . . ,_._ . .-

--~.": -:. 1Q-$iithm:~:Wo.tnan.ewb..o',:lias-.pr~- existing~an~niia, . ' PtecUspvSi:ng :factors :for,a tony of t_l).e -~-~ :. ,
::--, . .. =-~~~ft~~rlM'gt~ac-: coil.ditio_n;:'b-or~"i:n~vohime.": ~~--are.-hign~pa.iity:;,::P.reqplpm~:.;or~:;proloP.ge<hililbo'Fi!..-::: .
,:coti'i:racte4-.c:x;>nctiti.on-.secondary. to;dehydration.or .. : .. gen~r:al . ane:$thesa~ _:overdht.e nd_ed .u.t~lii-$ :, .
:. :P~~psi!L (rnMrosc~ -~yQr.a:mnio.s., Diultjfet.al pt egDa.ncy-).
-/ . ~- . .- oxytocln .aJ.J.gnleD.~toion .or Induttion .of h"bo.r.,... ~;
. : . . , P.~ist~-..:hexp.qr.rhage,. occurs.. within ..24 . : }+istozy of po~~ :hem:oir~ge.,a.mn.k>tli:9?.>id.:;:.... .
.; h~.8ftet5d~Ev~, ..When~lt'occurs24:hoursto o;>. . em:b-q~:im~'V.magne~wni~sulfate;:iri-. a:~.:: ..;. .
-: :.. .we;_i1!:,s;;,~et:.;:d-eEv.ery,;v:i:t:;.:iside~if}nated,,a:s~r.la te,~. -:. p a ijeq:"L ,. , . . . .. :.; .! -.".. .
. : ~ ::pg~he:tnorihage: P osf;partum h(!morr.hage . ,. .
. _: -bit'f'~ Q_lacenW delivery is ca:11ed third stage
.. '' :_.::_._h~~prth&~e:........... .... .~. . - ... . . ,
. It c~n ~also :_res ljlt .ft.t>ni :the jphibltl()~~..
..... coP:Ji~~~~gn,;:~Jii :~~g'WEilY.~S.~!-irKiJ;ia~~-:~
or ....':. . q

' .:: ane~thetic -agenla, nitrateS; :non steroi~_ 3.1iti:-

.-: :)~IGlmlCANE.'/iliP
. . .~
tNCtn~NCE ir..U.~ a~ry.: .
d tugs, ,:ix.lf:l!W.e~ill;X!l
......_!it . '
sulfate," ." bta:' . :
. . .. sympath9rn1rh~cs aiid :tw~_pi.ne. Other. ~u~- ..
. . . :orsop,6oO._y~4Y tn,a te.rn.W..dea th:!? world.wi!ie, irrclude}pla,'Ceptal~te;ti~eSi1.-,g '~rdhdoweri?,~e.-: .:
.Po~.t;partum hetnoriha ge rem~.ins -a ~~gnffii:Jant segp1~n~. ;~W~ ~xins,. {eg. chotioa.m,ci9.ilitis;-" ': .
'. .,pro.q)~ cont#bnting to 30 percent ofth ese d~aths end oniym.tretrifi~. septic~_ii1ia), "h:Ypoxi.a .d.h'~ :tq; . .-
: : :;in-:P.-e -d.ev:clopfug w.orld . hypoperfu~Hcn as Co1.ive~e ~t~ru3 in a"J.m.iptio'; .:
:. .... : . placent~-..R:e:t e:rit da ta .!niggdt t~at: :gr$i;l '<
. . The maternal m or t alitY r a te was 7 -10 per mu ltiparity .is not -an fudeperldent -r isk factO_r for ..
. . . ~:00; 000 live births in th e U. S. in 19 9 5 , PPI:f.-4 Ret~in:ed blQOd.may cause u~rine distentipn .
. ~~.ppi'oxiro:ately 8 per~nf eaused by PP:H. Philippine and may preven t effec t;i.ve eon tra ction.
:statistics su ggest that a p proximately 8 percen t of
'~e- (leaths are cau s ed by PPfi.2 The pla~nt<l: ).~ m ore like~y to be .te~~ at _:
.. extreme preterm -gestations {especially ..~-- 2~
.. _-:p eveloping n ations have,a .matemal d ea th ra te weeks), and significant bleeding .can occui::.. nus..
:betWeen 100.- 200 per .100,000 b irths com p(!.l'ed to. shou ld be a .~nsi!ieration :in alLdeliverles at.itr.Y. :.
. 7 <;..:15 . per .lOO,DOb birth s "in the dev eloped early gestations:
. -'.-c9U:ntries. In the Philippines, as r ep0rted by the :
..
, . .:. National Statistics office in 2006, the m aternal . Riskfactorsforbirthcanalinjuryir-e.o~~e;:: .
. .' . . ."~eiilli :wqs 162 perl OO,ooo births. The biggest vaginal delivery su ch as forc~ps and va9tum- : .:
. :, -.,single ca-lise of ma ternal d ea th in the Philippines extractio n, br eech extra~tion and 'i lltemal p<xi;ilic . . I

' ...:.5~ {lemorrhage~3 v~rsion. .: :-

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 CHAPTER 53: ABNORMALITIES OF THE THIRD STAGE OF tABOR ''821

Recognition of these risk fa-c tors during Blood loss is usually visible at the introitus and
prenatal care provides an opportunity to prevent this is e.s peeially true if the placenta has been
postpartum hemorrhage or at least minimize its delivert!d. If the placenta remains in situ, then a
magnitude and to plan for treatment. significant amount of blood can be retained inside
the uterus behind a partially separated placenta,
The -antepartum ot early intrapartum the membranes or both. Also large amounts of
assessment of risk factors may allow advanced biood may be ios't-as a resuit of slow trickle which
preparation and av.oidance of more severe may initially go unnoticed. but .may -Rtill ult:U.nately
sequelae. ABO and{RhD) blood type determination result in critiCal loss and shOCk. This is more likely
and antibody screening should be performed in to be tiue of bleeding secondaiy' to retained tissue
an'ticipation of the need for blood comp~:>nent or trau.ma. Routine care in the imme diate
therapy. postpartum period should include close
monitoring of vital si~s, amount of bleeding, ~~ci
uterine t-one . and size. The uterus should be
PR()GNOSIS . periodiclilly massaged to eJtpress any blood and
clots that have accumulated in the uterua and
There should be no deaths due to pustpartum vagina. Atony of the uterus is characterized by
henwrrha:geif the folloWing conditions are met:: uterine bleedi:n,g _a ssociated with a -boggy uterus.
1) Proper imd :vi.gilant monitoring of immediate Oft'!n at first., the uterus will contract with
pos~ patients_, 2} _. Readily av:a;.table blood ma~sage.,. only to. rel~ aga~n with .recurrent
and bl()on produ-cts, :3).: Adequate- operating . blee<fui:g., A Jaceration-is.-.suggested by~ per:sistent
an
fadlities;;!,lttld '4) ;Alert action by e~rjenced bright:r ed.bleeding, despite a ,firm, well~9ntra~ted
obstetti~.tea:r;ri.. The complications ofpostp~um uterils. -Sometiines bleeding may. be ..cau~!;t:-by
hemorrhage.are varied ahd .the -range o f degree of both'atoily and
trauma. - -~ :''"'~!~).:u:r::~. =
sev~rlty is quite broad. Hypo~olemia illaY lead. to r, ~

rnate:rnal ~bypotension; shock, ac-ute tubular Several additional factor3 :r eg;:~,vding

necrosis;" $ution coagulopathy, ciu-diac ar.restand
.death".:.,JO.tner cQmplications may be blood - :First, ;bloodJoss.i~foften- clid~Jy undere$~ated . .
transfu~ion-related such as blcod transfusion
reacti~ns, hemolysis due to ABO incompatibility,
viral.~~ (he~tit;is :and HIV -infe.ctiont. acute
lung.Jri~~-.ttruismission.:.at.ba.cteriaL.endotoxin,
tr~.nSJiiission.of-pa:r.a:sitic;agents; graft ver-sus-host
diSease, alloimunization to blood products, and
transfusion-.r elated immunosuppresion; Rarely,
postpartum hemorr:h age JI?..a y -be followed much
lat~r - by pituitary failure -(Sheehan Syndr ome)
which is char.acterwed by failure of lactation,
amenorrhea, brea-st -atrophy, loss of pubic and
3xinary hair, hyPothyroidism, and .adrenal cortical
'insuffiCiency. '
-No matter what the eause of bleeding, death
is alway$ from one or more of the following effects-
shock, anemia, infection, kidney failure, or brain
damage.
SIGNS AND SYMPTOMS
The usual presentation is one ofheavy vaginal
bleeding that can quickly le.ad to
signs and
syn1ptoms ofhypt>voletriie shock Rapid b~ood loss
reflects the c9mbination of high uterineblood flow
and the most common cause ofPPH, uterine atony.
postpartum hemorrhage , should be --C.Qn.$-ideted
sometimes resulting in a .delay in addr~$$.gt:an
important problem. Second, the blood vd_lume
e~pansion that 9ccurs during pregp:ancy
.compensates.for..nornialblood-loss,at-deliv.~.:...This
expan-sion . oecurs to _a lesser degree in
preeclamptic women. Third, postpartum
hemorrhage is likely to recur in s ubsequent
pregnancies.
PREVENTION
Active ma'nagement of the third stage of labor
(AMTSL) is associated with reduced ma,ternal
blood loss, reduced postpartum hemorrhage ,
reduced postpartum anem-i a, -reduced need for
blood transfusions and a decrea se in the incidence
of prolonged third stage o( labour. AMTSL is
strongly advocated for all births taking place in
all settings. During the third stage, the muscles
of the uterus contract downward and the placenta
b~gins to separate from the uterine wall. The
amount ofblood lost depends on how qu~y this
happens. If-the utenJs does not contracf~rmally
(uterine atony), the blood vessels.at the :placental
site remain open; and severe . bleeding results.
AMTSL speeds delivery of the placenta by

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 82-2 SECTION :IX: ABNO~MAL1T1ES OF. THE PlJERPER1UM .
.....
increasing uterine Cbntraction-s and p.revents PPH
}::>Y avoiding utenne atOny.
AMTSL includes the folloWing prt>eed'tlres:
L F.ollowirig the delivery Gi the baby, palPate the
.abqomen t o .rule out the p.r:esen:ce of -a.n
. additiQnal baby. ,and give o.xyt~ 10 units IM. '
N~ver give a ~t~tQnic l;>ef9re the deliVery of'
the anterior $houl~er. ;qzyt~ in:ay .tl:lso .be
. zivenqy oihet rou:tes '$nduding 5 uruts.IV:push
.' .o r ~0-~{j units in lL .o f normal ~e .at 60
, dr.Qpsjt!$.rute,~
2: ~f.o~ i~ Jl.ot av.ailable; .giv~:...Er.goroetz:ine
_!).~ .tl+g I, syn~~.metriiie {~ ampoul) .'IM er
-Misopfust0140(),.,.600 ~orallY (not a.pproveP.
in theJ1t~pp:in~s un(J-~r R.A. 37:20) . . .
3. .Alter ~ll,v.w'Ofthe :~1)y.wait. until pulsa~on
. lui.s stbppea-'{appi-o~~t~ly 2 to s rhiliutes}
.befote:Gljunpii:J,g and diViding the c;Otd, C],arnp
fifecerC!"~S to .t he ...perU:teutp.. If.it is your
:i!lsti:tU;tic'rlal>~li~y1 :ta'k~:,tlie:.,<;or-dblriod
.Siifupi~>1h~iuding1tUOO<i:;ge:ses~:~ , .. ., . ..
.4 . ~~p:filight<~J:l,Siol) :on~thc;~rd:,o;;hi}e;waiting . ;
for a ~tt?i+g-u~ecor..:u-actlon {approxi..mately
2-=3:-i$l.ute,s}. . : . . . . . .
5~
. .
'W'ithili~.S~il.rterine:contiactien '.en:comage'.
:.:r .. .~ ;..,. ~) .... :._,_.,4\. ;' . .
1
: ' :tlie~'m!>ther--ifpt~pus~.:.ana 'vezy~:gen,tly.;.pu.u . . . . .
:dovmvia.rdlilid'.ontwardro).:l;.)thecorrl:to:.deliver..~ .. :In. a~ditlon
.:th{:j)i~e~~.f~-~~bll'e' "ap'plY}itg sup:rapupic
. oo\intlt~ure i:Jh .-the..qtett:Xs With flie other
.. :fiaila:: ~.,..._~ 53.Jf-- - .,. : .....
-~
. ..
.Flglire S3.1..Application ofsuprapubicc'ountr-pressure on
theuterus. . pull .upwards to bring the entir~ ~eivii into
Scanned By:
Pulling te:o hard on the cord may.causethe
cord to . te~ off the pla~entl'l. or cause u~rine .
inversion-an ~cute obstetri~ emerge~.
6. If the pls.centa does not descend dur.Dg 30-
40 seconds of controlled conf traction , <l.o not
continue to pull on the cord:
a. COntinue t;o gently. hold the cor4. and wait
until there is another strong cnntraction.
b. W_ith the .next cont~action, re.p eat
.~ontroiled cord .tractiq~ wi~ ~ounte~-
pressure.
7. As the placenta delivers, hold. the plliccn.ta in
both hands. Gently turn it lJ.ntif the
membranes are twisted. Gently puU .to
complete .the deliv:ery.
8.i:f ili.e me'mbrartes tear, .g:entiy examine t!le
upper ~gi.,~ ?rid .~tvix \Ve~nng~teiil gloves.
Use a rin;g- (i\p~ng~}: forcep_s to grasp an:d ..
r emove any yieces o f..membranes: . : .
- 9 . .~e {he :pla<:;en:tli carefully-tc .~suie.that
.it i~M';PW.Plete., .. , .. ... .: . ! . .
Jt
lO:. ~he<:kJ:l;l.e;,fulld\lS: fo e~sur;e that is..well:
contract~4- P.p;lpate .for :a contracted .uterus
. .:e.very l~ .. ~utes.anct;.re~t ~terine-~e
;~:Pee:d!1 4unng.the _ )trrs~2. hotir.s,
.
COhs~Q,~r. the ne~d Jot ~l oX:ytocth .kfti$ib?--
a:r~~-CW.J:~ery~ofUie plaC<:n;a;'~womaT." lias
lB..cr&s-ea::rrs~J~c;tot,~:rqf]5P'lf.oi-~1Tiil'eS.i"tfnis
is ..S<?.~ .Qr :OOggy. r
lnsp~c;:t t.h e low.er g_enit~l ~ract :after all
deiiV:~:e~. When la:ci.rati.6ns =art! dniD:~ often
pressure l/! silmci:ent .tt;::totitro1;bl~ APPly
-pre:ssute with)t. sterile pad o~ ;gatiie.: ~
after. 5 $ir):tites. 'If'-hleer;iing per-sr~ts, the t eer
will +leed r~p~:ir. .:T~ars .;tP.rough_. the .~ .
sphiitete'r (third d~gr.e'e .tears), and tea;rs
through the anal sphincter il).fo the rectum
(four:tb:aegree te(!J~) ofte~ bleed sign.Ui~tly.
They . mu~t :be r.e.paired .properly to . stpp
bleeding a;id to .pr.e yent G9inplica:tious-.su~
as tectovaginal fistulas and/or fecal
incontinen ce.
The cervix .a nd up.P.e.r vagina sho\lld be
inspected followi~g ali operative v~ginal
.qelive.q es. Pl~ce.four fj.ngen in .the vagina-and
depress the.posterior.-vagin;U wall The anterior
lip of the ce.rvix .-will come .into. view.. if
netes sarj, gras~. this With the ring fcin;eps ~d
C
',{ '

CHAPTER 53: ABNORMALITIES OF THt:: iHIRO STAGE OF lABOR 823

view or "walk around" the cervix with the ring rapidly transfuse 2-4 units of pacl!ed re<l,plood
for-ceps. Push the cervix up into the vaginal cell {pRBC) to r.eplace lost oxygen carrying
vault to inspect the whole vagina for capacity and to restore circulating volume. (Table
lacerations. Upper vaginal tract or cervical 53.2)
tears must be promptly repaired as they e<m
. . rt.~ylt. in significant blood loss.
1'able.53.1. Physiologic classification of hetno:rrha~e9
M.\NAGEM~NT
Class volume Loss %Loss Physiologic Re13ponse

Rapid recognition and diagnosis of PPH is 900 15 Asymptomatic

essential to successful management. Resuscitative
measures and the diagnosis and treatment (jf the 2 1200- l SOC 20-25 Tachycardia &
~chypr.ea, narrowed
underlying cause must occur quickly befbte
pUlse pre~~e
. sequela~ of severe hypovolcl!lia develop. The ruajor orthostatic
factor in the adverse outcomes assoc)ated with h)rpotC:nf,lion
~evere hemorrhage is a delay in initiating
;;;ppropriate management. 3 1800-2100 30-35 Worseomg
tachycirdia.8Jld
Most ~temai deaths ~e avoidable and ar.e tacb,yptU:ll,
hypotension, t:OOl
du~. tO underestimation of blood loss, inadequate ex'tremlties
. . blood an,d._.flyid.replacemen:t .and delay .inoperative . ,

itltfY~PPP;-: .Any delay ,in .aclrievin_g hemos~sis 4 >2400

res'uli:s in.Jerminal co.a.g\llO.t>atb:y .(diluqon
coagtilopa!hy ~.-d late disseminated intravascular ; )';:, .:~":!:l~\t.-..f-;-;:
coagulopathy due to prolonged shock). (Table 53.1) . .:.1 ~ .:t,t,\ ' :. ,

At this;s4t_g~ even surgery may be too late. lienee

rapi.d 1U)d ;,~e:;;olute. action is p aramount. Once Table 53.2. Blood component therapyl 0
identifit;;.d., . , :po.s tpartum .hemorrhage .should . be
t.reate(;aggr essively. Sec~re help beca use
immedi~te cOncurrent steps Should be un.dertaken .' ~ . !""f . . .....

in .establishi~g intravenous . acces$, :b aseline

laboratory evaluation, administration Of blood
PRBC Rbc, wbc, plasl:i::ia 300znl t Hgb tgJdl
c"o'm -cinent . ther-apy~---:a~s - rn.aicaie(f - and
p . - ------ -- ---- ----~---. -.- l --- . .. . Platelets Platcl~ti;, rbc, 50Ql.l t Pta1etet
dateO:n:iiultion of the etiology to ~ .able to ins titute
w'bc, pl~snia c:;ount
specific tr'eatm.ent aeperidirig l,lpon the .cause.
7500/rilrri1

G ENERAL M$ASURES
. FFP F'ibrinogen, AT lll, 250 ml t Fil:liinogen
of
As ~oon .as a di.a.gp.o!>is hemorrhage is made, clotting factors, lOIJlg/dl
an IV inf~sion of crystalloid sol~tion , either plasma .
nermal saline (NSS) or Ringer's lactate with 20
units oxytocin using at. least gauge 19 needle or Cryo- Fibrinogen, factor 40ml t Fibrinogen
abbocatheter is started. A blood Sample is taken precipitate VIII, von Wille brand lOmg/dl
for ~sc with p1~telet count, typing and cross factor, factor XIII
mateh;ing 1 ~ari.~ . eoagu.lation $.tUdie.s. A central
veno.u s press~re line will aid in as lies sing the
patient's CVP. Less than 5 - 15 em wat<!r indicates
patient is in shock. Another IV infusion .is s tarted Urine output is :one of the m<:>st importa nt
for rapid volume replacement. pa rameters t<:> follo~ in the bl~eding pa.tient:vih.en
~ . care(ully measure4, the .rate of u.rine :f<;>~tion,
Ord4r blood transfusion if b1oodJoss .is ongoing in the absence of diure tics, reflects the e,aa'.ciuacy
ci,nd .thought to be .in excess of 20i)() ..mL, .o r if .t he ofxenal perlusionand, in tum," perfusion.~qf other
patient's Clinical s ta te .reflects .developing shock vital organ~. because re11al blood flow is especially
despite. aggre~sive. resuscitation. The ;goal is t9 sen s itive to blood V()luine chap.ges . . Urine flow .at

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 824 SECTION IX: ABNORMALITIE;S OF THE PU.~RPERIUM

least 30 mL and preferably 60 mL per hour should
be ma-intained. With p'otenUally severe
hemorrhage, an indwelling . catheter should be
inserted promptly to measure urine flow.
Initial laboratory .ev,aluatioJl includes a
complete blood count with platelet coun-t and
blood typing (if not previously perfotined). The
clotting mechanism is likewise assessed.
Pri:mary co.n.sidera'tion ia to contr:o l the
bleeding. Paramount is knowing the cause. The
uteros is palpated. tn uterine atony, ihe uteJ,US ,I:;
soft and-boggy an4- tbefundl!s may be higher than
usual. Because the bleeding may be dl.le to both
- atony and lacerations, meticulous effort .s hould
be .done to eli~"ate the latter. The episiotomy
WOWJd and Va,g4-ia are examined. With -adequate
~sure d :as~ij~ce. the centix, upper vagina
and :fomice,s :ate :mspec~~. While examining the
cerv'Pc, no.te,Whe'the'I' blood em:erges from. the
ce.r vieal c ansl.:Next;- ~l9ratioP. .:of.the .uteritie immedL~tely . if:bhnanual massage arid. oXytocic-
. cavitycjsdoP:e'to:elit:nftw.te;the:p\)ssil>ility<o~tez;,ne-.
rupt\u-e andretaini!d pl.a.cental L~ents.
intra~enously.The total maximum dose is 1.25
mg. Hypertension is a relative -contraindication.
Prostaglandins can.also be used if:t:xXytocin and
ergonovine fails. 'The 15:-rnethyl derivathe of
prostaglandins. F2 a (Carboprost tromethamine)
if available can b.e given with .a n initial
recommended dose .2 50 meg {0.25 mg) g:Nen IM
and repeated .i f necess~;try at 15-90 minute
inter-vals up to. a inUill'lum. of eight doses.
Carboprost is a~:sociated with.:sideeffec~ namely
diarrhea, hypertension, vomiting, fever, flushing
and tachycardia. ~ectally a<bninister El 20 mg
suppository. Two .t abs cf Mi$0prostol (C}'totec)
may .a lsobecolne a 'Valuable agent in the b'eatment
of 'Pl>.H. The low cost-of the i,irug and its heat
instability make it better fo.r m~e in developing
countries. A new -~xytocin analogue; cat~tocin.e,
may also be used.
Blc;o(i trarisfu:sion .sho.u ld -b e initiated
dm'gs~fall i:Ql:stQp'.'thet~bl~eding:-:~~.,- .---. :-

. ATONY OF..THE UT~ltl]S .

4\t the;::~pUW.t;;Uion:.' slte( tnost ' 4hp.0lt,ult' for

a.chie~bt~:'belri.oslas.is.-.:.are.-,. -co:n tr:action~and :;,:...
.l'etrietlon -~r fue'l'Ilyometrium:to compres~ the
. vessels tUld t)bll~~ theit 1u:tn.~n. Failure .of the
m.Yimetfiutp: lo'-'oontract :m'iy "rnp!alf :resUlt ffi a
mgn:ffieann:srooat(l-~ :.oonsiderliii~ -tliat otooa:now
to the '\.l~rus al)d p)aeer.:ta .~s :l ip to 600 mL/min
a.t term.
11 tbe bleeQ.fug :continues . buUan\lal uterine
compt:e,s.s ion is e'tX1.ployed. with a .ijst -insid~ th~
vagina, the .knucld.s on Ul~ ah:teri.or a spect of the
'Q,teru$ an_d an abdon11nat hand .pr.s~ing on the
p()sterior asr)ect .o f the anteverted :u terus. {Figure
_53.-2) ,
At th~ sa.me tline~ OXytoc.i n.is:.a frrst line agent Figure s.a .~. 8i.mwua1 compressid~ or the ute~s a:nd
be-cause of the paucity of sid e effects ,. It . is massage With fue :libdbminat ha:nd usually will d fectively
incorporated to the IV fluid 30-40 units per liter, cprttrot hemonhage'from uterine atony. (FrOm -Wiliia="s
titrated to control .a lony. Rap id IV bolus of oxytocin Obstetrics, 22nd .e4ition).
i~ not recommende d becaus e it may ca u se
hyPQtensiOJ) or cardiac atTest.

Us.e other "Uterotoni.c t:~.gents cif . the uterus.
remains atoniC :despite pxytod n administration
-~d bimanual ma~~ge. The traditional second-
line age nt tor uteririe a to.rty is .er.gtinovine -(or
. ergotrate) given as an initial- dose.0.2 mg given
After. circulatory support is established
including optimliiilg bemoglobiri and coagulation
- states arid cons.er:Va;tive'.means :fail ta stop ,the
bleeding, do not procra stinate. _The suivival rate
of bleeding patients is proportional to the length

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 CHAPTER 53: ABNORMALmES OF1HE THIRD STAGE OF.LABOR 825

.
.
of time it takes to control bleeding. At this point,
surgical measured~ most likely the only life saving
option. H,Y$terectomy is the definitive procedure
r:'
:

to control hemor:rhage resulting .f rom refractory

uterine atony. Bleeding however .may be controlled
by- utilizing one or more procedures that allow
preservation of reproductive capacity.

More recen,:~y,. . ~Peri~nc~: ha:s been .. ~ained

using oa;tl!fe'ters specifically de~igned for
In
postpartum hemoiTbage. low resource settings,.
condoms and .s uthlcal gloves have been used.
Continue utero.tonics and -commence broad
:spe..."tt"Um antibiotics.

Hypogastric: ~~er.fligation serves to diinini$h

pUlsatile tlow into the pelvis. How~ver thi$1s much
. more difficult to :perform., more tonun:on.ly Figure 53.3. a-Lynch prot:e~ure.
a~soci::i:ted v4th q~age to n~"l,)y str..t!;.~ ~d
less lU..-ely to su~e<t than uterine a..rt_e ry ligation "-
'Whieh:is ~relatively simple ..proeedure.and.t :an be
. ;.J:ligbly._effe.ctive .i n :contr-olling \)leeding~ uterine
so.:!li-Ce:'these arteries p rovide.apptoximately.QW/o
pf uterine blcvd .now.

A.nother . pr.bced ure that In<;ly _be qone is

selective arterial tenibo1iz.ation {uterit'l.e artery
~e.til;l;>O~~o~). Tlijs --procedure is :perf,mned ..Qy -
inserting a catheter into :the co~n .femoral
artery to access the uterine arteries. The uterine
arteries arei hen.emhOUzed 1;\Smg.~~yl~hol
~clts,J~_gtfun~ ll!Y~Jx~. 2~ble 1P be candida:ti!...
for .thi~Lpl:Qce:dure . C<>.mplicatians.:.inclu.de.J~ Figutc S3 ,4.Cho.prooedure.
hematoma fGrmation at theinjection .s ite, i~emic
pl~encmenon including utecir).e Jle<::tosis j,a :rare
instances .!md contrast related :a dverse :effects.
Ba$ed{).n cU11'ent evidence, it a ppeaci that the
procedure _when per:f<>rlnd by -expe.r ienced
physicians. complication rates .~ low; butii:tiare
cases, can. inc~ude hyster~ti:ml.y ~d death.

Recent case series reports advocate the use of.

transmu:ral ut.e rine compression ~utures to rapidly
control -t>Ieeding. (Figures. 53.3 . "53.4 & 53.5) The
B-!-yoch --proce~lure is -a fundu-s compression
.~ufure that is placed at the time of laparotomy
after delivery of the fetus. F irst bimanual
cqmp~ssi.on of..the ute~s ~s ~PP.lil!4. to qetennme
if ble~ng can be controlled by compression. If
bleeding is controlled, the suture is placed through
the posterior Uteripe Wall and
then QVer the fundus
to be. tied anteriorly~ This procedure e(fectively
prodpces tamppn ade by ,compressing together the
anterior and posterior wall-s. 5 Figt.!re 53.5. Pereira procedure.

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~
826 SECTION IX: ABNORMALmES OF THE PUERPERIUM

The patient's reprcxiuctive history and attitude manual exploration, With ;ontrol of the uterine
towards retention of her uterus are imJX>rtant fundus with the other hand. Any Clots are
considerations m:
de<;iding management but at removed. The eavity is .gently explored with
times hys~rectom.Y is .r equited .to save her.life. attention to any defects suggestive of uterine
. ..
rupture. .

If rupture of the uteru:s is identified,

H~tp frOm Mn.~ I !m.s
Ast~sa mat~~ conditi,on.
EtiolQ0':6f&teecung
M~eUlt~tetus
OxytQcio 'infu'Si0r1
" Shoclc.Sa-rmmt.- .Shiftto hospital
TampOliade. : . ..
g .r\pPly cn:ipt~o.n :Su.t'.ir~
SysteJilicp~lVic~~~uon
Intetvettti~~ ~ology.
Subtotal./ 'fota,l h}'st~rectomy
!aparotomy is immediately done. To preserve
rept.oductiye function, repair blay be dl>ne if
poss.ii;;le. Usually. howe~er, hysterectomy is
mandatocy for a favorable outcOme.
When a hetnatOIJla forms. the patient
. complains of P .a l'n. greater than that with
episiotomy atone, With developing .anerilla, and
eveh hypovolemic 'Shoc1c. Pronipt t'e~gnition and
appmpiQ.te~($tea,fi ~inorbidity.

R~potted inciden~ ~es.widely, from 1:1500

B~g;while'~t.~e~u.terus"is"firmly c;ontraeted:.
is strong--:Vidence 'Of .g enitaL tr:actlaceration,
retained p}aCf!tltiU ~en!ts odX>th~ Alatetation
m.~Y,:be suggested bf :bti~t red :bl~g;~;Ptoper
CJiCP.OSUre i~:requ~~: h~nce;. the nece:>.~uy..(or. ~
~si~tant:~d. gOQd.Jighililg. 'l'o asc~tt.am therole .. in~tnunentaldelivenes;,:vulVo.i.-~ :Vat"..cOsi.ties
.of laC.eTatiQ~S ;~s:~a e;ause .o f t>iee.,d,iiig;. c;areful and ptP}b'ncged -~~d $tage Of.'\abpr.
ins.~tioit ofth:t{ vaii.Ua, t~fvii . a nc,luttrus is
. es.se~~.
GerVical insp~ction directly visualite ;;utd
inspect the -cef\'lx withthe aid of tjng fo~ps. The
anterior 1ip is grasped and the cervix :is ins~cted
by using a secopd rirt.g forceps placed at the
2 o'c1oc:kpo$i~qn. fo.Uow~ ~y~rt>~s.$iYely putting
the. fo~p.s: ahe:ad.'9f.on:e. another iih~ the .e ntire
circum:ferehtebas 00.~ J,as.perited. s uture any
bieec,iiA~,l~$io~~lqpgr. fuali.2,~m. To ,aid ~sur(!,
gentle tr:a~ti,pn can be used withan . assistant
pushing down the utel'ils.. The ~~i;t should be
c~efuliy ili$pcted-.fot lacero.P.on~. ~cerations of
the vagm!d'Vaul~~must be W~ll7:visu~d and their
f ull extent realli;ed pr,ior to t:ep~.
. lf the .bleecljng- is due tp lacer.i'l;tions in the
vagiua or ~n'ix, these should .b e repaired
promptly putting the ftrststitch at leas~ lcm above .
the ape;x of the t~ to take. care of- vessels that
. may have r etracted.
Ruptute of the uterus is diagrios ed by inserting
the whot'e hand inside the Uterus and doing
to as fte<tq.e nt as 1:300, with large hematomas
l'~tooo:\>a:ginill'cle1i~es.- ~.. "
The Jrtost ,cqn:HnQn etiOlpgic factor is
inadequate h emostasis' .durin'S te'p a1r . bf an
pi~1oton1yorva,ginal1a~r:ation. O thf!r ~'llse~ are.
if $U~n'l6i'aL it .J)re$~rit$ .as. a urii}aterai
sw~um-g'WlJ:li"1:nr&JYnri~a-an~F~Yiliosis.
Tr.eatliienrooniiif:S:ot~~tioirWlili-Jfiitioil ot .
b}ee~g VC$sel$, :~liil'lination Of dead :sPa.ce by
sutut"Ul_gi.-'1 ~m. or ifthis:is i)ot feasible, packit1g
the va:gW.a ~glltl.y.:.Pla,ee a :foley catheter ;beet~.use
urln~ tetentitm ~ oocur l;)ecause .of pain and
tissue di~tention;. :Remov the 'pa,ck after 24-48
ho:uis. ~mbolitation may be used in both vaginal
ari;d vpl'Var :h~atomas that are unresp<>~sive to
surgical .man~gement.
,Bro~d Hg~e~t and . retroperitoneal
hen;iatornas are less obvious, and thetclore, niorc
. difficult to .diagnose. When they are suspected,
ultrasound, intra.v.enou.s pyelography, or
co~puterize4 tomography scanning is helpful to
ass.e ss.the $~and progress of th~se. hemato~as.
They are .initially managed . exp~ctantly if the
patlnt.is sta:ble:a.Jld the,lesions are not expanding..
In an emergencysituaqon with active bleedhlg and
mar-gin.a l -catdiov~:scular s~aht's, e;ploratory
laparot6my should b~ done. to determine the
source of bleedin~. Use surgical procedures to

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'!!~;.
CHAPTER 53: ABNORMALITIES OF THE THIRD STAGE OF LABOR
evacuate the hematoma and attempt to tie off any
bleeding vessels. Ligation of the hypogastric and
ovarian arteries is usually necessary. Selective
arterial emboiization may also be done.
In the presence of bleeding after delivery of
the infant. manual extraction of the piacenta is
dcme immediately. (Figure 53.6) In the absence of
bleeding, however, manual extraction .of 'the
placenta is not indicated U:ntil 30 minutes have
~psed because studies showed that there is no
increase in hemorrhage until the third stage
exceeds 30 minutes. In a third stage longer than
30 minutes, there is substantially increased risk
of hemorrhage regardless of the method of
olacentiu delivery. The incidence of hemorrhage
~ay be reduced and the third stage shortened by
prophylactic administration of oxyt<>cics tv cr IM.
Figure 5.3~6~;M8nuill extraction of the placenta.
~ECHNIQUE OF MANUAL REMOVAL
Ade quate a n ,aJ .g esia or anesthesia is
mandatory. Aseptic surgical technique should be
used. After grasping the fundus through the
abdominal wall with one hand; the other hand is
introduced into the vagina and passed into the
uterus, along the umbilical cord.. As s oon as the
placenta is reached, its margin is loca ted and the
uh}ar bor:der of the hand ins inua ted betWeen .it
and the uterine wall. Then with the back of the
hand in contact With the uterus , the pla centa is
Scanned By:
827
peeled off its uterine attachm~nt by a motion
similar to that used in separating the leaves of
the book. After its complete separation, the
placenta should be grasped with the enti."'e hand,
which is then gradually withdrawn~ Membranes
are removed at the same time by carefully teasing
them from the deciduas, using ring forceps to
grasp them as necessary. Some clinicians prefer
to wipe out the uterine cavity with a sponge.
HEMORR...JIAGE .1-"RCM RETAINED PLACENTAL
FRAGMENTS
The placenta must be inspected routinely
after delivery for missing cotyledons or for
evidence of fetal vessels col.Jrsing to the placental
edge and abruptly endirtg at a tear .:i n the
. membranes suggesting a retained succenturiate
lo.be.. Uter,We .explor~tio11.has.also.been advocated
to recognize and remove a re Wfied cocyl~n or
succenturiate lobe. Cateful curattage us~~~pig
curette can also be done to make sure. tbtiie:,fl.fe
all ~em~ved. Ret:aiiled small placen-tpfh~ts
:;eldorri cause immediate postpartum hemorrhage
but is a common caus e of bleeding,late;;in;-the
postpartum; ;. ~~.:. .;,~~:.
-.: -~-t;"J ::--.::.:.:~ Jrl-~7:-t1.
ABNORMAL ADHERENCE OF THE PLA~ll!tn'A
}f. :2!l m~~;,t!._~~y!Jgp,. _fu~_.nl~~~~ :~9t
be sep~<~;t!!d from its ute.rine. attachment because
a cleavage plane between. the placenta and the
uterus cannot be t6cated, a clinical. diagp.osis of
a bnormal adherence of the placenta is established.
No further a ttempt should be made to :remove the
pla centa manually or. by curettage because of the
danger of increa sed bleeding, perforation artd
infecUon. This condition is associated with a high
morbidity and mortality.
Placenta Accreta
Placenta accreta is a ny placental implanta tion
in which there is abnorma lly adherence to the
uterine wall' as a result of partial or tota:l absence
of the <:lecidua basalis and imperfect dev!!lopment
of Nitabuch's layer. Placenta accreta is when the
placental villi. are attached to the myo~trium.
Pla cental adherenc e may involve all co'ledons
(tota l placenta accreta), a few to several cocyledons
. (pa rtial placenta accreta ). Place nta in creta is whe n .
the villi invade the my ome trium and placenta
~
 8.28 SECTtON .IX: ABNORMALITIES OF THE. PUERPERl.UM
------------~------~----------------------------------------------------~' ~

percreta when the 'Villi penetrate through the
myop:1etrium.
The incidence of placenta accreta .has
increased 10 fold in the pa1>t 50 years most.likely
:driven hy'incteased ce~n r~tes with a current
freq'Q.ency of l per ~500 de;liveries. Women who
had 2 or more .c esarean deliveries with an tenor or
centr-"alplacenta pr.evla. have nearly ~ 40% risk of
developing placenta actteta.
Placenta aqcreta has been
'in a 7% "mortality rate as well as intraoperative
and postoper-a:tiv:e .morbidity associated with
massive blood transfusion, infection, ureteral
d~age ancf fistula formation.
' ..
ro,sk facto~s for ,pla~~nta ;a.c~rete includ;e
pla~nta, preVia with cH Without pf.e:v:i~us 'l;lteriile
._~u.rgery.,'~tjor. hly,o mectomj. _.p rior
~eli~ery1 ~Ashe':t!:p.~?-s sy;n.-(lr~n:tie., submucous
.myo~'an<i .mate:rn.al.-~ge ok~er than 35 years,
.bis'tory; 6~ -cllre.tta.gir ri:ra:p.u:~.r.e:Xtr.a:c'ti<1n. of :fue
pi.a.ceri~ ptevio~s re.1;SlneiiJ)lacepta:..a nd infection. ..
.Profu~ h~m9tJ;bag~:~er.v~alddivety i).so .'may
:he :ali~ to ;P~~nta 3-'ccreta,:
more recent years placenta accreta h as emerged
as a leading indication perhaps as .a r esult of the
intr-oduction ofprostaglandin for uterine atony and
an increased incidence of accr.eta due to high
cesar~ r~te.S;.
If the clinician is .e;,.,-tremely confident in the .
diagnosis; it may be prudent to complete the
delivery of the infant and proceed with
hysterect-omy while the pla centa remains
att<:!.Ched. 'Pr.ofu.se hemorrha_g e can OCCUr when
r~p0rted to res.ult attempting to separate the placenta.
Qerterei i.nesthesia should be considered s ince
:tb:e procedure is.prolonged and require adequate .
inttq.operati\(e exp9s:Ure that may involve packing
the upper a bdbmen. .
Conservative approach of leaving the placenta
in situ fol:lowect by lll.e thotrexate therapy has been cesa~.ean
reported 1n local literature a viable option. as
Treatment consisted of c;ord. ligation clt>se to the
placenta, oxy'tocin. and .anHI5ioti'<';s, and
me.tholr.exate 50 :m.g on alternate ~ays or weekly x
6 doses plus folic a cid.. Ev;;~.h.to.tion cons isted of
weeklyHCG.,and
..
w.eckly Ultrasouhd.
. . .
6
~

. . Ifthe:dfa.go..O~s or st:tong' suspici0nofptacci!ita

ac~eta: :j-~for:med ; b'efdte .de:lj.ver.y~:. t.he ..p,atient
.shoum~.' couli~~l~d' . .ii:bout :lhe likelihood of
-hyster~eeto~y and blo~H;1:. tr-ansfusion. Blood
:rrt.uc..tS:imd~aott:ing.:fa~o.Fsshot~1(H>--availa:ble:
....-. . ... . .. .: .. . . ...... ..: : .. . . . . . - . . ... . - J. . - . . .
- ---- .... .- ... ... . . .

Bitra.S<?li()gr;:\phy, '1-agri.eti.c ~.es6nance imaging

an& colori:>Qppte:r st-..:1,d'ies.-at-e ~~pful to make an
-~~ diagiwsi,;s, a,ftlio1,1gh at -this tll:rie, :(io
~:liagpost}e tec))que iftords the dip.ician 1OO%
:a~@:ran~e of e{fu~r ..t\:llin:g :ih o"t tulii:ig :.o ut -the
presence . of pla;eeri,ta acc'r .e,ta. {Figure 5 .3 . 7}
Ultra~6~nd with::boppler is. more:.s\lperi-:>r than
gtaysc~e sonography ih diagno:sh:ig ptacehta
accreta. Three ultrasound criteria were identified
as "imporlant' fu. the diagnosi~ plac~nta accreta. of
These are: l)lntraplacel.)tallacpnae, 2) Thinning
or disruption. ,of hypoechoic interface betv;een the
u t erine .s erosa and bladder,' and 3). Lo.ss of normal
venous flow o.f the periph~ra~ placental margi,n
Figure 53.7 . Placenta percreta.
..._;ith pooled OR '01 3.6: Of the thr.ee criteria
merttiohed, the intr:aplacental iacunae is the I
highly .associated fiq.dings 'irr. the diagnosis of !
I
p~actrhta accryta. Sekctive . a rterial embo.l.ization and I
autot.r ansf.usion .. may al'so be . done . I
I
Utenne ati>ny was the predominant indication Autotransfus ion dev.i ces (Cell Saver) collect blood I
for eme-~eng; :hystere.ctorriy in the 19Sb's but in from the operative fidd via an anticoagula ted I
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 CHAPTER 53: ABNORMALITIES OF THE THIRD.STAGE OF LABOR
suction device, followed by processing of the
product via filtration and :differential ce~trifugaUon
with subsequent reinfusion of red blood cells with
the p&tient through .a second filten!d system.
B~ne'fits .o f auto. tran~fusion L11du<,l.e .l ess exposure
to homologous blood, risk of autoimmunization
blood born pathogens and immunolo.gic
complications. Relative contraindicatlons to
autotransfusion include heavy ba'c terial
contatnination.
UTERINE IN\T,ER~ION
This is turrung inside ()Ut ofthe.uteru.s , usuany
occurring:at the _time of or 'a fter delivery .of the
placenta _and .is potentially a -life th.re~tening
complication. Prompt recognition and torr~ction
will-reduce morbidity and J]lortalit.y.
incidence va.."i.es widely irom i :210(YP.eliveri~s
to 1:6400 i d~liveries .incidenc~ .is :Pilr.t ially
cipendent qn the experience of the ope~to.r.
. }nv~-~~i~h' is usually. a con.seq~ence of
:mlsmanagement Of the thi&d st~ge of labor.
Attempts tg ,9~Jiver the.placenta such AS e;;a;essjve
traction oft' the cord or fundal ,pte$.~Ure {Cr.edes
.m a ne,uyer).. ;with -the p lacenta still atta ched
e$J)eclan.yWiih fundal implantation :and rehQted
uterus. are the most common . cause .. Other
p~po~~ng fu.cto~;s h;lcl!ld;e ~~er.ent p~P~.
short cotd'; congeri:ital predispqsit.ion, .in~~d
m~M~'??;P~:P~~~.i.:<i~ -~~y~freWcQ~;QLth.e .
placenta and uterine relaxati9n after gener.ai
an_stheS:ia; tough cord.
If the inversion ~ends beyon.d the level of
is
the ce~ it t .e rined complete. If ni!t. it -i s said
to be incomplete. (Figilre 53.8) If the -corpus is out
of the introitus, it is prolapsed inver.siott.
Acute abdominal pain with sudden and
profuse hemorrhage occurs, followed by shock It
h a s often been s tated that shock t~nds to be
disproportionate to the blood loss. Studies
however, showed that blood los.s is often massive
but greatly underestimated. Complete inversion
m ay..present as amass protruding out of the cervix
or vagina. B.i manual examination confinns the
suspicion if the fu'n duscannot be.felt abdominally.
Delay in treatment increases the mortality rate
appreciably. Two lY infusions are. started
immediately Oactated Ringer's and whole blood) .
Under gerieral anesthe s ia, the uterus i.s
Seanned lly:
829
repositioned. The palm {)f the hand on the aenter
of the fundus with extended fingers, the tips of
which are along the rim of the cervix, the fundus
is pushed upward th,rough the cervix. After
reposition, with the h;111d maintaining the fundus
up, oxytocin is incOrporated to the LR solution.
Bit:lanual massage is done to promote.contraction
of the uterus. The hand will then feel the
.c ontracting uterus pushing it out into the vagina.
This hand in the vagina continues to monitor for
.any evidenc~ of recurring inversion . The
controversy is when to remove the still attached
placenta. A study Plentioned that the largest biood
loss occurred in case s in which t..')~ placent4 wss
removed prior to repositionin,g. If however, there
h~ partial detachment, the placenta should be
removed first , .Th<! .i la-tter . seems t~ be more
convenient ~ause the place.nta adds bulk and
makes repositioning .more difficult. .
Figure 53.8. Incomplet:: uterine inver sion . The diagnosis is
maoe by abdominal palpation . of the craterlike depression
and vaginal palpation. of the 'fundal wall in the lower ~gment
and cervix. Progressive de_grees o.r i!l'!ers ion are s hown in
the inset. (From: Wiliiam's O b s tetrics, 22ndEdition.')
Occas ionally, the cervica l-ring may be t09 tight
to permit vag'ina i r eplaeeinent. The ring may be
incised via the va gina l approach :o r lapaJP!omy
may be required. Laparotomy for uterine inv'&sion
is rarely necessary if recogriition and treatment
are done promptly. P:i'9 phylactic antibiotids a re
adminish~red. . . . . .
C
830 SECTION IX: ABNORMALITIES Of THEPUERPERIUM-

COAGULOPATHIES . Seek theadvice of a hematologist in cases of

massive transfusion or -coagillopathy.
hi the immediate postp:artutn perio'd;
disorders of the coagulation system and LATE POSTP~..n.TUM HEMORRHAGE
'
platelets d.o not usually resul-t irt excessive
bleeding. 'rhi's -~tnphasi:tes. the efficiency of Late postpartUm hemorrhage refers to vaginal
uterine contracttort and retraction for bleeding beginning after the first 24 .hours
preventing hemorrhage. following delivety. Generally,it occurs withi...~ -7-9
days .a lthtmgh rarely it may develop several
coa:gulation .. stu.dies are no- longe.r months later,
routinely per'fo:rtn~d in 'P regna-n t women
.including th-ose a\'lout to undergo ces.a rean It is most commonly associated with uteriile
d elivery .. ln~tead, .hl$tor:Y is r .elie'd to. uncover subinvoh.ttion, which in tu.rn is usually a
previo-us episod~.~ sugg-esting .pre .existin_g . consequence of infection, retained plaC.ental
h~tnb'st~S'i& diSt>l"d~r-s.' .fragment'S or an .a bnormal healing of the
thro.mbo~edvascQ]ar sinu~es at the placental site .
.Pre Xistirg ~bn.cr~alities of th:e clotting A physical fmding of sqbinvohitkm is -softened
sy.Si;eltl s'ueh S.$ f~rnmal 'h,ypofibrinogenetnia :m-ay uterus :larg~r than expected for the time during
0 .c cur but .acquitpd.'tthi'\Ortnatiti-is are -m-~re puerperium. 11i1les$ . b.leedh.lg is active,
cpm,tnonly p.t~blettta:tic~ DlC relat~ to .abruptio conserv.a :tive rn.'am\ge~H:nt may be . done .
placcnt~ :..l1-lt.J.;r.P YJld:rcm~,. inttau terine fet~l Ultrasound is don e to .detect r:etairied ptoduct of
denli:~;~oti~-;fluid!.tml;;oljs~~~d..8epsi~ .ntight concepuonor d()t$. With a ,no~hl 1,1lttastlund,
o.c\:lr.. 'FinaUY~:iUlutio~~1<>.p:a.'Jhy.nray-oe'f.;ur : . antibiotics, an~q~~ics~arcrgiV:en. , lf th-ere are
follol'rint - llia$~iv.e. -r.Pll .- an,4. .J~e~U$itatio.n. with , .. retainedptol;fu~,p!!con~ption,cun~ttag~is.dqne ..
rn:ystiilloid"Srii:l paCked':~d biOQit ci:U~. .
SuM.WtARY
.tn- pr.~Vititisiy: heal~hy women:',: dilutional .. . , .
c,a~l~pathy - is !'l~~ ' tisual!Y-:'~bsieWed . until Mutti-ple .inip.r.ovements iil; obst~ti'ii:: ~ care
apptO~~ately,-.1lO%~rtnt: oR:tbe- ~originaJ ~.b1oad.,:: ..; mcludiitg ~t<:~i~i'lidv~c~s-';in~blQdd :banking;
vol~e.h~$ 'l>~el),_ -~~~1~ce41 . ~~s.Y.:l~Jt momt()r antil~i~tic _ p:tt~'PY o,b~teU"ic anesthesia and
henmsti;ttic te'~ :mq1f$ ,.fu -allwC>:mth who requke oiyti '.'~&et;J:~~ ~ye -1~ tl> iinpr6ved lD,atemal

.~~~~r~~~~=e~~~~~: -~:~~~;:t~:~;;~~~~~x:~~:tf~J~\.~':
p~nc~f.,e -~it;~s, - fu:\i~F$ ~Ufl:a"ee$, .or wou_nd~. maternal mPthiQity and morta1ity in fil()dem
ad~tior;:Al bli:iod .pr.o'dubts 'l.:\te :r.e:quiiC'd. tnfuse ob$~etrics. tJtet.In:e f!,tol}y remains the most
fres.h ft~n p.tas~: ,~gin_nmg Wl.Th 4 'ti4 iiitd co:mm.o:n contrlb'litor to this potentially letha l
With addiiiotmiurii.w\t) ,heonaUZe t~e. a~ta~qn 'P:ati~nts . expetiel}~ing post
clirti'ii:ril :P..ro.blem.
te:s t.findirtgs. Many a~tl);ori,ti'e$ Teoinmendthe partuin bemorrh~ge usually respond 'to .medicru
ad4!tion of'l.up:it J:rF.p . f~r every 5 units of packed and conservative su~gical thetapies, bi1t . may
RB'C to :P.at~e-l}ts who requlre Gontinued. . ultimateiy requir.e.)lystetectomy for hemos~sis.
tra.{lsfu$ion. Early recogriit.ion of -r isk factors and preparation
.fornieditaland surgical jntervention may r educe
tr s_urgicafil:).tetventiwd~ necessary~ rriaintaih " the d~gree ofir1it1al''blood loss artd' t hus re~ult to
the :p!atlet .c ount at PlOte than 80-100 x 10 9 /L. less severe ctnnpllcations.

POINTS iO REMEM13ER

OefiriitiohS of p()st partum hemorrhage (PPH)

..o ~ditional!'f,~efined ,asblood loss greater.than 5QQ,mL in a vagin~l delivery .arid greater than1;000
mlin ,a. ~s~rean-delivery . . .
... o any ble.di~g that-results :Jnsigns .and symptoms of hemodynamic in$tability if untreated-is considered
. postpartum hemorrh~g~ . . . .
o a.decrease in postpartum hematocrit level greater than 10% of ~h e prenatal value

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 CHAPTER 53: ABNORMALITIES :oF THE THIRD STAGE OF LABOR "831

'
Post partum hemorthage occurs within 24 hours after deli~ery
Third stage hemorrhage is postpartum hemorrhage before placental delivery
Causes of PPH ( FourT's)
o Tone - uterine atony
o Trau~- uterine, cervical, or vaginal injury
o Tissue ~ retained placenta or clots
o . Thrombin - pre existing or acquired coaQlllopathy
Pred!spcsing factors for utarlne atony ate high .parity, precipitous or prolonged labor, general anesthesia,
overdistended uterus (rnacro.somla, hyd~arr.niQs, multifetal pregnancy), oxytocin augmentation or
i~~uctlon of labor, history of post pa~m hemorrh~e. amniotic .fluid embolism and magnesium sulfate
Placenta i$ more likely to be retaineq aiextreme preterm gestations (<24 weeks) and significantbleeding
can occur
'
.Risk factcrs for birth canal injury are operative vasinal delivery such as forceps and vacuum extra!;tion,
breech extraction, and internal podalic versipn
Complications of PPH: m~temal hypotem~iOn. sliocl<, ac\Jte tubvlar necrosis, dilution coaguiopathy,
cardiac arrest and death.
RarelY, P?H may-be: :followedm\lch Jater 'QY -pituitary'-fqilure(Sheehan -syndrome) cchatacterizea by
tal!iire,:of lactation, amenorrhea, t-.reast &trophy. loss of pubic and axillary hair, hypothY,:oidisffi/;.P.J'ld'-
adrenal cortit Insufficiency , -' . ~~~;'j~?'.
Rb~tine care in t!le immediate postpattttm period shouid ir.cluda close monitorjngof vital signi amO\Jht
of bleeding, ar.d uterine tone and siZe. -'
BiOOd loss Is :often <;linically under.estimated.sometimes resulting in a delay in addressing an impOrtant
problem . -- - - - . - : : _~ - ,-.:.::.;;: ., . .
. Th~i>k,oo volume expansion that.occurs ~uring pregnancy compensates for normal blood loss.r~t-tki~~-~:-_
. r
PPH is likely to recur :in subsequent .pregnancies ; ;.,-;:

. . . . '~ -- .
of
_Urine ouiput Is one the rno~t h'nporta~t parameters
.. ~-- - . - ----.. ---- ~- -
to follow in the bleeding patieni
' ... . . ., ... ------ ......... --- . -- ... . . - . .
R.apid.lY..bOJus. :o.f_ .9xy.tOCifl.is .riot .reCorrtmended..because Jt:.m.a.~:. caus.e. hyp.oteos!on. or cardiac .arre.st
Hypetension is a relative co.ntri;lindication Jn givin~ ergonovin~ or ergotrate
Two tablets of Misoprostol .(Cytotec) C3dministe~ rectally may also become a valuable agent in the
treatment. ofPPH .
.
Blood trc:~n'sfusion shO\Jld be -initiated immediately if biman\Jal massage and oxytocic d,rugs fail to stop
the bleeding
Hysterectomy is tile definitive procedure to tontro1 ~emorrhage resu:ting from refractory uterine atony
The B~tynch .procedure is a fundus compression suture that is placed at the time of Japarqtomy after
delivery of the fetus. 'This procedure effectively prOduces tamponade by compre.ssing together the
anterior and posterior walls
Other compression methods are the Cho and Pereira procedures
Bleeding while the \Jterus is firmly Contracted is strong evidence of genital tract laceration, retpin ed
placental fragments or both
Rupture of the uterus is diagnosed by ins.erting the whole hand inside the uterus and doing manual
exploration, with epfltrOI of the uterine fundus with the other hand.
In vulvovaginal hematomas, the patlentcomplains of pain greater than that with episiotomy alone; with
. dev~loping anemia, and even hypovolemic shock

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 "832 SECTION
........._ IX:.ABNORMALITIES OF THE PUERPERIUM

Most common et'.olo9ic factor of vulvovaginal hematoma is inadequate hemostasis during re.pair of an
episiotomy or vaginai laceration.
In the absence of bleeding, manual extraction of placenta is not ihd.icated until30 minutes :hiweelapsed
beeause :$tudi~s showed that there is no increase in hemorrhage
.
until. the-th_ird
. . stage
... .exceeds
........ 30 minut_es.
The incidence of hemorrhage may be reduced .:md th~ third-stage shortened by prophylactic administration
of oxytoeics IV or IM.
The pl<:rcenla must be ins~cted routinely after delivery for rnissirrg eol:y.l~ons or fOr evidence of fetal
vessel~ coursing -t o the placental edge -and :abruptly ending -at a ~r in-the m~mbranes suggesting a
. succenturiate tobe.
A cHnl~l <li~gnosi$ ofabnorma! adher~n.ce ofP!acentais:establishefi if on manualextrcrction, a cleavage
plane batween the -p_lacenta qnd the uterus cannot be l-0Cated
Placenta .-,CC(eta -~- whe~ th~ placental villi a.re .attached to the m~trium as -a result of partial or total
abse~ 'of the deciduas basalis and imperfect aevelopmEmt. of the Nit~buch':s IC)yer.
Pl~cerita increta is wher\ the villi irwade the myometrium
Pla_centa percretq. is when the vllli 'penetrate t'1:oi.Jgh the myometium .
Wom~n \'fho h_ad 2ormore c~~rean-deliveries with ~mterior or -central p)a~nta previa hzve nezrfy a
" 40% risl<ot.. qeveloping
. place{lta:acereta. _. . . .
. Hi.Sk raq~Jor'::plaGenta.aqzreta)MI_ude placet.ta:Pr:~.ia wi!P orwilh?\Jt:pr.e~tioos uterine surgery, prior
- - r)1yp(n~i:?my,,prjo_r ~-~r~n.~iliveiy."'Ashe,nnan:s:syndro~.--SI.ibftl!.:!CQll~;myomate:an~hmat~?m~l:- a:g~
'oldertl:tan 3~_years, hl$toty.-ufcurettag~. _manual extra~ibnbt ,t fie planta, previous retained placenta
:lind: inf:etticn:' : ,
Uttr~riOg~phy, tnagn,eticr~s9flane imaginfi .. and G()lqr.t)op-pl~r s~die$ are.~lpfutto make-a~tepartum .
diag_nos~.bf plaqmta?mr.eta: .- _.
Three tjltre$cuntt c;:Otenawf.!fe k!entifiei;fas :irrrPoitantin the dlagn0$is 9t"ptacenta-aweta: 1 )ointrapJ~centa!
mCt!.nae:h\ghtyassoc!ated findinti; 2)"1hinntngordiSinl"ptlort',qf:~oic-in'~ena~:petwe~i-i'lhe uterine
setOS9and ,bl:ad_d:er, and 3) Loss of notmal venous -ftow th:Penp-~;-ar:p\3~ntal margln With pooled
QRQt,;3..fL . . . ._. __., __ ___: -. - .. .. - -- ... ........ ..... - - --. .. - . .
The"inos(commona~:.~se:of:u:tegr.teiinv~-rSibn---tS ~xcessi-)l;~;lr.:t~6on':Qn'~~cotd::t:n<fUnci~!P.res;~ure:cc:;:ecres
.maneuver) Witt the p~nta still a~ached -e~peciaUy With fund_at imi5Jgmation .an~ r:e!axed .-wterus.
lfs.-.d:>mpl~te. uterine i~version if ttie -_-inveffiian -e~en:d~ beyond rre, ~vel of. ih.e_ te(._;ix and if -not, it is .
term~ ln~mpfete. lt'sprolapsed inversion iftheeoiptis:is o.ut P"tttie Jntioitus. . ..
Coagutation ~tudies are :10 l 91'lger {OUtinety perfo~ : in preflnant WQm.en including abe.ut to _.ihose
un9e&!)-.t isarea'nd~iivery. lh$te~}d: history is r:e!ied'to tincov:e~:P~vious eph0de.s suflgestin_g:pre e)<isting
nemq~~sis .cUsord ens. .
Late.P9stpa_rt"!fTI hemorrhage ciccurs 24 holirs.:~o .6 weeks after d1ivery. )

.Late .post part!)m.h emorthC!g e i~ rtrost commonly associ~ted with uteiin~ ,sutlinv.o.IDtion whiCh in turn is
usual!y:iio"nseq~ehie ofl!lf~ction; refain~d ,pl?centai-frn_griien~ or-.C)."n~abnorinal heaiing oftneth'rombosed
vascu:ar sinuse~ at the placental site.

3. National Statistics Office. .National Demographic and

Heaith. Survey "1990-1995 data: 1WG Maternal and
i. CunninghamFG,Gail.t NF, Leveno KI. e.tal.. Ob"stetritai .Chlki-Mortality. National Statistical COOr<ih1ation,Board;
, Hemor:rhage: :l2nd edition, NewYor:k,.NY:McQraw Hill. 2006data.

2 .Bel-g cS, Auash HK, Koon.in L~ T.ucher.LM. f1-egnancy~ "4. Ghoi PT., Yip .C , -Quincmeg LG, Cooh OJ . Crystalloids vs
related mortality in the u:s.,
1987-1990~ Obstet cc.>lloid~ in fluid -resuscit.a:tion: A systematic review. Crlt
Gynecol1996 (Medline). Care Med.{Mcdline).

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.~
~- CHAPTER 53: ABNORMALITIES OF THE THIRD STAGE OF LABOR ., -833
L.:...

.5. B Lynch C, Cohen A, Lawal AH, et al. The B Lynch 8. SOGC (Society of Obstetricians and Oyne.~.ologists of
surgical technique for the control of massive Canada) ALARM International Program- 4th Edition
postpartum hemorrhage : An alternative to Septennber 2007.
hysterectomy. Obstet Gynecoll99T(Medlinej
9. Baker R. Hemorrhage in obstetrics. Obstet Gynecol Ann
6 . - Pang~ban RE, Teotico, R. A con$el"Vativ!: management 1997;6:295.
of p1acenta pte'Via .perc.reta: Aoa$~ r~port. Phil J Obstet
Gyneco12006; 30 (4): 192-202. 10. Martin SR, Strong TH Jr. Ohstetric Intensive Care
ManufJ 2004 McGro.w Hill Publishbg Division.
7. 2007 Compendium of Selected J>Qblication # 293 F~b
2004. Co.m mittee Opinion-Clinical Ma~agement
Guidelines for Obstetrician-Gynecologist, Number 76,
l . Oct. 2006. Replace Committee Opinion Number 266,
Jan 2002.

- ~~ .. u-~-~- . . --. ''"' - ..

-~-- ., :/~~-~:~.'.~t-:.: .
., . .;:;~ _;..~: ~- -

- ~-~~ -
. . . . ..-
tj;

.l
}

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 . .. ... ..

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.

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~
 54

INFECTION AND OTHER . .

ABNOP~MALITIES OF THE PUERPERIUM

OSCAR V. RESURRECCION, MD

Puerperai Morbidity

Definition
'
Differential Diagnosis of Fever after Childbirth

Postpartum Uterine Infection

Risk Factors

--~ Microbiology

Pathogenesis

Clinical Examination and Diagnosis

Treatment

Sequelae of Uterine Infections

Other Disorders of the Puerperium

Thromboembolic Disease

Diseases and Abnormaiities of the Uterus

Hemorrhages During Puerperium

Postpartum Psychiatric Disorders

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 836 SECTION IX: ABNORMALITiES OF THE PUERPERIUM
DEtiNITION AND EPIDEMlOLOGY
Puerperal morbidity is defln.ed as follows: a
. ~e~~rature of 38C ( 100.4 o,F) or higher, which
of
.. oceui'$ on any 2 the first '10 d2.Y$ p0stpart~~,
o:e;;:clusive of the first 24 hours, and which is taken
. orally by a standard technique at least four times
. daily. ..
Thi.s defmitior1, however, may not .ap,ply in the
.'ge.h~ sense ~use :of th~ challging ptactiee 'Of
. eru-ly' ~tiel)t diScll~g~ . and due to qli}ck response . deep v~ii-.s. l>hysical ex-alnirtat,lpp :rrifi:y s how pain .
~( the .patient to n:e-w~K"~tibiot1e~ .that th,e or ede'llla on. the affected leg br UiguinSJ
t~~~'t:etutt criteria. for .m orbidity is nQt met. . .
.
. . . bl .the U.S estimated ovetall mortality rate
frl>:m P,9stpartum infection is 3 . 1 per 100,000 live
biith$~ second only tc pregnancy induced
:~n.sion. Locally, it has been reJY.)rted that
. -~f ~~ ~te~ infections, puerperal sepsis has
.the1jighest.fa~ty rate .at 32.1% and followed PY .
:in~~ ~epsis (chorioamnioniti:s) .at 2.1% a;rid
. .. ~$t1];:1;)y post-.~bott~.bsepsi$ at .1 .5%"
. Th~ ft>Uowing . .ma:y caase fever following
:-eliil4blrth:
. ___ ~'M..Oi.t. pe.rsi~t_en.t f!!ver~ ~ter _cijjJc;\1;)itt}1 ~re
. ~u~.~by-.. gem"tal tract infections. The course of
. :i,al>Qr.g reatly influences the development of tb,ese
;.tnfeetions. Important risks factors include:
. p~1Qi:lged TU:pture bf membrans, .intrauterine
d~.nic monitoring, uterine manipull;ttions, .and
. dit'iitaJ .~tions. Pepencling On the pa:ti~nt's .
: rl~k.Jactots, uterine bfection~following a vaginal
. : :Qcli~ are relatively uncommon. Endometritis js
diaghosed after 1 pen;ent to 3 percent of vaginal
pi~: . It is up to 10 times more .c ommon after
:u.s:ue~ bjrth.
Py.e lone p ill'itis
A typical case of pyelonephritis presents as
feVf~ bacteriuria,pyuria and costovertebral angle
t<:nderne ss. The urine frequently contains white
'blood cells and bacteria.
>~reast Engorgement
If temi)erature does n,ot exceed 39 oc and lasts
.less than 24 hours, trea tment m ay not be n eeded.
Scanned lly:
Breast engorgement, which causes breast fever
. . '
needs to be-differentiated from infectious mastitis,
which is mainly bacterial in nature. The
.p redominant organism found in mastitis is S.
miteus, often the peni.cillinase-produdng type.
About S-11 percent of lactating womeri with '
bacterial mastitis develop breast tenderness.
Thrombophlt:bitis
Thi;t.conditir>;runay affect Q<>th superficial and .
area.The .
coriditibh .i s 'treated.with l1}tra\'ei}ous heparin. .
POSTPARTUM UTERINE INFECTIONS
Sy.nonyr.ns are endoin.etritis, metr~tfs ,'
endomy.ometriti!> and endomyoparametritis.
Cunningham prefer!i the tenn metritis with pelvic -.
cellulitis, as ihfeetion in,.olves n otonly the decidua
but also. the myot'netriuin 'cU'ld parametrial tissues.
Of these, ,e ndometritis is.the most .commonly. us~d-- __ . .
term -t:b .deseribe p(;stpartuni uterine infection:.
'!t is an imiX>rtant cause ofmaternal mortaUty
worldwide, althoughthis'isvery r-o.:re indeveloped
countries ~use of the advent of antibiotics. ..
ll)fection.s may o~cur within 48 hours (eai:ly~
onset) or up to six weeksaftef delivery {late-onset)
There are several ris.k factors for the .
development of postpartum infet tions. The most .
important faGtors :a.re: route pf delivery, duration .
of labOr, duration .($f rupturl,! of membranes an(!
.the number of vaginal examinations.
Route.t ;f D~1ivery
. This .is the single most s~gni.ficant risk factor
for the dev.eiopment of uterine infection. Infection
folloWing vaginal delivery as compared to cesar~an
delivery has been noted to be Uncommon. The
freq~en.cy of endometdtis following vaginal .
delivery rarely exceeds 2~3 percent while that
after cesarean section ra nges from 10 percent in
low risk patients to as high as 95 percent in high-
risk populations. Women who are h igh risk are
those with prolonged ruptur~ of membranes and
labor, multiple cervical examinations and internal ..
fetal moni torihg . The incidence of metr.itis~
followine- surg ical delivery varies with .
C
 CHAPTER 54: INFECTION AND OTHER ABNORMALITIES OF THE PUERPERIUM 837

socioeconomic fact-ors .and through the years with MICROBIOLOGY

the emergence of antimicrobials. For .a ll WOJtl,en
at higQ. risk for pelvic infection following cesarean Bacteria native to the perineum, vagina, cervix:
section, the American Coll~.ge of Obstetrics and and bowels cause most female genital tract
Gyneq:>logy recommends the use of sin_gle - dose infections. These bacteria are of low viruience but
perioperative antimicrobial prophylaxis. become pathogenic when e~osed to devitalized
tissues and organiz~ -clots. '
Lbor
The bacteria coniinonly responsib1e .for the
The length and dl.p'ation of labOr are some of female genital tract infections are shown iri Table
the risk factors .in the development of postpartum 54.1.
metritiseven in vaginal delivecy. This is probably
due to an incre~sed number of examinatinns
'resulting tQ an 'increased contamination Of the
Table 54~1. Baeteria cotllmonly responsibie fo:r t~n:uile
lower 1,1terine ~gment. genital tract inicctiorts.
Rapture .of Membranes Aerobes Group A; B and 0 Strept~
Enterococcus
Some authors have evaluated the incidence .Gmrn ttegative Bacteria.
o! ~trauterine infection in reJ;_ation to the length~ E .:~li. !Oebsiella-a.nd Ptote1lnpecies.
M time .t4~;_ melJ1bra:nes hav:e ruptur.e d. They Stapbylococeus.a tir.eus
repo.rtedJ:h~t allamniotic fluid cultures inwomen "Staphyl9eoccus epidel"ln!dis
with 'i-uptut m~mbr,aries for more ~an 6 hou.--.s .'G.an:lnC.rella vaginclis
t:Oniained~tbogeruc:bacteria. Ninety..,.five,p ettent Anaerobes Peptococcus.specles . . - .. .

of tbse women devel~ped endo.m etritis. Peptoliittt:ptOCQ.c<:us $~es

.. _....
Bacteroides fragili~ group
i~b..~r,,?f~Va~ Ex:amllliltions and, Jntenurl Prev.otella Si'cies
fetal MoiJ.l~~r-b.;lg C!9sp:i<Uwn.specie~ .
FQ~J)acteri'\ltM>pecics
. ;~veraHnvestigators reported~ direct increase M.obiluncus species
:. :. :~.~:.i ... ... . .
in postpartum en<lometritis that .paralleled the Othen Mycopl;isplll;~~es
num~ of vagmru '~ihatio:ils aria: the l1$e Qf ~E~~m~~-~sh.Qm;~:t~s
ititetrtatf~tar_m-o1iitmitlg~attl):Ougn oruy-:-afw-ilata N,~s~,&ollorrh.~
afe ir.vrutaore tcY~support mrs ob-serv.auoti: 1\Vo --~~--~~--~~~

.repo~ .state that tqere are no conclusive p.roofs

that v:a.ginal . ~xamination it~.c::xeases the rate of
infection$. The author$ believe 'that the high ris~
~tale$ of the wom~n requiring. mon'itodng the
impor tant variable, not the moriitoring.itsdf.
' I
SocJo economic Factors
Patients from tbe low s ocio-economic class are
generally observed to have hi gher pu.e rperal
inJection rates than o middle class :patient$. 'The
causeis undear; but differences inflora, hygiene,
nutrition, .etc. have been postulated.
Other Factors
Anemia has .been cons~dered .a risk factor as
well ~s poor nutrition,, young ma~rnal age and
multiparity. However, these factors have not been
proven due to lack of studies. .
Pathogenesis
As the placenta .is detached from its.
attachment to.t})e uterus, its site compOsed of
necrotic material and blood provide an excellent
culture medium. Following a ce~ean section, .
uterine infection ensues through an infe~ted
surgical incision and a s the basalis layer of the
endometrium is .iatrogenically disrupted. The
preponderance of devita lized tissue can be the
result of clamping, lacerations. ti~sue handling
and too many unnecessary sutures.
The necrotic material primarily at the p~~ental
site plus bl<;>qd provides an excellen.t i~lture
medium for bacterial growth. Infectio!f,once
established may delay uterine involuti<;>n:$rhese, -
coupled with microhematorna formation a}ong the

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838 .,., SECTION lX:ABNORMALfTlES OF THE PUERPtFUUM

line of tissue re..,approximation creates a favorable therapy with penicillin plus an aminoglycoside.
anaerobic
. bacterial condition for infection.
. Antimicrobials for post cesa,rean endometritis
include ana~robic coverage.

When initial therapy consists of Clindantycin

plus Gen'taniycin, the response rate of
endometritis after cesarean section is up to 90-
95 percent and major infection complication such
as septic thrombophlebitis -or pelyic abscess may
.be reduced. ~prevenient is ~xpected Within 48-
72. hours. There. are very few, if .any, antibiotics_
that ~ efficient against an microbials causing
pel~(; irife.c tion a :s listed in Table 54.2. The .
following .a n:tirnicrobial regimens are found
effective a,gainst the .most common organisms
causing puerperal infections.

Beta...lac:ta;:n Auti~lotic:!

These are the :pe.n icillin.s (fiperacillin,

Ticar-cillin); ~phalosporln$ (Cdbxitin, Ce!otetan,
F1!ure !54,1. Pathog~esi
. :sect:il)b; . . . .:
ot 'J.letJitis1
;I ..{o!Uo~ring ="'"'"'" Ce(otaxf.P.leh mcnobt;J.etani:s and catbapenems
The.y:o_a r,e-';bacterlcidll};and ,al(,int-e.r fere'.w ith
bacte-rial cell w-all synthesis The var-ious
CJ,lNJCAL .EXAMJNATION AND J;>IAGNOSiS penicillins are not ,alik-e =in their .actiVity :as t:lteir
actions;.ditr~r':, depending on the bacteria the
.Rever.is: the:tnO.s.t .ittl~t.,:etiierloufor,the. . speCific .~ni~illitts .:are mtetatting mth, :
diagnosis:; of~.po'StpartW:Ji.:t!t:etrtti~> Fever.,which .
j:>ersists:;.qurlrig:'$~.~po#pa.rt?.lJJ.l~~ri<xh;dmatrdsr:~ .. : Th-e:~phAlol>porfus, the -cephamycms and<the.
inves~tion of utepirie .:iti.fe.dicii). .. oxaM beta.,Jt\ttanis a te .entirely ,$ ynthetic or are
.. - - se~..:a-y'nt~'t:rc-:ttenv1rtiv.aot - ~m~tra~tetial
The (llignQ.'$i-s ofendonietnti's :is b~sed on the ci:>-ri;:pci~'nd_s. p'i\idu'Cd oy the Tu:Yigus,
~olloWing slgns ~d sytilptot;ns; fever, -~b<i'6mi,nru Caere.un;mb:lm: ln eo-ntra-s:t to the penicillin
pain, malaise, foill-si!lelling discharge or lochia. nuclet1~ .the ~phalo~porin nucl~us .is inherently
Bimanual exatninatiqn may elii~ u:ter;ine apd m<5r-e -re~i.s4Uit to .be~-~cta:inase degradati~>n, and
parametrial tenii~rness. Clillls ~Y be sul$stive therefore iti~ 'i.!l.Qre.acti:V~ against bta-tactafilase-
-Qfb~~tere.mia. 1-eukocyto-si$ is coQJlilon. Elev.:a.-tlon . . pr.q-du~ifig bacteria such. . as ~taphylo~occus
of t~:niPef3.tlire rliore than; 38q and persi~ting 3.\li'CU'$ atuf:scherichia coli.
du,iing th~ pOStpartum period may be a"dUe to-an
ongoing Uterine 'infectio'il. Beta..lactams are safe arid fue niost common

TR;EATMENT
. side effect is hypersensitivity reaction .

Curative
Once diagnosed, broad spetrum antibiotics
should be initia~d. Oral antibiotics ate given orily
for mild cases following vaginal delivery. In
inod~rate to severe cases including.thO&e delivered
by c"Csa:rean section; parenteral- antibiotics
indicated.
Approximately 95 percent . of patients . with
endometritis following vaginal delivery P""''"'"'"' rl +-~
CllndaliiycinGentamy~in
This r.emmen.:is proven to be vexj'.effective
against endornetritis folloWing cesarean section.
A major problem with the use of Clindamycin is
the development t>f diarrhea. This is due to the
production of pseudomet.nbranous colitis as a
are result-of overgrowth of Clostridium difficile,.which
produces resistant enterotoXin. This is -considered
a t1osbcoiilia:l infection. 'G entruhicin i~ nephrot9xic .
and ototoxic. In the event t>f a diminished
- ' - - - - '-- ftl tration rate, combining Clindamycin

Scanned By: ~
 CHAPTER 54: INFECTION AND OTHER ABNORMALITIES OF THE PUERPERIUM ' 839

and a second gene r a tion cephalbsporin or e~dometritis py 70-80 percent. Arnpicillin-.or ftrst
nwnobactam is recommended. gerteration cephalosporins are ideal for
prophylaxis.

The frequency of postpartum uterine infection

Table 54.1 . .Antimicrobial regimens for pelvic infection
foll~wing cesarean delivery.
Clindll.Illycin 900 mg plus
-G~ntamycin 1.5 mg/kg q8
intravenously
Plus Ampicillin
Most widety-studkd regit:nen,
90-97%
Efficacy; ooce daily Gentamycin
dosing acceptable .
Added tegimen with sepsis
sy.n~ome or suspected
enterocotclll infection
can be diminished by avoidance of U nnecessary
cesarean sections, prolOnged labor, especially with .
prolonged ru.pture :of membranes, ihcrea~ed
number of vaginal and cervical e~inations.
Good nutrition and pr~vention of anemia are .also
important' in the prevention of this .c ondition.
SEQU&LAE -QF UTERINE .I NFECTIONS
Most women with metritis will respond well to
the antimicrobial therapy within 48-72 hour-s,
however, a number of complications may arise
from other s ites.

Clind.amycin Plus Gentamyan substitute with AhdotulnaJ. WounCI Infections

Aztreonam .renal ihsufficienC"J
-": ~,. /
Abdotriinal wound infectio,n is .o~e ~f ~e m,ost
Exten.4edsyectrum Pipel1lcillin, ati:l picillin common infections associated W:lt:r.:"c~sat:~an
. .Peni~J: ~~ section. The over-ail wourid infecti:onrat:d';i$;~_:15
perce(l:t with an ave11tge of 6 percent ar).d 2~peicent
~ended.~s~lr.llil Cefotetan, Cefoxitin,
. ..CefotaXime for those who rec;eived prophylacticantil;>iotitdl~i:sk
.Cepb1~?,fins
factors for this c.o:mplication inclujie t)be.Sity,
lm.ipenetti +~llastatin
~ - . . .
Re~t'or s~ind.ications prolong ed rqpture: of membrane~~.rdia~'C;~~s.
anemia, corticcster?id ~s.e, UrtlllU~osup~~~i()rt
,'"2- 1'7"' .... .

. .......
Aside fr.om its use as an antipro.tbzoan, this
drug ~.as observed to have an antimicrobial
-activity specifically against most anaerobic
()rganisms. This .agent combined with Ampicillin
and an arirlnoglyco.side Will be effective against
inost. organisms With serious pelvic infectit:m s.
Jmipenes;n
This drug is a carbapenem tha:t has a broad
covera-ge :for majo:rity .of organj.sms causing
metritis. Imipinem is met~bolized in the kidneys
and in the event of renal. iinpairtnent, . Cilastin is
used i:il.combination with lmipinem. . of the pelvis or abc,torneri by direct extel)'s ion,
. ~rev"ntlon
- and .causes peritonitis, It may involve ~;;~dnexa
Theadve:ntof newer antimicrobi.a ls in the past
decade and the introduction of prophylaxis during
cesarean section have decreased: puerperal
and poor hemostasts. With hematonllr'fq~~t;ibn~
Fever lH'>tJ~Y. ~&ms 9n the fourth. postol>~tive
d~Y:..W~~mf...~~..tn~.-9r..!lf!rlnage.~may~atso .~ .
no.te.9. Tr_efl,tm:<ml in.Ghtd.e..s..u~e...oJ .antimicrobials.
and surgic~ drainage if.abscess is present.
The use of propl?-ylactic an.t ioiotics in high-risk
cesarean section deliveries was recom:mended
because the repo.rted infection risk without
prophylaxis ranges. from . 45 . to 85 percent for
patients undergd!pg cesarean' s~tion after labor
or rupture of membi.ans compared With a risk: of
10 percent or less for elective cesarean section. h
was noted that the roajor factor responsible .for
this increased ris k following labbt or rupture of
membranes . is bacterial contamination of .the
amniotic fluid. ... .
Uterine infection may exten.d to the other areas
lymphatics or venous routes. Through the
lymphatic system, it teaches :~e abd~m~ .ca_vity
as perisalpingitis or ovarian a}?scess. The
parametrium can develop parametri~ t ellulitis
and form an area of induration within the leaf of

Seanned 8y:
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~
840 SECTION IX: ABNORMAUTIES OF )l-IE PUERPERIUM

the broadligament (phlegmon). Occasionally, pus Peritonitis

m~y cllsse<;t posteriorly ioproduce pelvic abscess.
If the abseess is accessible, it cah be easily 4rained
surgically by colpotomy incision.
Wound Dehiscence
Abdominal wound dehiscence is the
separationof the wound involvitlg.the fa~iallayer.
~el'()saC:lguinous discharge is f1rst noticed around
the :firth po$tt>J>era~ive day followed by disruption.
Most wound dehiscences are followed by post-
cesarean -metritis. treat~~t - inc:;iudes surgical
debrid.ement followed by secondary dosure of the
iriision -Witll adequate a.nesthesia..
This condition is occasionally seen after a
cesarean section complicated by metritis with
incisional necrosis -or dehiscence. It mav also arise
from rupture of a parametrial or adnex"al.abscess.
The patient present~ with severe pain; however
they xp.ay _n ot present with abdominal _rigidity .du_e
to abdominal will laxity. A feeling of bloatedness.
or vomiting due to adynamic ileus may be early
signs of peritonitis. Treatment involves bowel rest
and antibiotic coverage.

Septic P~lvlc 'thrombophlebitis

PelVic vein thrombophlebitis may occur in

association with ,pelvi $urgety or. as an--extenskm
of puerperai . uif~U-on alo_ng veJJ.ous routes. The
OV~ veinS are tis~aUy 1nvqlved-because -.they .
,dteJn~~tl1.e- \i'pp~r.~:uten.is:rwhi.'clr~~v~lv.~=s~:-vei.t;ls :..
draining iii~--: pmteAtaL's ite. "'The .usu4J.>djriital' .
course is :t..nat C>f'Tev~r . of und~t~~n~d c etfoJogy
Willi no demonstrable -foou's of Infection as high-
s.p~g t~JriP~-~t~te~; (j!hiU.s.,~(i .t~chycatdia
(}~spft:e .antib.iP#Q; ~eta:ge.:xn sQi:he-wotneh; tlie
-ca;r(;iii,1al s~Pt. .:tin'd sy.iJi;ptoro .:O f .Qvarian vein,

=:emJ:&fu$m_
::.~~:41~;~i;~~~~ij1f.~;;;.
.1he-.4.i~tQQ.i~ .r.m.l!~~~ .~~~hl@.~~4e; .of
-susp~cion.. CQ~tocy i$ usually 'by CT scan or
MRI. Titatinen:.d :ricludes anti:bibtic therapy and-
.li~Parln --- - - , ... - Figure, S4~3 ..~geof pelvic abscess bye6lp<Mmy~

Infecti~ns -othe Perineum, Vagina and -eer-vVt

Infections of the episiotomy sites are hot

common c omplications after delivery due to the
decreasi:,rig freq\}en~y of performitl g the procedure.
Episiotomy dehiscence 'is commonly aswci~t~d
vii th ,infections ..Other Ia~tgrs'.in.c.lu.d_e coa,gul~Ugn
disorders, smoking, . ~iabetes and "imm~no
suppres~ion. Limned data suppon: that faultY
technique ffi'\-Y coO.:tril?ute to .such a conditi<m.
Vaginal or cerv'i cal lacerations may harbor
pathogens .that may ascend and cause di~ect:
extension to the parametril:!.. Serious infections
Figut~ 54.2. :Ext:en:siop!l _
1-: Peritoneum; 2- lnferior V~na:. a- Ovarian Vein; ma.y follow a (ou~hdegree laceration. Treatn1ent
4- Collltllon mac Vein; s- Uterine Vein; 6- Fallopian Tube; consists - of dra-i"nage, . debridement and -
7- <Niuy; 8-Ureter; 9- Parametrim:n; -10- Retroperit~neum-. . antimicrobial therapY...

Scanned 8y: ~
r
;!.~
s :
'!):
!; CHAPTER 54: INFECTION AND OTHER ABNORMAlfnES OF THE PUERPERIUM
Necrofulng Fasciitis
This potentially fatal co~plication of perineal
and vaginal infection-s is .a rare occurrence.
Retropsoas, subgluteal infections and necrotizing
fasciitis of the lower extremity have all been
repOrted. in obstetric literature. The ori.gh1 o( the
infection is presumed tc he a parava:ginal
hematoma. Aggre$sive treatment with wide
debridement of all infe.c ted tissues is indicated.
MortaUty is fllmost tOO percent Without surgical
treatment.
T.hrQmbaembolic Olsease
The frequ.e ncy of thromboemJ:>olism
coxnplicatiPg pregnancy and the puerperium has
d~~ ret..~ntly and niost cases are ide.r itified
during .the P,Uerpe(ium.
.DiS"cases\;e:nd Abnon:milities.:o !the Uterus.
Subi."'.Vblution
. Arrestor I"etardation oftnvc;)lution; the proa:ss
. by:Whlclitlli:e.puerperai uter:Usi~ normally iestoted
to. its original proportions. It is accoxit,panied by
prolongation of lochial discharge and irregular or
excessive uterine bleeding and sometimes
hemonhage. On bitna-naal e~amination; -the
uterus- is large and soft-er than normal. The
recognized causes of subinvolution are retention
of _pia.Gental fragm~nt and pelvic infections. -
Ergonovine 0.2 mg every 4 h (nirs for 24 to48 hours
is recommended. The metritis can be treq.ted with
appropriate antibiotic therapy.
Postpartum Cervicdl Erosions
These are complications of the late }>9St-
.partum period . Shallow cauterization or
Cr'JOtherapy can be used to remove persistent
exub.e ra.nt granula:tions or :delicately exposed
endocervical columnar epithelium without
causing stenosis of the endocetvbc.
Pelvic Floor Dysfunction (Relaxation of the Vaginal
Outlet and Prolapse of the tltertt$}
Extensive lacerations-of the perineum during
delivery, if not properly repaired presumably are
followed by relaxation of the vaginal qutlet.
Stanned ey:
"' 841
Overs~etching or changes in the pelvic. ;'Support
during parturition predisposes to prolapse of the
uterus and to urinary stress incontinence. In
general, operative intervention is postponed until
childbearing is ended or if serious disability
notably urinary stress incontinence results in
symptoms s ufficient to require intervention.
Posfpartu.m Urinary Retention
. It is the absence . of spontaneous micturition
within 6 hours of vaginal delivery. In cesarean
sec.tiot;ls, if an indwelling_catheter is placed it is
defined as no spontaneous m icturition wit.hi..n 6
hours after removal of the catheter. It usua.Uy
occurs in 2.1 percent oJ women with vaginal
deliveries and 3. 2 percent in WOmen with cesarean
sections. The risk factors fqrPostpartu~ Urinary
Retention would lnclu4e nulliparity, iri~tnUnental
.delivery ,.proJonged flr$t.and.s econd stages .of labor
~nd ..epid.ural..~ anesthesia . Pharmacologic
treatments would inClude the> use . ~ of
,anticnoll.nestemse ~gents, chclil?-~~ti~!ig'pha
adrener.gic blocking a gents, ptostag1art~ih: ~:l<'2
alpha and diazepam~ Bladder r e st ts.::'a lso
advoca ted.
.Hemorr~ges . During Puerperium
Puerperal Hematomas
Episiotomy is the most common cause. This
occur:~-rn 1:3o<f't0. t:t~s:O"Q ~~fzy_ef!~.~, -lf!iJ~i ~
class ified ~s vulvar, vaginal, vulvovaginal or
retroperitoneal. Vulvar hem<:~.tcmas most often
involve branches o(-the pudendal artery, including
the J)osterio.r rectal, transverse perineal or
posterior labial arte.ry, Vagimil hematomas may
.involve descending bra:...rch of the uterine arteries.
. Vulvar Hematomas
It is readily diagnosed by severe perineal pain
and the sudden appearance of a tense, fluctuant
and sensitive tumor of varying siZes covered bj
discolored skin.
Smaller ~ulvar hematomas may be treat~d
. expectantly . How~ver, if. pain is severe or it
continue s to enlarge the besttreatment is prompt
incision and evacuation of blood clo.ts with ligatl.on
. of bleeding points. Hy.povolemia and severe
anemia shot\ld be preven_ted by aqequate blood
transfusion. Appropriate antibiotic treatment is
valuable.
~
 842 SECTION .IX: ABNORMALITII;~_ OF THE PUERPERIUM ,,
------~~~~------------~~~----~------~--------

Subperitoneal and Supravagina:l Hematomas adequate blood transfusions~ appropriate

anesthesia and surgical assistance.
They are mo~t difficult to treat. They can be
evaluated by incision of the perineum, but unl~s Postp.artmn Pqchlatrlc Disorders
th~ is complete hem.ostasia, w:hi~"l is=ditlicult to
achieve by this route~ laparotomy is advisable. Maternity blue is also known ~s "po.s tpartum
blues, and is believed to be .a transient sti1.te of
heightened emotional reactivity experienced "by
half of w omen within:apprQ.Xi:Jnately the ~t week
after parturitioQ. Ther e :ar-e -several ' moods
Serious ut~rine h-emorrhag~ oceasionaUy observed, at'ld the most coxrunon is happiness.
d~vtlops 1-2 Wek~ in the puerperiu!I).. This is . Some moods would include weepbies~.
u.s~.:~e ~ult -of abnormal involution of the depr.es~ion. anxiety., poor concentration and
placental tite. inita~ty. S_ytriptoms -are mil~ and _ may last for
. ...
only a few-day~. however closely monitoring the
Retain-eli .pllic~ri~l fragm-ents tnay cau~e patien-t would be prudent-and. attention should
.blee~. in the pUC,rPeiiUJ:n. Th~ r.etaii\f!d pi~ce or be geared toward development -of depression.
the pla~nta ~et;goea n~s :With depo$ition
of .f lb!i,n -tin~ m.~y eventuall-Y form a soce.lle.d Postpartum 4epr~ssion on the otherhand is
placenti!l 'PQlYJ>. - Inl~ t;tea~en~ ri:.:i.y be best simijar to other ~jor -t md m.ipor depressions. It
..djree\ed.to t.tre .c~i'i~l of tbe .b leeding using develpps in 10":15 pen~e11t pf w.o.men follpwing
_. in,trav~p.~~~ . 6t,Y.t~: ~r&t>no~..ne, . methyletgb- delivery~ Up to 7Gpe~ntofwomen with preVious
.-~oVihe~t-Pi#~ta'gJ~:ri<Uh$;"~,fl:te.~l~~g;s:rtl:>s{~es; . . . , . postpantuni:4epi'essic;>n~~Jj.ld.:ha~e.~a,_subsequent.
the wo~- i$:si,rilply. 'o'b~ ~~'Pt cwe~:g~ - episod~. Without :treaQ:nent, the I)atutal cou_ r se is
is. gtne~}t ac~ptetJ if the l;)}e~dtng - })e:~ist$ ~ . _one of" the ~dua1 itnprovement_S in 6 .monthS.
:such treaunent fa1!.~. -- tti.S imJ)erat_iv~ -that fu~ Most Jtuthorlti~s .recommend .t r.eattnent with
. wotuanl?e:infoone<tthatjf~~~'~s to;wntri>l . . antidep:ressantdrugS:;<ho'iVever..:~uaijon,and ~e
the btee(Jipg, 'h ygterec!Qmy tna:Y be life,;saV:ing. choi~'-of;D:ifutl.tteatmet.tt,,sh~1.4-be,entiiisted. to .
Furthetriu;re;"'.aiTangemenbk:inu~t.be"' mad~;Jon " . a_, P$Y.Cbiatrlst.

. PQINIS.]O RJ!MEMBf:!R.
. 'T.empetatqre
. .:
sa~e r ~gher occurring. within 24 hours pris~rtutn
-
does nqtdefine. puerperal;morbidity.
.

.Of lhe :maternal infections, ,puer;peral -s~p~is has th.e highe$ftifalit't (32.1%)
.. .
Genital trat:infections cause most pernistent fev~r
.
after childbirth .
Risk fi3to~ for genital ihfeCtions include: prolonged rupture otmembrahes, intrauterine electronic
_
monitoring, uterine manip.tilations and digital examination.
. .. Endo~etntis .-is diagnosed :.iil 1-~% attervaglnai biith and 'is 1o ,if,,es more :commoh.atter cesarean
birth. .
Differential diagnosis -of fe.ver following {;hitdbirth. are: ~eni~l tr~ct infections, pyelonephritis, breast
-engorgement :and thrQmbophlebitis.
E:ndcmetf!tis .is :the most coinmonly used term to desctibe postpartum infection.
. R<;>ute of delivery, dul'ation.of labor,, du~tlon of rupture.- of membr~ne:s .and the number. of .vaginal .
examination ar:e-.the risk factors.for the development of.postpartum,_infections.
Erid~metritls following V<igirial delivery :rarely exceeds 2 :.... "3 peFCent while -that of cesarean section
ranges from 10 percent in iow risk to as high fn 95 percent in high risk populations.
,~.

!1.: . ---------~-=-='7"""-:=-::-=:-=::c:-:::-:-::=:-:-:-::-:::=-::-:::::;;::::-':':=-::::-:::-:::'::::::::::-::-:-~~---'-
.;;, CHAPTER 54: INFECtiON ANO OiHER ABNORMALITIES
w-...
OF THE PUERPERIUM 843

High risk women are those with prolonged rupture of membranes and labor, multiple cervical
examination and internal fe~l monitoring.
Use of single-dose perioperative antimlcrobial prophylaxis is recommended for all women at high risk
for peMc infection following cesarean section.
Prolong~d tabor and increased number of.. niatemal examination are important risk factors in the
davelopm~nt of postpartum metritis. 1
All amniotic fluid.cultures in nJptqred membranes for more.-than 6 hours contained pc;tthogenlc bacteria 1
and 95 percent of those women developed endometritis. .
1
The ialt3 of puerperal infection from low soclo,.economic ciass is observed to be higher than do middle
class patients.
.Other risk'i aors for P!Jrperal infection include poor nutrition, young maternal age and multiparity.
Bacteria commonty found in the peiineum; vagina, cervix and bowels cause most femal9 genital tract
inf~tiOns. These include: aerobes, .anaerobes and others like .mycoplasma, Chlamydia and .neisseria
gr..oup.
Nec:-otic material ptimarity a t .{he place:lta! site plus .biOOd :provioes an excellent culture medium for
bacterial grcwth. '
Sighs..and symptoms of endometritls are: fever, abdcmin<;~l pain, malaise, .foul sm.elling discharge or
lochia.with uterine and parametria! tetldemess.
. :{;.: .. . .. .
. . ~
., .,. ,. ' ":._!~!,' .. ~~~~::
.
....... : . '1. .",

. . OrarahtibiOtiC$ ar$ given .Qnfy for mild cases of endometritis followln.g.-vaginal :delivery. 'Ill ;sevei:e'1h,{'.
cases and these deliVered by cesarean ~section. parenteral antibiotics are ii1dicated. ~..:,., , ' , :~'P'~t:.
F0!1~1ng vaginal delivery. 95 percent 1::/f patients with ehdometritis respond to penicil!ifi plus''
aminqglycoside. . . -
.....
. ,., Anlih'i~robia!s for postcesareao endometritis include anaerobic Co"'~rage. :: ":~~e-.;~:,:~~~:;;"
Alitimicrobial regimens fou-nd effective against the most common organism causing puerperallftfetuons)t.;.;,.
ar.e: Beta-lf;ictarn, Clindamycin-Genlamycin, Metronidazole. and Jmlpenem.
t
~ Ampicillirf or"firs"t generntioif ce_pnalosponns are.RJear ror propfiYfaxis aurmg cesarean seCtion.
I

Complications from uterine infection~ may arise from other sites like, abdominal wound infection,
woond dehiscence, septic peMc thrombophlebitis and perHonitis.
Infections of episiotomy sites are not common complications. Treatment consist of drainage,
debridement and antimicrobial therapy.
Subinvolution is Characterized.by prolongation of lochial discharge and irregular or excessive uterine
bleeding and sometimes profuse bieedlng.
Ergonovine 0:2 rilg every 4 hours for 24 to 48 hours is recommended for subinvolution. Metritis can
be treated with appropriate antibiotic therapy.
Relaxation of.the vaginal outlet and prolapsed of the uterus can result with improper repair of extensive
perineal lacerations during delivery.
Absence of spontaneous micturition within 6 hours of vaginal delivery and in ce.sarean sections, 6
houts after removal of an Indwelling catheter is termed postpartum urinary rentention.
Late postpartum hemorrhage develops 1-2 weeks in the puerperium and.is usually the result of abnormal
involution of the placental site.
"Postpartum blues is a transient state of heightened emotional reactivity .experienced by hc;ilf~f
women within the first week after .parturition. ;~
Postpartum depression is defined as beginning within 4. Weeks of delivery where symptoms must'be
present rnost of the day, everyday for at least two weeks.

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844.

11. MonifGRG. Infectiou-sDisease in Obstetrics. Infectious

Disease Inc., 3..._,ed.ifi.on, ~982 .
.1. .Cunningham FG, et ai, Williams Obstetrics, 22D4 ed. ,
McGraw"Hlli Companies Inc., 2005; 711-721, 1~43. 12. F-aro .S . Peruci.llins. Obst"t Gynecol clin .N Am 1989
T6{20): ~s7- 269. .. '
2. Sweet RL, Gfobs RS.l.Qfectiou3 Diseases ofthe Female
Genital Tr;act. 2"" edition, Williams and Wilkins, 1990; 13. Martens MG~ Ce~rih:s. Obstet Gynecol 'linif.-. :
. Am 1989; l6(2)t29l - 30,3. . .
356-382. . .

3 , Baja-~o 1$:-Mi;t~ Infections~ the ,Fb)iip_p.i nes

14. Dinsmp.or MJ, Gibb~ RS. Th~ 'rol cf the new~r .
ai;l-titilicrobUil.~ts in obstetrics andgynecrilogy. Clin
Morbidity anliMOrtali_ty, i'oGS-~uai COnvention, }ji:)V~
199.2, Manila. :Book of Apstra.ct3,:p. 29. Obst'"t.cGyileeol190S; "31{2): 4~- 433.

4. Jaibuena _JB, -Llave CL. Ma~tnal mortality from 15. Faro s. Anti'biotic prophylaxis. Ob"stet c.Ynecol Clin N
puerperal sepsis. PhilJ Qt.stet Gyn:ecoll984;.B(3): 1S4 A:m 1989~ 16{~r. 297- 298. . .
-l$~ .. 16. Crorobleholme WR. u~ of prophylacti~ M.tibiotks i~
Qb~tef:riqs and::gmet:01ogy, Clin Obstet Oynecoll988;
p. },ucas :MJ, ~Uri.""lin.i~ ro. Urinary irit~tiOl;l ih
31{2): 406-471. . .
pregnang. Clin dbstet Oynecoli993;.36: ass.
17. Grant TH: ?o-s~~~ oyarlap. v~in th!ocqosis:
6. -~~tr.uP $, -et.:al. :ACUicpueq>eral b~ ahs:cess: US- . C!ag::!O:~ .t>y C)gt -~truSiQO. int:P, the _inferiOr-vena cava
. guided Utirinage. '.Ra.Qioll-993; i~(B): so7~ 809.
at te::1ogr~hy. A..TUJ .RadioUg:9.3; 160: SJil-S52.
7. :CoxsM... :G~pL. Po:StpartJ.rmenaome.tritis. Obstet '--
'GJ!lecolcC!irl N Am 1'98.9; .tti(2): 3{;'2 .:._ 3'il. . . . 18. :!'olhlld.'KC;.et..aJ..J>-vStpa.--tu.m-pov~ vein thtomOOsis
. . p~~'.as ~~ .Q9stz:Uction : A-~ xeport and
. B...Yon~""\lra.~~en.~~-q(~~ep.~o~etritis::o. ~- ::-...- c~ykW.."~~~:J}J[01<1~i3}i1~:49: ,tsJ.? "-.1540...
Cli.n:O.biJtet-GprCcoti98e;-3l{iz}.;~.-:.A9S.~ ... - . . . . .. . . . . ..
19. Chatwani:!).; .e t aL :Po.st:pa.rt\l.IP. 'pe,ravagi.xuU 'hematoma
9. D' .AilgdQ W ;; :Soko{ :~:. 'l'im~+-rdat'ed ;periprui:um $.9:.1o~'~qjllty ection.. A:!n J :Ob~etGynecol
~~fS.O~po~ morhlditj.;Qbstct:GyneCol .. , i.i_19~;' :16:6(2):'~9~- "60(}. .
T98o.; ss~' 319: . .
20. Yip.S ; -tclll.~i:hal:y .re~tion. kn.J Obstet,
:. . .G ynec61;2006;.i{)9(3):602"6C-4. . .
10. :q~~tri,Lp~J.;C~"":C:u~g~;.F.O. :;'r~~1bactenai~.; .. . . . .
~eg~esis of i.ofe2t;iori..foil~.g ~~on.
()_bs,t~~ q?.:~! .~?.?::i!~=:2:'!~~- .

. .,

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 55

INJURIES OF THE BIRTH CANAL

NORA A. MARTIN, MD

Lacerations to the P_
erineum

Hematoma

' (njuries to the Cervix

.Rupture of the -Uterus .

Rupture of a Cesarean Section Scar . :~ .. : .

Rupture. of an Intact_ (Unscarr.cd) Uterus

Traumatic Rupture of Intact Uterus

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 . 1

SECTION IX: ABNORMALITIES OF THE PUERPERIUM

iN~RODUCTION Epidem,iology
. .
Childbirth is seldom completed without the Most of the superficial perineal teara
~nce. of at least slight injuries to the birth associated with injury to the lower portion to the.
-~l and sometimes, extensive tearing occurs vagina ar.e s een in multiparas delivered with'
in ~pite of skill and care. Sometimes, they may perineal support, while-separate upper and middle
. be totally unsuspected especially ii there are no vaginal lacerations associated with perineal tears
manifestations of excessive vaginal bleeding. in the perineum or cervix are observed in
Injunes should alwa:ys be looked for and their primiparas without thP. benefit of adcquat~
repti.ir should form part of every operation for the . episio~my. :--..
rc.s toration of the lacerated perineum. Mm'e
i~po~t a..re the injuries to the leva:tot . ~i
uti~rlsociated with. tears throu;g h the vaginal
muco~ thl\t escili>e: detection which eventua)l.y . Oftentimes, su(:h h:u;:.e ratiorts ~ould be
.lea~( U>.-peMe retuatio~. pr\'tnted.with :fUl ~p1e episi.QtoD}y. Theperfueal
lacerat;lonsarecau,sed by 1) th.e nipid and ~dde.ti
... ,'~ortunate1y, extensive tra umatic lesions are expulsion of the head, 2) excessive site of'tbe
raa--:e :m modern obstetrical practice. Intrauterine infant, 3) difficult fon;:t;ps, and 4) bree~h.
~ot8.tion -fer .t he possibility of uterine rupture ~tion and. lack oi elasticity and friability of .
~ i$hb,u)':d be -done especiaJ~y following certain maternal tissues.
bl)s.tettical procedt." "es like difficult forceps
: .d~liverles, fu.ternal podalic version, COII1plete Sign$ 2-nd Symptom s
. l)~11 . eXttaction~ and :difficult:. delivery: of' the
stwtnaer among :others; Postp1:lrtU.in:bieeding .de~pite\a..firm con~cled:.- .-.. :
uterus added Wi.t h hist~ry. of operative vagir.al::.
~liptu~ pf the uterus i ~ one -of -the most delivery sttongly s~,ggests genitaltrn.ctlacerations, ..
. ~~.$ -(!b$te-trical aecidents, Which can lead to retaincd secundineS ' Or-prese~~ ofuterlrte tear.
;-~~ ~(1 .-perinata} . d~th. :.~ W.ith.lncreasing.... -Usually, bilateralla~ra.tions c:>fthe.vagipa ~~-;_ ..
. Jn~eJ}te:ofcesarean se~tlop, rupture of.:t;bescar a tQngu.C..Shaped:.-por:tion of -the.~.vaginal .muco~: >
m:lt',il)~uent~.pregnancy: :has: beeom:e :a .tn:atter:.of- (Figure-5 5-..l)..-.: ..
-~~~: .With -the developin~ trend of ~owing
: tiiatof~r{QU.9..wing p.rior ce~ean. section,. the -v--- -------~---- - ~- --~ -~- -- -- --,-- :-"-
. ~d&~ :Of uterine ru:p ture_.m ay increase; The
, ACfu~ inCidence of uterine rupture among
. .
.. pie$n~t and part-.:trient women is difficult to ~

as~s.~.

:UtiERA1"IONSTO
. : .. THE PERINEUM
. . ; Most perineal tears exten'd to the va~.na.
' ~T'Ji,~: ~nsioos are easily overlooked unl~ss the
~is widely retracted. They axe classified as
;{itst. second, third and fo~rth degrees. First
d~~.ee lacerations .involve the fourch et, the
~t:ineal ~kin and vaginal mucous membr~ne.
Se-cdnd degree lacerations extend to thcdascia and
muscles of the perineal body, a.s ide fn:~m ~k~ and
~u~sa but not the anal sphinGter. Third degree
tac~rotjon~ incb.lde all affected structures ill the
~nd degree plus the anal s phincter. The term
:tou.rth degree lacerations. has been discouraged
bY Cunningham et al. However, other authors ~till
:Ute it. It means the third degree t ears that extend
: .through .therectal mucosa exposing the lumen of
th.e rectum. ~- 55.1. First degree perineal laceration.

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CHAPTER 55: INJURIES OF THE BIRTH CANAL 847

Diagnosis and rectocele. Injury to the levator ani muscles

'i;"
and rectal and anal mucosa without ad~quate
Thorough inspectitm of both vagina and repair can lead to incontinence of stool and flatus
pcrin.c:um b. vital to avoid overlooking such tear.s . or development of rectovagina l fistulas.
The vagina should be widely retracted. Atte~tion
should be given to the anterior and laterai vaginal FUERPERAL HEMATOMAS
walls. and no.t only on the posterior _p ortion. tci
che~k if lacerati<mS are. deep enough to need Hematomas ar~ circumscribed extravascular
re:i>rut'. .In case~ of deep laceration, the levator ani collection of blood, usually dotted, forming a mass.
muscles maybe torn ~d it is only "b y careful repair ~ey are mo.s t often the result of trauma sustained
that relaxation of the pelvic floor will be prevented: during childbirth. The ruptured vessels are
A tear in the upper va,gina is a rare but serious are
concealed it.'1d ii they small, the development
condition, so is a lateral extension cf the :cervical is .insidious and recognition is delayed. Failure
teat.. It opens up Qle bread Uga...rnent and may; to .do ari adeql.\ate episiotomy or toJigate the .
.Elrrect the descending branches of the uterine bleeders at the an:g le of the episiotomy wound or
~ey with :oCcur-rence of profuse hemorrhage. laceration can form a hematoma; severe enough
to cause hypovolemic shock.
Dlffereiltlai Diagnosis
Pelvic hematomas can be divided into three
If the uterus is contracted and v~gina _and main types: vulvar, vulvov~ginal, paravaginal and
perlnetiplhave ~en -~!ned ~d no iacerations retro.peritone~. Vulvar :hematoma results from
~e .found~ :thebervi:it bas to be checkedfo.: bleeding the laceration of vessels in:the su~rficialtf~$Cia
tears. :.:A.S''for other bleeding tendencies, blood of either the .anterior: or posteriorj:~~j.vic,:.~~~
:dysctasla~is: always a possibility ev:en if a distant Common. physical signsare.sl.,lbacwe vol~ ilo-ss
(;,ne. and vulvar pain. The bloOd loss. is limitedr:,bY= the
Colle's fascia and the urogenital diaphragm.... In
:Ma.ft .. "'eiiie-Jit
~ - -,,.
the: posterior'ill'~; blood:loss is limited by.the:anal
fascia an<} becaUse of these b ounQarlest -~s:
. :'...-A:vt~n~cti.a.T'Id runple episiotomywi:l1p~e-vent . will=extend=to.the ,skin whh:' bluish.. toi.btack
most-of these tear:;. Several _a uthors questioned "discoloration, and visible hematoma.willk':r~~ult.
the'" libei"-cil use of median o ver mediolateral Vagin al hematomas which are marked by
episl6~ifiY beca:~se of itlcr~_sed development .of . accumulation of blood in the plane above the
Uietlllrifali(f"iciurfn ae~gfee'"Tacera11ons;abar pe1vrc: d1apnragin may resul"fTrc>m trauma... to
~i?hln.~ dyiftinctiori and: d'yspareuiilaTri.l>otii . mateinai saft tissues ctudtig.delivei)r~- .They. are
.s pontaneous deliveries as weU as opeiative frequently associated with forcep deliveries, but .
deliveries. Vaginaldelivecywithout an episiotomy can occur spontaneously. It is unusual for large-
was found. to result in an intact perineum but wa:s amounts of bl6od to collect in the space <'.bove the
assQ<;iated Witb a,n increase in anterior. labial pelvic diaphtagm,.and the-mostfrequentcomplaint
l;lceratio.n s, while routine mediolateral~pisiotomy is severe rectal pres"s\lre. Examination will reveal
~s not :p~t~t .S,gain~t a."l~ ~phin~er.tt~"Uln~ a large mass extending into the vagina.
.as>conipar~d to delivery b.Y perineal ~uppdrt.
.curr.entl.Y. thete Js iJ1suffieient evide-nce .~o Retroperitoneal hematomas are the least
.recommend rO\,ltihe use.of-episiotomy,.arid ".its .:use common but the most dangerous type of
shou:td. ~ ba$eC,.011 m&vidual cliriital judgment. hematoma. . It occurs secondary: tO" laceration of
. Re~ "dflhe~t and :seco:n(t:degree.tears are -~etr one-r;>f the ves.sels originating from th:e hypogastric
~i[#~to.episloto~Y repairs. The repalh>fa tPil:d artery. A vein may rupture at the base of the broad
. it~:ttr~e',~~ is }no:i6 tomplicat~d. First ~tet> Is-to ligamen t perhaps due to increased venous
tepaidbe te<;:talwaU involved.. Then the pre~re~thl pressure during pregnancy or trauma of delivery.
fasciaj s united~ Th-e .epd~ ofJhe anal S.phirldh The bleeding may spread over the pelvis a:nd up
are d~fined .and: suttii:"e<L The fascia .of.t he levator towards the perirenal area. lt.eau ses severe pain
~i museies md'~~s: fibers are approximated aiid and differentiation from actualuteri.rie ~ture is
as
va,g,M.. i;i" repaireq !n .$e~ond degre.e tear. dlfficUlt. they rilay r~sult .from uterine -~ptures,
-Suturing o(just the extetrtal "integument may lead -phi<:ent al abruption or an extension o'Y\-agin al
"to .formation of relaxed vaginal o utlet, cystocele h ema:tomas.

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 84B

Etiology

Small or moderately .sized vulvar herilatomas Such lesion~ of the cervix may follow difficult
unle~s observed to be enlarging, maybe left alcfne . fo.;-eep~ .rotations c:> deliveries performed :4:1 an
to ~ventually organize .ailcl absorbed. Howeyer, 4r~6mpletdy dil~ted te~ caught betw~n the
conservative management of large hematomas forceps blades :and fetal head. Sometimes, the
c:a;n re's\llt j..n loeal .infection, ~ptieemil;l. and edematous anterior.lip or'the cervix is co!!l.pressed
profuse.hemorrhage. It .is bett~r. to incise the . between the ~ad and symphysis pubis ca~ing
skin, 'e\f.a:cu~te t~e .clots and fife .d~d .space severe isc~emi<i. , .necrosis . a:ild ultimately . . ,t. ......

oblit~:rat'd with ~ututes. Th~ area then. .s hould. sepa.riti.On.

be ~ompressed witih .larg.e .sterile dres:~ing.,
retriQved aft-er 1:4 hours.'..Vagi.ri,al hemato.rrra~ .. -Sig~ :and $jl'l'D.ptoms
should be treated by incision and. ~acuation;
The inCision need nof:be closed as the e:dges Will . Ju-s t like the lacer~tion:s of th~ perineum,
pu'Jl :back tb:g,th~.r cUter. the tl9t has -l:>e~n ceriri~ ~Ce:q:ttions prese:n.t as vaginal bleedi.i)..g
i-emo'ved. A vaginal pack sh<;>illd."be :inserted t q which may
be profuse if a large ,;essd is mvuhred.
tam:p9nade the raw edgs. The pack can ~ Passage of"a circular fleshy mass :before or cift~:
orembvd 41. lZ to _l8 .hou.: ts. the de).ivecy c>f the b~by is pathognomonic sigri. oi
:iil.tilila:t-, di!tac:hmen~ Q:f the eerviX.. If extensive
. Treatnr~.nt of retroperltont~ he~atomis lacerations ate nPt sutured. "the deti:~aie murous-
mv..ol;.~~,s~ ~loi"t::\.tion '<0. .ligati0n .of the se.~~-etilig ,end.oc~rvi'cai ila~ds. a.r.e eX:Posed
h~a~tii.O'v~~~e~::-Qn .Jhcri.late~ side .an:d ):f. _ prod-tl'chig p6:rsis~nt1eucorrhea .rl'ter:puerperiQ.m,:
'lini}ate:taFEg~#o.l(;'is l in~.e~::J:'~tater:bepa~.e: :~.f-'
-. 0

., . . . : ...
e;xte~sii>:f'-'.al;ta~t:orii:o.sis:..;b.~tw.-e.~:,b-O.th::S.iae:s,. ..
ligatkiu .isotd~ri:e ' .on .th~. cptittaJ.ate:x;~, ,$id.e~ on
~Siofl.; ft.:b:r~y. ~"J10S.sible~te:ope~,_:!;1)"e.heme.tor:jla lf::sP,ouldbeTOUtip.e t o do: Cerocal in$j>6ction.
and~Jden.#,_ry.;.tae bleeding :v~1S~. .='$: :1lll ;~f.:Qies~,. . ..after.~ opr~tiv.e . vaiinal.' delivery, pa:r.!].cUl.arly . .
.repta:q::ment of blood.-.- lqs$. a.."id Nqtu"me:.~uppm;t is force.ps ext:tactiom,..
.-Pi:om$<! bl~edPlg durlng and
~6\i~...... : .. aft~ ;the ..ih;b:(L~~e: -o (:lcibor'. Wi~ a- ~ntracted

' I
:~~:::;~;=~~r:::r~&~=~
G~s~e~"USjng'Vaginabetr:ad:ors-plps-O'ium.
-
fon::epa .'~e-;<1ePlf!d >-nbcessaiy C!-Ud .r.>uSb.ing thi
Cq-Ame~ed ut.ero~ tqw~4s ..~. .perineum....t)i an.
-a3~~~t~ mike things ,~siet "f<?{the .~n.
emca(~cep'l..ti~P:s up -t~ .2.Atm-a:re :reg~d~ (F~gwe :S:S~~} . . . . . . . . ..
-a s ineii.t:.able .in -childhiiUl.. such t~ en the
~~~-#~e- liehl ~~ntan,eously~~g fhe fi$h.: ... . .l,,.
n:io_"Q.th ~pp.e~~ee of .the m:U~tipa.rou:S cer..ri.X.
'~l.Y. av.#lsi_op. o'f the cerviX.O<:'Ctl.r"a where.ip: the
cervix ri),a,b:e eilti:tely or partially '4etached .from
. ":t he .~~ V!hen :~~ "ent;rr.e va.cgm~ portjon is
avwSed fto.rh'the.':fest :of.th c~~.:the <:OP.~U~m
is t~ed ~ular or ci;r:c:u'lar detahment of tlie
.cervix.

-Epidemiology

Theset:e?<rs .rarely extend either caucial to fb,'rtn

-~umatic. la~erations:.:o f..the :up~r thir.c1 oLthe
\'.?.~- or. cepha1ad to involve the -i0wer-ut~t4ie
segnient with. involvemen~ 9f llie .u:t~rine a.rttzy
and its major branches .forming "briJadJigameo.t
hematoma. .Fl~u.re 55.2. Puerperal heroa:toma.

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 CHAPTER 55: INJURIES OF THE BIRTH CANAL 849

M~nage_ment incision or a clas-s ical scar has an i~~sed

probability of rupture as compared. to a transverse . .
Deep tear.s require coaptation w~th either inciSion in the lo~er Uterine segment. Classk.al
figur~ of 8 or inte:rlodting absorbable sutures scars may rupture even before labor or even
under adeq11ate lighting and exposure. Repair s...-veral daysbefore tei:ni. Dozen;s of studies report
should be started 1 .em .abov~ the angle of the that for women who had one pnoc cesarean: birth
lac.e ration ,so as to a.;oid missing the re.t niCted "w'iith low horizontal incision, suc cess with trial of
blood vessels abOve the angle. Lacer~tions less labor is at 78% arid the risk of Uterine rupture-i$ ,
than 2 em need no repair if there is l).o active about l% or less. So that a worn:an with 1 pteviuus
bleedi,ng sirice they heal sponUW.eously. transverse l6w~segiD.ent cesarean section should .
be offer-ed trial .o f labor,. p.rovided there is n o
RUPTulm OF THE UTERUS contraindication and tnatenial and perinatal risks
and benefits are thoroughly d!Cu~sed with the
Rupture of the uterqs can either be .complete pa:rtuxient. Available data suggest-t:hat a tli.$lof
with direct communication between the uterine labor in women who has had more than one
and peritch~hl cavity or incomplete if the two cesarean with a low horizontal incision is likely to
or
cavities are :separated by uteririe set:osa b road be successful but is associated -with higher risk
:ligariient. R~ptm-e oan ocettr .in. both unscaried o-r rupture. OxytQcin ' augmenta~on is not
and SCarre4 uterus. However; .obviously ~ latter contralP.die.ate.d in wpmen q\.l~ed: tu: ~deygo
has higher,risks. tri.81 of labor after eesarean -~ecti~ .aithougb it .
.. """''~( '
...
~y-be;;~..ssociatedmth.an increasedrlsk.o futerine
'

Ace~ .s ectll)n scar can either ropror,e .o r r upture and sh<>tild be used .with .cautioli 'after
deltisce .dq:>end.ing upon the presence .o f five (5) appropriate. eoun$leling. How~vei;r:ijd.u~~~;;~f
featUres .ruunely: . Ia;bor .w ith prosmgtaridih El (misoprosto'tf;:tmd
ptostagla:ndin E2 (dirio.p rostone) is.~~~~~
1. Se~~Qn .of the :;;car thro~ghout its whole increased risk of uterine. rupture and -shoUld: n()_t
length;_:~ . : be. used liS part of trial of labor after ce~
. , _;:~ -: ]:~;~;.~:;~~;~ ,
' . '. i

.o!~t-:>--:-.- section. ,.
2. Ruptill:e 9fthe fetal membrane. . . . .. .. :. -: .
:. ;:,~

Sometimes a woman may have "'T"or .J

3. -cohununkai:iori between the uteri..'le -and
pentOnearcaVifY.
4. Extrusion of all or part of. the fetus jnt9 the
peritoneal cavity. -
5. Massive bleed!ngfroril the edges ofthe scar or
. 'from extension ~fthe rent h'100 uninvolved part
cf ~e uter..1s.
.:
The above meniJoned features make the
rupture complete while in co ntras t with
Q.ehisce:nc:e o{ htcompJete .r upture, the fetal
me~braties are not rupt\ited, the fetus is not
extruded into the pe ritoneal ;avity, . separation
does. .not involve ali. of the layers, the o verlying
.perit(jneun:i is intact and . bleeding- is abs.e nt o r
minimal.
Rupture o a Cesarean SectloQ. Scar
The behavior of the different .types :of incision
through the body o_f the uterus differs in
subsequt!nt pregnancies. A. vertical uterine
shajled .sce.r on_the ut.erus or one .that ~bles
on inverte'il"'F."lt'oweve-r, -~trreses'Cal'S"'iii:tra.t
<:Qm__;no.n:1r.isesomat:edll1afoetween 4% .ani:l '9
%-ofT ~haped s:ars are at -risk :ror' ~pttu'e.
Heaimg of a ~-sa.rean section :scar was believ:ed
to result rom x;egeneration of the musculartissue
rather than by sc~r formation. Thi~ was
contradicted.by works of Schwarz and colleagues.
Th~y had concluded that healing occurs maLrU.y
by fibroblast proliferation. As the scar shrinks, the
connective tissue diminishes so what is left is an
entirely muscular ar-ea, sometimes thinned out
because. of poor healing; The basic pathology
comes from failure .to coaptate the
inner margins
of the incision or rr()m hematoma or a bscess
formation in the area.
Rupture of an Intac~ (Unscarred) Uterus
s~ontaneous rupture of a~ inta-~terils
during pregnahcyis exceedingly rare. :PrecUsp<>sirig
factors to rupture during :pr egnancy are those
which mq.y prodllce weakness .of the,uterine,wall

Scanned 8y:
 1 .

sso .....

such as: Qxytocin induction, of labor in wo;nen with
hjgh paritjr. Rup~ of an intact uterus during
l,al?Or.!Um:ost alway:; pecurs in the lower u~e
segment. The-stretcl'iip,g and thlnnin.g .o fthe lower
uterin~segtnent and the recurring contractio'n and
retraction of .the 1,1pper s.eg~~~t fih~rs
simultaneously push the presenting paJ.i:.d own1:he
birtl) -canal ~d. pull the ~en:Ix upw~q.rds over ;th.;
fetus .. I_( the m.uscclar :fi~ ar:e weak.-or .i f the
desqent of the infant _js. ar.te.st;ed by pel:vd,c.
contraction, _m9-:lposition 9r fetal anomaly, the
-degree o (-;streteh to. which. the lower .segment is
e xposed_. ma.y ~xce.~d the ten.~ile strength and
rupt;ure ~"l,lfs. -
To date, studies have show-n that uterine
rupture can be detected by 'e lectronic fetal
monitoring, abnormal .fetal .heart rate patterns,
especially v~able or. ptolonged deceleration.
pa~"lls, -
. . . . . . .. , .. . .
.P rior to th~ onset of labor~ the p atient with. a
of
beginning_ p~pture D;lay complrun . hypOgastric
ot suprapubic paJn and.tenderness. increaSed
i.rri~bility of :the uterus. and oftentime-S.m.in.in{al
vaginal bleeding . .A.-s the r~nt _g et$ bjgger-,
symptoms b ecome worse; There Js .m ore.bl~g
and P<':'Jn, so~etiroe~ leading to hemorrhagic
sh~k.

: Puring .labo:t' the :ela,.s sic . find.ings . .of

s:pp~tanet>us r.up~e are: ::shrup .shooting .s upra
.. :n~~ p;~ant U:~~s -i s res~tant tO ~.rn,al Pt:r?ic psi,t;t and len<L"'Tne,ss, cojnplamts that
tta_.ilma. but oecasio~. a b}bw or .a fall -on~~ '"s~:n;rr;:t'hi;ng :r-ip:~>~d ot . .tore" .. .!n..si'-:e. ller.
a:;od~m~il. .may ._q me il...:~e< .or a .r.uptut~. D~g contractions ..that slow. dqwn or ~orne less .
labor.;.-.tiaumatic,- :~_ptur.~. on.thejow:er.. ;ute1~ intense! dis.QJ>pear?nce .o f .fetal .heart tones,
.segi;ri"Wtma.y.f~froin.-.oper.atfv.tJ::t~:J:l~:Jnflited. ~ssion of. $.e presenting J?&r:t or ""lo's~ -Qf.:the
./.
b_y)~~~:P.~.d.~~a. S-iin~~~w~Q~.;~: -s}:~tion~l.a~?-1Y.~~inal>;~l~.~9-i1Jo"g:-r;~li~~ :m<>ll.ler.: . .
rli~tfotceps;apj;$.~~s;~br~-.-~ctio'n~. . e~pel;ien~es . S.~lll:e relief . aftet. 'However., . thfs
;hydr:ocephaly an-d ,:fpr:c:eftiJ\.fu~9ial 'pressttr.e; . shoUld '!lo.t -giv.ellie clinician:false .ho~~>:bei::a~se
~(Table. 5S.'1~ . th:e .: ~fietmB.;tlf would 'be : $i"~n~ . of ..
... . . .. . . . . he.m-opetitone~ :and. hy.povo.lemlc sho.c)c... A
. .RjJ.pture ~g. du$g..labpi.ip.vQlv-~~:' the :.. . c.ontra,c;~:e4:cU~s ~a,ybe.!~~t:,QO,g$ide the fetus.
lo~:~~M.s:~~~~-~g ~Jn~Y:.~~P.<17:l;t~d& ..... FetaJ:p_art~ .may~_.J:>~o~~~9'r.~..-,p~able.:~; .
. m.~,~~w~;s.~r ~W.U~>tp.e:~r.~vparW-qie::t~rc,is<: ?efpt.e :the :pr-evious.e~~ttn:i;n?-tion sometirn.e s
<;9rifin.e~i'tl:l~~!92.ttuterln~~~e~~it'g.~l?:~Y . .~t;P.atj.!f:~alble:edm~ay..:n.e"slighbiliq.,may
m.n$J:x:.ans~er$ly:9t;:bli~ti.ely.....l(.~~teai..mvolv.es i:n.irhic abmptio .plaenta.
-onl-y -fue-thi.Ckt;\e~.s .of th~ . :muscu:lar. :w;,ill1ea$.,g
the perlton~u-min~tt (~ incompl~te _ ruptti:t~h In - m.p~es.Q.:u.e tf.?. d:elivezy, the 4'au.ma is
extensitril.-ofthe hcmit.toma foririatiori'in beti.ieen us.ualzy deteet~d att~r the
~pn{l stage of.~borin
,. :tb~~: ,i~v'es, of:th:e. :qri>~d lj.gani~nt :r,esuhs. lf a an ~ttemp.t to-ddive:r tp,e baby Y?'guian.Y after a
'-bQch :~f:fu* :;l;lteritt~ :ax;tecy .'i$ -in~qlv.ed, inassiv.e.. fun'd:U.-~sU.re. Itinne~te . PQ~t p aitum Q:keding
'Te4operltqne.~ ~~,ato:m.a -'.dis~~cting Upy:arqs and ;;hock :sh(1utd . a"lert the o b~tetritian~
.tow~ ii).:e ki~ey ,'ay a~ve1op. Paro:Cl))arly.~fua'ba:ckgtou:nd:o1pr.evious uterine
!!lani.Pl,i1l;ttion.
.In ~Q.t;np1ete ~ptures, the (ems escapes into
the .aPd.oin.j.nal i:a,.v'ity unless. the .pres~D.ting part Qn 'uterine .~loraticn, :~ te:ar- ~ the :ut.ezi..ne
is .:deeply enga~~d:,;.the' tl:~e~s :emp.~ed of i~~ w~ can 'be palpat~d. HqWeYe:i:. fuilur:e to.detect.
conteri:ta .~o~ '90rl~C:ts and go.es -to li.e along~ide. th.c tear l:>y no means prove$ . 'i ts :abse.n ce. If
the ~lled ~etlis. R a;rtial pla(;ental se:par.ation .st,r tmgly sti. spect~d, all l;il.ea,ns .for detection
.augment~ theb leedi.pg {urther. should be .e:Xh~-u.sted includitlg.ruldoccntesis 'to
identify hemoperitoneu.rri i f the .'Qapy has been
Slgns_an.4 Symptoms delivere4.

A ute'dne rupt_w :e cannot: be ac.c ur.a:tely Sim.Uar s~ghs ..-d:uring :pregnancy and: labor
predJ.i -or.;di.agnose_d,befo.re .p:_.:aqtually \)Ccuts maybe.assodated wifu other condition~ whlch
a lthough . gi-oss hema~riCJ,. !Uay~e sugge,stiv.e. A. h~v.e to be r:til~d . out like .a,bruptio placenta,
1#gh index of ~uspicion,-.always Jadlitates pr9tnpt . ruptured Visceta, embolic ph~nomena.and torsion
-di~_gnosis and manage+nent. . . . . ..of ovarian oi: uterine tumor, .

Scanned 8y: C
 CHAPTER SS: INJURIES OF THE BIRTH CANAL "'851
" ::r.'"

Management is still desirous of future pregnancies, if the rent

The event of uterine rupture .i s considered an
acute emergency that carries a h igh rate of
maternal and pe1i.natal mortalityi hence trial of
labor shou14 only~ jp.itiated in a .weU-equipped
institutionwith pro'Vislons "! or urgent laparotomy.
When t.lte diagnosis is suspected, prompt surgical
intetvention with.an ~rienced pelVic surgeon
and blood product replacement ari4 antimicrobial
therapy should be given. Laparotomy should no~
be delayed since hypovoleii4:C shock:eoul~ be;;:9me
irtevetsible up.less arteriolar bleeding iscontrolleq.
A'l s.pproxim_ate time frame of 30 mitlutes s hould
be considered adequate in the set:.up of urgent artery ligation is an 85 percent reduction in pulse
laparotomy: Oxytocin drip tnay be used to
:ininimize bleedingb y myometrial contraction, and
in turn vessel constriction. In desperate cases,
compression a,pplied to the .aorta in unci>ntrollable
bleeding, -Ql)c;l cla,mping -df the ~terlnc and ovarian ~mboUzation. Tl;l.is teC;bniqu:e has. also becom.e
vessels agjacent to the uterus.
Hysterectomy is the .m anagement of choice if
the darn.age'is uncontrolled. However~ if the patient
is small and clean looking, or if the bleeding is
minimal, repair of the wound can be done .
Unfortuna~ly, if the rupture is .in the lateral wall
and the uterine arterie~ .&fe severed, then blind
suture ligation ~ pose danger in hitting the
ureters and bladder. The fie!d being a pool of blood
plus the -presenc;e of J:>road ligament hematoma
can interfere with visualizati,on oi retracted uterine
vessels which can be extremely difficult. Another
prQCedure that can be resorted to include ligation
of the ovarian :vessels in the infU.&1.dibulopelvic
ligament and hypogasm_c art..ery Jigation. The most
imjxlrtmlt mechanism of action with internal iliac
pressUre in those arteries -distal to the ligation.
Another surgical method employed to control
refractory bleeding is selective arterial
pt>ptila.r for tJ;J.a.nAgement of intra:cb:l~le puerperal
hemato-mas. 'i'ltis optio.n of ang~cigrapht{;i.~ lly
direetedarterla.l embolization is feasible m'.ce.iitifs
with interve:Iltional .radiologists. -~ :,:~t.~:. ,:~
::';'~-,.~-\"; . :: f

Table
. ~ ; .. .ofj::au~3
55.1::rCI.a"ssi,fication
.' .. .
of uterine;
. . . rupture.
.
Uteri:le lnjuty or Anomaly Sl!stain.ed before Current
Pregn~cy . .
........ : ..
- . ~ - ---~--..---:

1, Surg,fiJy illv.olxing_the.mycmetrlum 1. Beforecdeijvery

Cesarean section or hys terectoniy , Persist~t iJitense -uterine contraction
PreViously rep~ .uterineoropture LaQ<>rstimulation with oxytocin orpros~glandins
Myomectomy incision through Ql' to the endometrium Perl'Qtlrtion byintQnal ut.:rine pressure catheter
Deep corneal resection ofinterstitial oviduct ~'Ua~ .
Met,roplasty Exterruil version
Uterlne-ovet-cllstenticn

2. Coin~d.entcl uterine trauma 2. D~gdeliver;y

.Abortion with instrumentations
Sharp or blunt trauma
. Sil.e nt tuptur.e in previou~ pregnancy
3 . Congenital anomaly
Pregnancy in underdeveloped ute~e
Intemal:ve;;sion
Difficult forceps ddivecy
Breech extraction
ToW anomaly-disten ding the lower segment
Vigor<?us -u terine p tessure during. delivery
DifficUlt manual removal of the placenta
3.Acquired
P1Senta increta or petcreta
. .Gestational trophoblastic neoplasia
hom Adenomyosis
of
Sacculation entrappedretroverted uterus

.\ .:. :_.

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. 852 SECTlON \X: ABNORMALITIES OF THE PUERPERIUM

POINTS TO REMEMBER

Pos.tpdrtum bleeding despite.a firm contracted uterus with histc;y of operative vaginal deliverf strongly
suggests genital tract lacerations, retained secundines
.. or presence
. cf uterine
... iear

A well-timed. and ample episiotomy with regulated de)ivar-y .of th~ head .~nd .ad~q~te perineal support
will prevent most of.the perineal lears .
,Injury to the ievator ani- musd~s ari.d rectal and ?Jnal mucosa without 'adeq:uate. fepaifcan lead to
inc<>t'itinence of ~tool. and flatus
, . or development.
'
or .reetova,9inal fistula
.
F;atiure'to .fig ate 'the bleedersatti-je angl~ .of the episiotomy wound or'iacerations ean 'forfr'l ahematoma
sever-e enough to cause hypovotem ic shock ,...
. . . '. . . .

Co~S~iV.ative -~anagement. of lar:9~ vaginal h~matomas can result In local infection, s.epticetnia and
profuse hemorrhage

Cervical .laceratiqns less than '2 em need no repair if. the're'~is no active bleeditjg since they :heal
sppnt!neously . ...

' .A vertiCal uterine 'incision. or ciassi~l scar.has an increased probability 'ot rupture and may ruptl,ire
.... ...before
.. tabor cr even severa!':days
. . .before ,term. .
'. .

... :; thcbmpfete;'n.tptUre.Qr.:aeniscer.ce':of<ceS.arean section:<scar\has the':foilowing~features;-name!y:

. Fet:ll-.membranes.are intaet.: .
.. Feuis is not extruded ,into the .P?ritonealcavity
OVerlying peritoneum is: intact
Bleeding is minirnat ~or a9sent
, .

- .. . ,OXyti)Cin induction>of. Jaber ir:t .w.otnen::with.:high pa~ity predisposes to spontaoeo.u s. rupture . of an

.:in~ct.uterus . -

. /iJi\gh'fndex
.. ~ --
OfSUSpldOR
-
facimafes
.... . prompfdiagnOSts
~.- . ..... - . Of IJteri!)'e rupture. .

ln rup:ture~ .due to deliyery, trauma is .d etetted after the second stag~e of I~oor, -a fter using strong
fund;atpressu re - .

Fqilur~. to detect the tear n ~tericie exploration by _r.o means ptoves its absence

REFEIU:NCES S. American C.o llege of Obstetricians a.~d Gynecologis ts.

~. Cu~gham FG, e~1;\l. Willi~~Qbstetric~. 22n<~Ed.:
USA:'P.re:nti~~Halllntemational, Inc. 2005.
2. Collate_d, Reports of the Philippine Obstetrical .and
Gynecolog.it,al Society.. ~997....: i.OO 1. .
3. Sumpaico W, et al. Textbook of Obst!!tric.~: Physiologic
and :Pathologic Obs.tetrics. 2"d ed. Queion .City:
.Ass9cla.ti;on Qf.Philippine Medica). b>li~ges,Foundation, ..
Inc. 2002.
. Vaginal birth after previous cesarean delivery. ACOG
. 'Practice BullettiiN<Y. 54'. 200TCompend.ium of Selected
?ublications.
. .. ........ ~ ~ ~ . ... .
6. SOGC Clinical Practice Guidelines. Guidelines for
operative vaginal birth. J Obstet Gynaecol Can 2004;
26(8): 747-753.
7. SOGC 'Clinical Practice Guidelines. Guidelines for
vaginal birth after:previous caesarean birt:l). J Obstet
Ginaecol Can 2005; 27(2.): 164-1'74.

. 4. Hendrtx N, et al. Postpartum Hemorrhage: Surgical

8. American ~ollege of Obstetricians. and Gynecologists .
Epis iotomy. ACOG Practice Bulletin No. 71. 2007
'},{a,nagernent. www.obma nagement.com .. 200?.
~ndium o_f Selected Publications.

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~
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.:-:.

,1. "

'
>,,

..
.-.~~- ,

~:
 -...

.--

....
"4

...
...

. -- -~:

..,
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,;..

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 56

CARDIOVASCULAR DISEASES

CHRISTIA S. PADOLU~A, MD

Cc:rdiovascular Changes in During Pregnancy

Congenital Heart lesions .._

Left-to-right Cardiac Shunts

Left Ventricular Ou1flow Tract Obstruction

Coan::tation of the Aorta

Pulmonary Valve Stenosis

Cyanotic Heart Disease

Tetralogy-ofJ;allot.-
Eisenmerger Syndrome

Rheumatic Heart Disease

Other Rheumatic Disease

Clinical Approach to a Pregnant Patient with Heart Disease

The Risk of Congenital Heart Disease in Offspring

Antepartum Management

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 ft~S. SECTION X: MEDlCAL.SURGlCALAND REPROOUCTIVE ILLNESSES AFFECTING PREGNAN~?G

INTRODUCTION increases circulating blood volume. i'h.e

Is it safe for a -wo~'"l With a hea..>i: <H$ease .to
' conceive? What ~hould we advise her artd how
~o~d her pregnancy be managed?
... .; . The answ~rs depend on the pro'blem and the
woman's cardif..C status. ln: some cypes of heart
'di~se,"V.thet~ -g ood eardiac function is preserved,
. the. t>utc.o m.es. .ar:e excelletit fl.nd ..no .speC'iaJ
.. . -w~:p~~~~-wilf~~~igi>'th~'Pr~
'' .:: mii.J:P.o$e:a~S9~ble ri'skreq~~.the prpbleJ;n
. N> ~ cone'Cted r~t or pre.~aney -rnl~d out 'pre~cy.
' aitcgeilier:
. . :. . .
. . . ....,.,
. .
Few
. women With heart disease . . .actually . die
du;@.g ,p r.egrtancy:. Heart disease complie2,tes
a:"~...percent
. , ......... .. of .pr.egn~t women and stilt remains
. . :a,i$-a. signific~nt c6.use of matemal mprbidity and
,_,,. ::: ;=iifi.indfrect :eause of maternal mortality. In :the
-:: :pti;fted: ~g(iq~;heart disease. is :a lea:ding.cause exaniinativb, .elec~rocardiography
.. .'of"i.lia~roa1"d~fu;ii.COttptingIor165 _per:cerit of .ech~bgraphy. -{Tabie 56.1)
:.:.-.. :t~nm~ernnl~d,eatlis 'Ov:er .fueperi<>dof 1997:~-:rg.g 9>
he~odynamic chan,ges of pregt:.ancy may not fully ..
resolve until 6 months after the delivery.
The risk for pregnant wou-1en with- heart
disease of having adverse cardiovascul&.r ~vents
such as symptomatic arrhythmia, stroke,
pulmonary edema, over~ failure or d.e::i.th is
dete~ed by th~ ability of their .cardiovascular.
sy;;t~m to adapt to .the .physiological changes o~ .
PJ,"~cy. bn~ '~ot ov~rem,P.haSize the need
:f or ~ thof'o:').l.g h as.s-ss:Qi~nt .'<?f patients before
'
B:~use of the phy~iiologie ch~ges in the
ca,r diovascuiar s~atus during pregnancy, in'any
healthy p.retm.an.t women .have .symptp.:ms
:r!Uniicldn.g these of the cardiac disease including
fatigue, dyspn~a :~d. ~ht-. h~adedl)ess apd a
numbe~ .of "abnot.m al" findings on physichl:
and .

. ...:In. the.. Philippines., the reported incidence of

'~ .=h~ rli~se a3~ated: with .pt~ancy .~ff.ects -. L eft;..tQ-.rlght.;ta.Yd!ac =sh~ts .: -.
. o~~ t-.36 pew.~t of.pr:tgrlant:wom~a :'lnl993, . . . . _ .. .
' .._' . :.J)~~:9n th~.statl.:Stics ot the Pliili:ppin.eO~tefr931 ....Jri .patients. ;with: .all::t.~riaL septal ddect.~ . -'
.;.$dt~eco10gi~..s0ciety;.;.the.~te.,otpr.~ap:cy . ventr.i.ccilar. ::septe.l defect, pr . patent dp:ctus ..
. ,.. -'~p~ted .ey heart -disease was .G...tb percent. artenQsU.s, bl~d c~n shunt from the. :lii:gh-:: . .
. ..: :~::..:.;:.:.:.......~ . . .. . pressWoe4dt:-siaeof.th:e~he<ii:H:o'the1ower-preSstJ.ie:.. -
. .-: -. GARDI0VASGULAA :GRANGES .DURING right ~ide. -- BWi:q_gpt~~0';increase in 'h;ft""t~: .
.' :. : P~NAN~ .. . .rigp.t sh'Q.nt:irig B:~ a :i.estilt of increase in cardiac .
. . . output may be attel:'J.:UE:ted by !;he d ecreas.e :j,n.' ' :.
: :I>.r~~ancy causes .an increase in c:aroiac perip4e.t al vascular a$istance.
'dUf:P\l.t pf 30 ~ 50 .pt<r~ent, .an .inti~'$e .in bl~
, :Vl:)_l'Wne ot -40 - .50 perc~t and ~ incyea~e in
: -~:.px)-g~n-ronsumpti.qri 9f 20 pe~ent ~g .d upng
, .theuci>nd ~ter ~md rema.irl,ing .high .:tproug'tl Tallie S6.i. Oo:tillnon cardiac fmdings in normal pregr-..:ari.cy:
....:~~:'rest of- pregnancy. . thi s "phy:s iolpgic .b.{gh sy'I)lpt&ms
..oritp~t state is s.cc:Ompanied by de~_rease in F.atigU~
... :~~.p;heral v<;~.~cular ~esistance .and bl?Od pres::;l:lfe. .t;>yspnea .
. IIit;i:ap~r,tum, uterin~ contractions res'uH hi Llgb:.t~he~dedness
_. . :eX$-l;llsion of ~0.0 to 500 ml of blood from the
Physical findings .
q:uet'9placenta~ circulation thus increasing blood
-yohfrri.e and _produces -an increase in cardiac
bi!;placed ~pical impulse ..
Proxp#1entjugu1ar venous pulsations
output and' blOod pressure. The bearing down Wll;iely split fust and second heart sounds
.. ~{forts of the ~econd .s tage of labor will diminish El~ocat.diogram (ECG)
.. -veno~s return and result in decreased stroke T-wave changes
.Y~hUne .and incr~sed heart rate: 1'her.e isalso
'Echocardiographic-findings .
.lo~ of the uteroplacental circulation Pt?~tpartum Mild increase 1n left-ventricular diaStolic dimensio,n With. . -.
.w.hi_c.h . Caus es .an 1n.creas e in blciod V.olu.me preS.erv~tion of'ejectiQn fraCtion .
:re~llifin.g fu. m fucrease in .cardiac output. Tl).e Functional tricuspid and m itral regurgitation
:fuopilization Of .extravascular fl\;lid a 1 ~" f,.-+'h ~- ,... __._., ... ~ricardial effus ion .. .

. Scanned 8y: c----------~

,__
,....
_.,...,_.._,___~~::-:-::;:;:;:~-:;:.-;:;;:~-------:---
CHAPTER 56: CARDIOVASCULAR OISEASES
It Table 56.2. Clinical indicators of heart disease during
i pregnancy.
)'
r.. Symptoms
Progressive dy~pnea or orthopnea
~
Nocturnal cough
Hemoptysis
Syncope
Chestpain
Clinical Findings
Cya.Ttosis
Clubbi,ng 9f fmgers
Per:sistent neck vein diste:nion
" Systolic murmur grade 3}6 or greater
Diaeto'llc: m-:umur
-~ Cardiomegaly
Persistent arrhythmia
PersiS.tentsplit-sea>nd iound
Crjterla for pui.D:)onary hypertension
Pregnancy, labor and delivecy are well-
tole:rated .. in the ab~ence or pulmonary
hype~-tenSioil. Rowev.e r, during.la:bor and delivery,
a risk oLparadoxical .embOlisui exists {venous
thrombOembolism passing fulm the tight side of
the heart to the left), p artlct!:latly \'.'it.lt an atrial
:s~unj: su~li-as- a patent foramen .o.vale.
.Le~;;:_V;ebtri~ular ;Outnow- Tract '0bstnu:tloa
(AQrtlc St~J.l~sis)
Corigetlital bicuspid ~rti~ valve is the most .
cotrimoii"" caiise -oraortic""stenosis"
. .. ' . . . . . - ..... ' ..... - . . ' . . . : Ui"":-re-
l' ..... ..... . shouTd""oe
women. Jn severestenoss, .t he heart must strain
to increas~ its output during pregnancy which may
result in heart failure or isehetnia.
In a 1993 overview of .l06 pr.egnandes in
women With congenital aortic stenosis, the
maternal mortalitY rate was 11 pe~enl &nd th~
perinata,i .m ortality rate wa-s 4 perte:O:t. However,
in a reore recent series of 49 pregnancies {59% .in
women with: severe stenosis), no women died.
However, adverse maternal -c ardiac events
occurred in .3 women .-\6%) who had severe aortic
stenosis.
Recommendations
Women with symptomatic aortic -stenosis
should delay pregnancy until surgi correction
of stenosi::. Absence of .symptoms does not
guarantee that pregnancy will be welHolerated.
In certain cases, bailooh valvuloplastydl.lring labor
and delivery may be pallia tive.
Seanned 8y:
857
Coarc-tation of the Aorta
Coarctation of the aorta is commonly
associated with a bicuspid aortic valve. It is rare
during pregnancy (9% of all congenital defects).
If left uncorrected before pregnancy, the woman
is at risk of ac.rtic .rupture in the third trimester
and labor. Even if the coarctation is corrected
before pregnancy, pregnahcy-induced
hypertension can occur due to residual
abnormalities 'L'l aortic compliance .. Restriction
is
of physical activity the only way of minimiZing_
j>(>,tentially dangerous suqes .in blood p~ess\lre.
The mortality rate W~l'l 3 - 4 percent or higher
ift.ltere were associated cart;liac defects, aortopathy
or long standing hypertension.
PuJmo~ 'Valve Ste!losls
J>uht\ona:cy valve steno.s is .t hat is mild: pr.that
has b.een treated, with valVl.liopl~~!YAi~$.tt1i
tolerated during pregnancy. Fetal-outcome ttr.;~,S?
favor&ble. . ." .. . - ~
.Severe steno.s is, -even Wasymptcn:~ati:;: . Jl:!.aY.
lead to righHiided
..
heart
.
failure or
.
arrhythmias~-
. ... . .: :;z ... :(:
-~ ~ ~- :-
Reconunend.a Uons
. . ... .
: :~
. Patients with sever~ pnlmor~ valve ~~o~i~
g nanf".
coiisiaer ecf"1or e:o"i':iectJoii"'beYo:fe
pregnancy . . it symptoms progress~ balloon
valvuloplasty may be feasible during pregnancy.,
Cyan.otic Heart t >isea.s e
Tetralogy of.F:d.llot
This.congenital anomaly is most corrimon form
of cyanotic heart disease. Its features . include:
a) a large non-restrictive ventricular-septal defect
b) overriding of the aorta, c) p.u lmonary valve
stenosis, and d) right ventricular hypertrophy.
If the problem is not corrected or palliated, the
pregnancy-associated fall in systemic vascular
resistance and rise in cru:diac output exacerbate
right-to-left :shunting leading to increased
maternal hyp:o xemla and cyanosis . .~ernal
mortality rate is 4 percent to 15 petcen~ (!;1,1'd fetal .
lqss rate may .be as high as 30 percent.. H6wever,-
the risk is low in women in whom the tetralogy
has been successfully corr~cted.
~
858 SECliONX: MEQICAL, SURGICAL AND REPRODUCTIVE ILLNESSES AFFECTING PREGNANCY .

Vaginal. delivery is preferred and cesarean assessment for volume overload and pulmonary
section is performed only if with o bstetrical edema. Treatment involves bed rest, oxygen
inclication. therapy and diuretics.

Eisenmeng~r Syndrome Percutaneous mitral valvuloplasty during

This syndrome invoives pul.m onary vascular
obstructive disease resulting from a pre-existing
left~to~right 'Shunt. ~
Most complications during pr~gnancy ..oceur
at terin and during the 'ft.rSt week postpartu:~.
Spontaneous abortion, intrauterin:e growth
restriction. and pr:eterm labor ar~ frequent.
Maternal
. mi>rtalit'J. is about 50 percent.
Recommendations
Preconception counseling should stress th~
extreme risks ft6m .pregnancy. Patients should
a.lwa,y..s: be ' off~red sterilization or _pregnancy
teimlriatioii. .
Rheumatic:Heart.Disea.s e.:.
pregnancy should be conside:red hi patientswho,
despite optimal medical therapy are in NYHA
functional Class III or IV.
Epidural anesthesia is advised in order to
~duce preload. Most women With Jritral s~enosis
can undergo vaginal delivery with epidural
anesthesia unless obst~tricaily cqn~dica.t~d.
The recom mended manner of delivery is vaginal
delivery with outlet forceps extraction.
Intrapartum endocarditis prophylaxis is requited.
Other Rheumatic Lesions
Rheumatic .A ortic Stenosis
R heumatic:a6rtic stenG>sispt;ses a risk dUring
.pregnancy siiniiar' to' ;that or
congenital aortic
steno$is.

Mitrril Steni>Si.s Pree<>n:ceptio~functionai class.provides a goOd

. estrmate of th.e patient's ability to tolerate
-MittaH:;tencsis.is theinostcouimon i heumatic ., , p.t_e gnatly; '. :Women -asymptomatic., heJor.e .:
valVuJat. les~!l ,of pi;egt?.ancy....; The.,;hypervolemia L .... ,conceptit>n.. gen erally .tolerates; pr~gnancy .~while..
and . taeqycardia a ;ssociated witli pregnancy those ~ptoxnatic or wt~ -~yere stenosis ate .at
exacerbate thetrarismitral gtadiertt; . risk of 'a'rlteoleft- v entricu1arfailure;

Atri~ fibrillation may res~ldrom the elevated Intravenous oiytocin-at delivery can cause
l eft atri.~ pressure. This can preclpitat~ heart in:tractabl hypotens ion and preplanning to avoid
faihJ.re, prhnadly due to a n une ontrolled its use is prudent.
vertt;ricular rate. ~ven patients W itho nly ild to.
moderate mitr~l stenosis may de:Velop aLrial . Patients with severe stenosis dp not tolerate.
fibrilla:tio,n and heart failur~ duriltg 'th:e blood loss, . tac.b.Yc::ardia and central neural-
.an~epanum ar.d peripartum petiod.s . blOi;kade or vena cavaLcompression. . The main
objective is .to avoid fluid depletion an.d
Recent s tudies found ho :mo.ttality but .hypotension. Early placement of a r terial and
substantial morbidity from heart. faihi.te ao.d .c entral :venous lines, m aintenanee of left uterine
.a:rfhithmia: the ris'k of cotnplicati~ns is higher displacement and cesareart delivery under general
in women With a 'history ofca:rdja:c events and with anesthesia are recommended.
moderate or severe. mitrai stenosis . In patients
with severe mitral stenosis, mortaJity cart be as Aortic or Mitral Regurgitation
higJl as 5 percent.
Even in severe cases, this is generally well
The risk of adverse fetal or neonatal outcomes tolerated during pregnancy.
also .increases with increasi"ng. severity ,o fmittal
sten osis. P e ripartum Cardiomyopathy

Prenatal manage01ent is directed towards Peripartum cardiomyopathy is a poo rly

-avoiding cardiac decompensaHon, With rePnl::~r 1 mri~>r~tnnrl.
condition with a n incidence of 1: 1500

Scanned 8y: C .
 CHAPTE!R 56: CARDIOVASCULAR DISEASES
to 1:4000 live births. It has been defined clinically
as the onset Of cardiac failure with flO identifiable
cattse in the last month of pregnancy or Within 5
months after delivery, in the absenc,e of hea:t
diseaSe befyre tl1~ last month of pregnancy. It 1s
a$sociated with older maternal age, greater ,parity;
black race ,and multiple gestations, Terbutaline
tocolytic therapy has been suggested as a factor,
, The diagnosis of peripartum ,cardibnlJopathy
presents a challenge because,many nom1al w~men
.in the last month of normal pregn_ancy expene~ce
dyspnea, fatigue and ~dal ed~!Ua;. sy;:npt?.~s ,
identical to early congestive card1at: 'failure. S1gns
B.Jld symptoms that should ~so raise the suspicion
of heart failure include paroxysmal nocturnal
dys:pnea, ~lle~t pain, no,c turnal , co<l.S.h, ,new
regurgitant murmurs, pulll1onary crackles,
elevated jugular venous . pressures qnd
hepatom~y. A high in~x of suspicion and a
!ow. thre$hold for . echocardiography in. patients
with the~SytPptoms and signs are essential. The sensitive: iridicatorcif m yocardial Waiction -than
di(f~.reitt~l. .diagnosis includes . myoca;-~i~l
infarctio.U, sepsis, severe preeclampsia; :a.tru:uotic concentrations, which irictease durilig)i~"'f;$'
fluid embOlism and pulmonary einbolism;
. T~ea~~~t of peripartum ~ardiomyopathy dissection.
:inv.QJv.es~~;.restrietio.n, .and. the use-of.. diuretics
tQ' dettca~r pUlmonary con~estion and volu~e
overload. :Hydralazine is the drug of ch01ce
Pte.~. Ul addition to nitrates or amlodipine.
:An:~otB1$in=co.nvettinge~e'ifihi~itors -~~-l~e
maiiis:ray of'treatriient post- partum, even m
w.others W\)o are breastfeeding. The beta-blocke:.-,
caivedilot, ha& been shown to . improve overall
survival in women with dilative cardiomyopathy.
Other calcium .Channel blockers may be associated
With a negativ~ iriotropic effect and should be
avoided.
As cardiomyopathy manifests in the. final
trimester, the fetus is usually mature and can be
delivered safely before or at the commencement
of medical therapy-..' The mode of delivery for
patients. with peripartum c?rdiomyopath.y is
gene-rally based on obstetric indications. After
stabilization of.the mother's symptoms, induction
and vaginal delivery can be attempted. The
advantages of vaginal delivery are minimal . blood
loss, great~r hemodynamic stability, avoidance of
stirgi~ stress, and. iess chance -cf P9st:<>perative
irtrection and pu1monary complications. .Effective
pain mariagemcmt is neces sary to avoid further
increases in cardiac .output from pa in an,d anxiety.
Seanned 8y:
859'
Regional anesthesia has the additional ad-.zantages
of reducing preload ~d afterload, and minimizes .
the fluctuations in cardiac output .of labor.
Regional anesthesia is contrairfdicated in
anticoagulated patients.
My.ocar~Ual Infarction
I.schemic heart disease in pregnancy is
uncommon, occurring in 1 in 10,000 deliveries.
Myocardial infarction is more common during the
third trimester or perlpartiun- of e ither the first or
second pregrumcies. Ifmyocardial infarction6ccurs
'?.'ithin 2 weeks cflabol'and deliveq, mortality may
be as high. .a:8'45 percent. Patients typically pre$ellt
with ischemic chest pain in 'the pr-esence o f an
abnormal' ECG and elevated cardiac enzymes.
Syinptotns n:tay often be masked or \inclear dlh~g
labor and delivery. a.n~ the ECG :and cardiac
enzymes ptay l)e ln$ettsiti.v~. Cardiac specific
troponin 'I greater than 0. 15 ngfml is a more
creatinine kfn-a se .muscle-bot1e ~~t.~!'nl
~r ....
1... .... , I
labor. The differential diagtiosis iri:dudes'L}jte::::
edanipsia, acute prilmoriary embpli cmda 0rtic
, . _, .~
Management 6r :myocardial.infarctiom~t'iSt'
involve early coronary angiograpny/tlii~t\'he
imm.ediate ,postp~\l~ peri~d . spqrtt~eO:us
coronacy .artery_..dissection .is...the.:m~sLoonunon
causeof..~yQCard~-inf~tion~ T,:w~nty-~ent- of
wome'n with pi:(ipa.rtum myocardial ihfarc.tion .
have angi.og(aphip evid~nte .o f ath~sclerosl.s or
intracqronary thrombus~ Increasing maternal age;
prevalence of type II. diabetes and the mCid.ence
of smoking in young women may cause this figure ..
to rise. Successful treatment includes coton:ary
stettting or ~mergency . coronary artery' bypass
grafting.
The administration M intramuscular or
i~travascular ergometrine after delivery is .
associated with myocardial infarction due to
coronary artery spasm. In women at risk ofi~hemiC
heart disease, ergometrine should be withheld.
CLINICAL APPROACH TO A PREGNAliT .
PATIENT WITH HEART DISEASE ...
Many cardiac probl~ms can~ idenif,oed or
~-=--
optimized in the preconception -an~ antena tal
period, . particularly in those patients with
congenital heartdiseas~. previous cardiac surgery
~
860. . .SECTiON
. .
X: MEDICAL, SURGICALAND
. '
REPROOUCilVE
. -
!LLNESSES AFFECTING RB.EGNANCY
.... ~.o;

or cardia:G-Telated. :proolems in previous. Before .c onception, New York Heart Association

pregp.an;cies. {NYHA) ft,ihctional Glass ('I'aql_e 56A) does not
alw~y.s :predict. how lh~ patient will cope with
The following .aftas should be consider.ed in pregnancy and therefore rygular clinical
:the clln.ical .qpproach to the w.om~!. with htart as.$essmeni u~ing echocar.diogr~phy and
disea~who is pregnant or considering pr~gnancy: electrowdiogracis may o~ required in .addition
risk stratificatio-u, antepartum qtanagerc.::nt. to regular Jetal m~mi_to0-ng. .
peripartu:.m. managemt;nt, recurrence of congenital
lesion jn:the ntonate- =a nd s ite of antepartum and Risk $hou);d be ideally assessed before a
perip9.rtlim cit-e. patier+t. ~omes pregnant. J'he data ~eeded for
P,sk as::;,e.~stnent ..can be. acquireq fro'!ll:
t-HE::RisK oF -co~G~tNIT~ HEART nisiAsE . . .

m OF:ir:Sf.RING . .A. thorough c ardiovascular history -and

eriun:i.p.ation :.
Fo.r Prew_a!lt:. wp~en 'vi~ congeni~ :h~art: . . .
A.l2~lead electi'oC<~.rdiograrn
dj~e. t:Q.e,Jisk f;f Qieir.. '(et:Jrs having stnichrral
caidiac ..defeet$ va."ies .a:.bout 3 p-ercent to 12 A transthoracic echocardiograrn.
~~t ~~W:~id With...;__ baclcgi-9und ris1c !i(O.S An arterial o:cygen: saturation measi.\rement by
Pct:cent .for. .ilie ~neral'PO_purati:olt. $p~~all2:e:d percutaneous oximetry' {in Patien( s 'With
c#f~c :~t.;~~im~d ~.eeniilf5. shmild. therefore~<! ~yanosis)
o.f!Ei-00. Afetll:il.ut:hal transhicency mea.surem~rit
-at .12~1~ weesgestatio-p: i~ a ~se~:screenirig ~est . ..T he underlying cardiac :lesion s.hould. he
tth6ciA~denfe.of.()~~W .he<U-t di~~ Ja,.orJy... de'fi.W!d' a,nq, ven':t dcular . fu.nction, . pultn!>nary .
'LJi'OOQ ~~ ,t;J..o.;:mal:~uit~ru,,:~ic'1cn:ess). :_ F~tfi,J.
-pis~-y.re:, .'severJty "(j'f obstr-uctive' lesio.n:s;:
~<Wic:ee~q,:~peffortP.ed~.ar::H4::.:,16. w.e.elc-s~ pen>iSfenc~:of shunts.: and .p resenceof'hypoxemJ,a: .
ge;sta,tiq~ :_shou1d.::.b<; offe);'ed to . ofuets Wj.th. a
should be assessed.
s:b:?n;s. fatriily ~o.ry . of cong~nital. h~ .dis~.Se
to d~t'ect moderate:to . severe ::congenital .hea:r:t lf. -pQl'!'Sible, . sugery to.-corre'Ct the.cyanosis
'-', ..i-M:.,:
1cSiQ.'zi~ ~..._.. :can:.,..._
.l~ws;u;;;t.~ -~;.: .repea~.
t~..::~ at:1s.-.=:-:
'2..2... . ..shbtil~Hb~.:,p,...t
--:veek s. -. .for. Iried: ,...,rior,'to,
..... ..:c~nceptioii-
_ to:; .
: impr.i:>V:e =: mate:t.nal . ariP, r eta;l outc.omes;
.:P~:Nb~~t(i).~6,otm-s~t.:iff<i Sympt~Piatic o'Qstructive leiipn~ ~hoUJd. ?J.~ ~'
..... --:----. -----.... :--..-------- ... ...wrr~tect....... :. ... .. . .. .
. Df$cl!s-~qj;l.s-~fuliti~e ptegrra:ncies; ia:'I:Qily-
:pJ~tilg: tW~ <>n.tliac.eptipri .sh'o\.'4~. b~.@n. :~~ DUring :-pregn ~ty, ca.rqiovascu],az si.rrgeiy: is
.~do.ie#.i;t~!#tpr..v~nt aecl.~~n:w ~-=1~ :pe~?~~Y. . In.Qr:e li~ge:ro\!-'~ invqlviilg a 6 _pe.rcent .Ijsk of
~~.\l,;l'pr~cie~ :ui wq~en. With:cqhge~t:a} niat~rnal m;ort:.a)Jty anP, a 3o p-ercent risk of fetal
heart: :.tfi~li-se. <totme'eling '.ha$ to :adat:ess how mortality, . .
.
. p.e~ey~~ay:ied::?,otJcQs~~e~~tpet:b~tejs.o
'the te6.is:a:n..a. the: testottlie fa.J1l.UY. T:ne.~uriseli.rig -Ri~~ c~i b:e styatifi~d .aceordi~g .tti the 1,1.a:tur
$<;fJld: .i~edrri~ ,p_ipvirGi'ea ui',~09mt 'Clime -~y ,~ of the ~dia~les'ion artd. matemarJactors. (Table
56.5) . . ' .
o l:i'Stetriciim With, ~rttse m hea:rtdisease '<d~a
c.~rdiologist with ~p~cial t r.:aining in adult
ANTEPARTUM ~i:ANAGEMENT
.c~nl.~e:$.t:il ~e Cl;isease.
Limitation of phys.ical activity ..is helpfut- in
'Table 51L3. :Counseling of wom~n of reproductive age viith severely a'ffected worr:te'n with :ventricular
congei:),itafhearl4ista~. dysf\:fn~tion;left heart obstructibn, 'ot Class III. or
IV symptoms. Hospital 'admission .by mid..:second'
Wcmen shoUld be,given infor:roation <>n triines'tet '!;nay be
advisable-for some.
Matem!lland.fetal morbidity and mortality. ~ssoci'ated _., ..
with pregnancy .Be.ta~blockers rather thl3-11 digoxin should be
Ris~of-teqUrcnce.of coqgeriital heart. di.sease'in fh.e use'd ~to contr01. he.ar.t ..ra_t~ for patients. v.:jth
off~P.!)ng . ~ 11. -
Maternal life expectancy. . . : fu.nctio:n<U.Ly significant m~qal stenos.1s. Empmc.
L~vd . of aurieillance, neeif ..for treatment, .a nd therapy wi.t:h .be~a-plocj.<:ers -is offered to patients
~ntidpated.hospita.lization:requi.r:ed-during pregnancy . with coatdation ; marfan syncliome and as~ending
... Contraception .. .

Scanned ev: c
::\nrtnn.,.thv for other reasons. ..
r
~ --------------~~~C~~~~R-OO-:~C~A~R~D~IO~V.~~~C7.U7.LA~
~R~D~IS~ . -.-..
- EA~$=Es~-.------------------
~~. ----~----------------~--------------~--------~------------------~--~~~---
861 .

lZ Table 56.4. N~w York A:ssoci:at;ion fql)ctional classification Arrhythmias Should be Treated if Warra!:lt~d
i of heart fa,ilure.
} Premature atria.l or ventricular beats are
t> Class I;_ Uncompromised
common in normal pregna.11cy, and in'patients with
Patients with cardiac disease but v:jthout resulting preexisting arrhythmias.
limitations ~r physical ac;~Vity. Oit)a:Iy physica} acthity
does riot cause fatigue, palpitations., dyspn~a or anginal '
pain. Pharmacologic treatment is usually reserved
for patients with severe symptoms or when
f:. Cla.ss u ... SlighUy compromised sustained episodes ate poorly tolerated in the
Patients with ~anliac diseau -r-esulting in slight presence Of structurp.l abnormalities; Sustained
ljmit:ation ~physi~ actMl;y. ~eyare-coo~le atr.esL tachyarrhytlunias such as atrial ilutt'!r or atrial
QrdiJ)ary physic:al.a~;:ti'<jty :results in .fatigue, palpitatio~s, fibrillation should be treated promptly.
dn,pnea ~- a.ngi,(lal. paili...
Ifpossible, all antiarrhythmicdrugs should be
. Chss m- Markedly CQmpro::ni$ed
avoided during ,t he first trimester and those known
Patienfs with cardiac disease tesulting in marked to be teratogenic should be a voided throughout
limi~n of ppy&cal ~ctivity. They<$e comfortable at rest.
. Lei>s t han onlln.ary pbyi>it:al a(:tivity ~nlts in fatigue, pregnancy.
pelp!t,at;ions, dyspnea or ~gina!~-
~- Anticoagulation Therapy
{;;.
r.
z . ~>a\;ieD.ts- . ~wtth. c.ardiae disease ~tm._g ~en inability No currerit strategy is equally safe for both
r
'!-~
to> can'Y O!i : ~Y physical f!.Ctiyi!;y Without dil!co.Illfort.
.SymptolnSot~cmsu:fliciencymayC':'en be preseni: at
mother and fetUs. .. ..
.~ ,1 :-.. .. j;f-.'~;:;!~~:: ~~;;-.

: -~: . .- ~~~;::i.~" .j
l: res.t. lf at).y plly$}el iti;;tiYity :is un'dertaken, disComfortis
. .
. . More recent guidelines recom,m_~.ll~Jmec, ...
l~ in.~e;~
adjusted-dose heparin during th~ . .ent'ffe
~~~
....;_:;, pregnancy or.adjqst;e4-dose heparit1untiHhe 13th .
(
w~k of gestation~ waii.ariri from the_,J4th,..w.~.ek,.,
:: Table:SG.:S. :nt~.g .cafitiova$C\ilat-riskin pregnancy.. .
~~ - . -.:.,~:1~1... . . .. . . to~e~d<Ue of.~e .~n-;.)D.ester ~d;lli~~~~~;_, .
adJusted..dose h~pmm. ,.;:..
~; Low"riskf~bii:es
~}.- SJn.allleHo.-tit}lt$hunt . : ,;::,. ...

~ ~~~PE~~@9.~~~~~~~C: !i.Y:>~s.9on Mos.t cot;imibtt!J: used cardiovascular drugs for

'~ I_~la~~~ val!~ .flroh'i~~~ without si~~~t pa.!\:~~~~lliJi~~~s~~s-~~ffi~~p_ii<iD~~a.n-d
regtuJitation . expose the fetus to their pl'!.armacolqgic effects .
Bicuspid IU)rtic valve Without s~oilis
~ Mild to moderate ptilmo'('...alystenosis .
Some drugs also enter breast milk and may axTect
~ '
!.'
~- Valvulaqegurgitationwithnoanal ventricular systolic . the neonate and infant. Although many dru.gs
fu.nctioc routinely used in pregnancy are rela.tively safe,
. . tho benefits and risks for mother and fetus have
Intermedlid~.-'.Sk feattires to be weighed carefully. (Table 56.6}
Untepaired or p~ted cyanotic congenital }:leart
. disease
Lirrge left-to-.r ight shunt Perlpartum Management
UncoiTected coarctation of the aorta
. Mitral stenosis Cesarean section is indicated only for the following.
,. Moderate.iwrtic stenosis conditions:
.Prosthetic :valve
Severe pQhnonacy at(mosis . Aortic dissection
. Mo,derate~fo-severe :systemic ventricular dysfunction
Marfan syndrome with dilated aortic root
High-risk features
Ne:w York'H~art Association c la$s III ortv symptoms Taking warfarin within 2 weeks of labor
Markedly liinited pby-Sieal activity.or unable to perform
any physical activity'Without symptoms .P retenn induction is uncommon. However
Significant pulmonary hype,rtension
once fetal lung maturity is 8,ssured, a planned
.Marfan_syndrome with aortic root or major valvular
involvement induction and deliver:}r maybe warrant~d for .high-
Eisenmenger syndrome risk patients -to ensure that appropriate staff and
Severe aortic stenosis equipment are available.

Seanned lly: C
 862 SECTI<?N X:. MEDJCAl SURGICAL AND ..REPR0DUCTIVE .ILLNESS~S
.. .
AFFECTING PREGNANCY
.

Table 5{;.6. Safety profik:~ 'ofeardiac .dnigsin pregfui.ncy. not recommend .routin~ endocarditis pr.ophy1C\Xis
for cesarean section delivezy ,or fox: uricomplicated.
The lowest p<:>ssible effective dose should be used, and a
s~gle drug regimen sbou:ld be -aimed for.
va,girial delivery without infec~n.. Howe.v~r, some
centers-do lidmi.nister endocarditis prophytarls-f~r
Relatively safe vagirul.l dellve-zy in women with structural heart .
Adenosine . disease. as an 1.mcomplicated. deliv.ery ca'."lilot
Amiloride always be .a nticipated.
. B-bloc:1:rs - Close monitoring is essential because
they;m{!.y-1;!1fect.fetal ~~.may blunt the
reW.heaJ;t ~te>~nse under hypoXiC co:q.dl$ta Pain c ontrol should be offered with epidUrar
caicium. channtJ. blOcic~ anesthesia ~d adequate volUn:).e pre-1oading. The .
~ -~ Use Of epl_dura1 fentanyl .i~ -reco.m~ended fot
F1ecainide cyanotic patien:t~ With shunt lesions -or. significant
~-;; ;. Hepa.ri!!
.aortic stenosis because it does n ot lower
uo:ocaine peripheral vascular res~stance..
- M~el;ine -.
PrOcainatnid,~
~e The prl,ndple is .t<?, m~~ ::i:h:-! s~ of~bvr
insuch a way ~fit does not e-..xcced the woman's
No~ :s:afe capacity to co~ with it.
Angiot=p.sin <;OilVerti.ng';.:Cnzym.e ?inb.ibitoi.l!t.
an&t9tensin U re~t-or antag~~ists - Risk--o.f
n~D:ll.~ r~!:\1 Uill~ at_:1d ! typ6tension, renal Positioning fu~ patientort'iefUateral deeitbitU~
tubWm'.dySgc::netli3 .mt:raUtedne gr-owth :re..-tricti<>n. :P(>sit!en leS:Sensthe h ettr.ody.na:iniC fluctuations
:~=~~;~ct~f~~;:I~O~~e$; as:>~i!it~<i -v:1ili: contrattion~ -wben the _pa~ent i-s .
.supme.
of .t;he .~:C:irtral.:n:~u:~ !-8Y~tem,.'_, intraC:z:-:...nial
h~'fi~e:. . . . ... ..
Nfii~4-ato'h;e . .,. .o ~at. :\:>.~.::u.~ied ln :~~~ia:.l F~rceps or vacu~-m extracti~m should- be .
. -~~~_-but. .~.-9~ '~~rl}~iqi.srit and' COJ;isidered ~t-the end :o f the :S ecimd stage oflabor
. . . ~tC:nt:fu,m>tiUP~~~ .:..: : : :. to shorten and ease deliverv
?~.ri.Y:t~im:--' ~,6r:hearf'.:d-etect8 !Jn'trautenne. . - ..:

::r!t.Es~..i~E . p~~..fum Manai~m~t

:..._.;..-

S,p~ti:i:i.'~:i~eti~:ne:-~e.d~: Epll~(}nde. is
- '; --.. r:

.- '.};3~us~- P,bp:cd:j:nami~ .. dcfes not'.t~~rri-to

P.~~~le._ _-. . : .. .. . .. ba~lin-e formany days after delivery. pan~ilts at.
"!
-:_:;. :.._ ._.;._ :.-.::::-~ .. -~ ;_ ..; , . . . :~: . .. .1~ .. ..:.- . : :_. m:~r.D.ediate o r high.nsk.mayreqt.Ure m o:o,it9ring.
.,
!. ,. . . .
.... :. ..
.
~ '.: ~, . . . . . . :
. st 72 hours' ;rv:.s
for a_t lea 'Y '"'
_'t>:'<>;,+:n>:n
~\,.:~
_. ..:
. . '. '7 . . . : . . . . . :' . . . . . . J :-':~ : : :

llemodyruimlc .~t>ttito_rt..n,g ..... .. ~'_::; .. =~::.:. . . . .. .

\.' - . . ;: ."" . . :.. . . . .. . ...... . .-:.-. P~tients with Eise nmenget synaron::ieare at .
. .No c~ni~~b.-suiS ~i'stS- ..-~lh :~si~g itrYaslve: risk of 'death. for up to 7 d-ays postpart'4m thus.
hemodyna~ic )P:o,J:litp:ring .d\.lrlQ,g hi.o.o:r ~'nd. _-req~i:tiil:g 'l.onger cbservati~Ii.
.de iive_rj. ...lri(r:a'"aftyri~ :J;UO~torlh g.or .-:cep:tnu
venous pressure
;mo:citpiifig..is:use(f.in'inte.r-Pietib.g SUMMARY
sudcJ.~n dropJn.'eystetillc .. bloo<f pre:ssure.'. ..:. ... .' ..
~ ,. ~
Altl\oUgh pregnancy c.an P9se subst.ari.ti.al'rl~ks.
.. ' 0 ,

Heparjn . . a~tic~a,gulation s hould he for women with . heart 4isease,

. it remains.
. . -feasib
. le
discontin11ed -at ~east 12 hours before induction, for .most with suitable med~cal support. Pre-
qr reversed W:itP. pro~ne if spontaneous labor pregnap.cy co~seling and multidisciplinarY' care
develops. It is u~~a1ly resuttled 6 to 12 hours including . c a rdiolo gists, obstetricians and
pos tpitUnl. an-esthesiologists. are ,es~.n.tial to h elp these
women have -their owrvchildreri .at the minunal
Antibiotic _prqphylaxis f<Jr endocarditis is .not . po$sible risk.a11d thus: allow: them.. to reach .their-
routint. Americarr life's full potenti~:
. : . Heart . Asso. c iation gu-idelines do
. . .. . . .

.
Scanned 8y: r-.
~
 7
'-~~~~~~~~~~~~~~~~~~~C~HA-._~P-: : TE_- R.=-56~-: =c-~A-R=-:D~I0-V.~;-:S~C: -:U:L.A-_.:R~=o_I: : S-"'EA~_s~E:S~~~~~~~~~~~~~~~~~~~~-8-613
.... ......

1
-~ . POINTS TO REMEMBER -~~~.
Heart disease compliC8tes 1 to 2 percent of pregnantwomen and stilt remains as significant cause of
. rr~atema.L tnrbldlty and indirect cause of maternal mortality.
tl There are signs and symptoms of physiologic changes ir. pregnancy that may mimic those with

;
fi:
,,,_ cardiac diseases.
~
The cllriical .manif~station i3nd-management of congenital heart distmses with valvular defects during

I. -~::
<
pregnancy d~pends on the degree Qf outflow tract :Obs~ction and level of cardiac decompensation.
Mitral stenosls is the most common rheumatic valVular lesion in pregnancy. Most women with mitral

I
~--
:~;
?
stenosis ~o undergo vaginal delivery with -epldural anesthesia unless obstetrically contraindicated.
Recommended manner Is vaginal outlet forceps extraction. Intrapartum endocarditis prophylaxis is
required.
Pelipartum cardiomyopathy is defined clinically as .the onset of cardiac failure with no identifiable
cause in the last month of pregnancy or within 5 months after delivery, in t'le absence of heart
disease before the last month of pregnancy.
lsch':::mic-.heart disease in -pregnancy is uncommon but if myocardial ~nfarction occurs within .two
weeks of. labor :and delivery, mortality may be a~ high as 45 percent
T,~e -clinical approach to ,a gravidocardiac is comprehensiv.e: risk stratification, prc-pr.egn.ancy<<.
councseling, antep~rtum man.agement, multidisciplinary care, peripartum management. ~ alid'
consideration of recurrence of cor>,genital :lesion in fue .neonate. ,,.: :-:;:-i ''~;,,'

.~ES 7. Ray P, Murpby .G J ana :ShuttLE. R~cognia~tand~

1. Siu S, Cob:pa.n JM. CSJdiovascular problems and
p~gmmrr. ~ ..!lPR~~ J<?.:~~~ent. ~leveland
. C)inJ-Med 2004t 71:977-984.
2. Cun~gham FG., Gant NF, ~eno KJ, Gilstrap LC,
Hauth JC, Wenstrom iffi. (editors); Williams Obstetric~.
22nd edition, 2005, Me Graw H,ill Medical Publishing
Division, 1017-1041.
3. Baja-Panlilio .H, Vmanueva-Gutierrez R, Pagtakban-
LUnaL, Negre:-ParejaM,:RamoeMMJr., S:umpai~ w_s.
(eds): Textboo~ of Obstetrics. 2nd cdition. Quc:=on City:
Associa tion of Writers of Philippine Textbooks of
Obs tetrics and Gynecology, 2002; 571-581.
.managerneQt of ma ternal caz:diac disea~itt~gr:lancy.!':~
BrJ Anestb'2 004;93: 428-439. -. .- ...
8. Avua-ws~lloSSi Eq, Rariiiies JA, et aL ftttnancy iri
pii.tie!l.fS With heart clisease: aperlence with 1,000
cases.CJinCardiol2003; 26:135-142.
9. Silv~des CK, Colman JM, Sermer M, Farine D, Siu
SC. E-ru-ly -and int-ermediate-term outcomes of
pregx).ancyWith CQogenit!:ll aortic stenosis. A:m J Card.iol
2003; 9 .1: 1386"1389.
10. Autore-C . Conte l.:{R, Piccininno M, et al. Risk associated
with pregnaneyJn hypertrophic cardiomyopathy. jAm
Coil Cardio12002; 40: 1864-1869.

. 4. Siu SC, Colman JM, Sorensen S, Sm?Jhom JF,Fari.ne 11. Tsui BC, Steward B, Fitzmaurice A, Williams R. Cardiac
... . .. D, Amankw.ah JC:3, et 8.L Adverse neonaUil and cardia-c arrest anti m~ infarction induced by postpartum
outcomes are more COmmon in pregnant women with intravenous ergonovine administration. Anesthesiology
cardiac disease. Circulation 2002; 10.5: 2179-2184. 2001; 94: 363-364.

5. Tqsk FQrce on
th~ Man~~emer1t of. Cardiovascular
J:?isea.Se D~g Pregnancy of theEuropean Society of
Cardiology. Expert con-sensus document on
management of cardiov!lscular diseases during
pregnancy. EurHeartJ 2003; ~4: 761-781.
6. Uebing A.. Steer PJ, Yentis SM.Gatzoulis MA. Pregnancy
and congenital heart disease. J3r Med J 2006; 332: 401-
406.
12. Yacoub A, Martel MJ. Pregnancy with primary
dilated cardiomyopa thy. Obstet Gynecol2002; 99:
928-930. .
.........
13. Hyett J, Perdu M; Sharland G, Snijders R, 'Nicolaides
KH. Using fetal nuchal translucency to screeifitor major
congeniW cardiac defects a t 10-14 weeks Q( gestation: .
population based cohort study. BMJ 1999; .318: 81-
85. .

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~
864 SECTIQf'l X: MEDICAL, SURGICAL .AND -~EPROOUCTIVE ILLNESSES AFFECTING PREGNANCY ~....-..
.-:

14. Qa.sqas SA, McPherson C, Frishman WH, Elkayam U.
Cardiovascular pharmacotherapeuti<:: considerations
during pregnancy and lactation. Card.iol Rev 2004; 12:
240-261.
15. Bates SM, Greer lA, Hirsh J, Ginsberg .JS. Use of .
antithrombQtic agents-during pregnancy; the Seventh
ACCP Conference on Antithrombotic and Thrombolytic
There.py. Chest 2004; 126: 627-644.
17. Hameed A. Karaalp IS, Tummala PP, et al. The effect of
valvular heart diseaseon .maternal and fetal outcome
of pregnancy. JAm Coll Cardiol2001; 37: 893-899.
18. Pearson oo, Veille JC, Rahimtoola s. et:al. Peripartum
cardiomyopathy; National Heart, Lung, a.."ld Blc::;d:
Institute and Office of Rare Diseases (National Institutes
of Health} workshop -recomm~ndations and reView.
JAMA 2000; 1183-1188.

16. l.,uton M, {)tengNtiin E, Ayida G, Steer PJ. Ca,rdiac 19. 8eauchesne'LM, Connolly HM, AmmashNM, Warnes
disease in pregnancy. CUrr Opin Obstet Gynecol2002; or
CA. Coarctation the aorta; outcome of pregnancy. J
14: 137-143. .Am Coll Cardlo120(>1; 38; 1728-1733.

..

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 57

PULMONARY DISORDERS

PATRICK 'GERARD L. MORAL, MD

JUDITH M. SISON, MD

Dyspnea and Physiologic Respiratory Changes in Pregnancy

Asthma
Diagnosis
Treatment
Disea.s e Severity and Treatment Options
Labor .a nd Asthma
Bacterial Pneumonia
Predisposing Factors
Etiology .
Clinical Presentation and Diagnostics
Medical Management
Aspiration Pneumonia
Predisposiog Factors
cnm~r~urse andPnatmacologicar Management
Tuberculosis
Clinical Presentation and Diagnosis
Management
Pulmonary Embolism
Pathophysiology
Clinical Presentation and Diagnosis
Treatment
Other Respiratory Disorders
Amniotic Fluid Emboiism
Clinical Presentation and Diagnosis
Management
Obstructive Sleep Apnea
Tobacco Dependence
Brief Intervention
Pharmacotherapy
Vaccination

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 SECT10N X: MEPlCAL, SURGICAL AND REPRODUCTIVE
. . . ILLNESSES AFFECTING PREGNANCY (~

' . .

.. :DYSPNEA AND PHYSIOLOGIC RESPIRATORY particularly at night or in the early momi.ng.3:

:cHANGES IN PREGNANCY Th~se episodes a;re. usually associated ,'Yith
widespread, but variable, airflow obstruttlori
.Pregnancy .brir_gs about physiologic chai)ges witl).in the lung that is often reversible eithe~
. that .:bring out symptoms attributable to the s pontaneously or with treatment: It has !>en
tesplfatory system. Adequate appreciation of these estimated that approximately 4 to 8%: of
:g }terations allows the clinician to di:fferenti.at~ the pr~gnancies may be complicated by broncl:Ual
. non:n.al from the ill pregnant patient. ast4ma. T~e rule of thirds may be applied to
; pregnancy b that one-third of the women will.have
, . . .. .In .the fi,tst trimester -of pregnancy., the tidal. a worsening of their asthma, a third will get bett~r.,
:. .. :yol*me i:ru;l'ea,ses, whiJ;e:;the ,n~$pit-a,~a:cy ra~.e 'and thi! rem~iq.g _ thircl.: Will -rem.ain unchanged.
;~:f.:te'lafrveiy :undlaligd. 'fhisir.es)irt~' in~ ... If:iheastlip:l.a r:~m~~ ~eve:rely uncOntrolled, this
.. f:elatfy.e..fi}'per.rentila'tion; 20 tO 4'0~ .~hOVe may ~ a~Sociated with in'creased .prematurity,
'~1fue with the niimjte ventilation increasing cesarean deliveries, preeclamp-sia, growth .
\ :up.w 48 percent by term. The arterial blood gas retardation, other p erinatal complications, and
'''i~~ct~ the$e ;changes with .a resting arterial matemaJ morbidity and mortality.
.~~n .dioxide tension. (P\:02 ) fu:opping below 35
. , rd,fJli$.~. partially. cvmpensated for by increased 'The mechanisms responsible (or the alterd
: ~ : .C.~~:fiif;atbon~.te excretion .{ 18 to 21 mmolfL-}. asthma course during p:r.egn~cy are Jlndea:i-.
- , (~. :ha~ been, descriJ;Ie.d as th.e "dyspnea -of There are muitiple biochemical and physiol~gr .
.... ".. ~cy" .andha~ been ascribed -to the increase changes during pregruillo/ that may poten~y
' -.mj)ev~;la t>f p,:oges~erpne from the. p4!.~nta, that improve ot exacerbate .gestational asth.ma. 'I;'he.
.. r .:,?.tltnlllB!t'e-s::tb.ce~ c~nttal::..r.t_:s,p.ira.tory.'n:~en:t~r.' . , .. increasect'.pr ogesterone)evel;:has,;.been postqJated:". , ..
. ... 1\ppt,o:#ma:telY.Q9.:p~r~nt ofwomeamay;~mplain;,, to. increase, PG.-28, suppr.essi:hg..~ta2-r'!ceptors,.. . .
,c)f:pltjs;ologic cl,y;spnea with exerfhm while .20 and increasing sens~~ty or. adenosine receptors,
. . : : .-~~may ~rience it even.at rest. 1 which may exacerbate asthm~-.jf~rinonal effects
. . . ~Y affect.:inun~.me functions. as deereased natural:'
. . ,.~~n.itcomesto~matemal .oxygenation; .total . kiiier ,{NK). cel~s phagocyt:{c acti~ity and:
. :(;-of;l:~p}:io:n:._.an:4;ic,~saLm.e.tahoHc~.rate';aiso:- -'..:.. cytbtoxicity, together~With sup.'piession:,of cellUlar, .. ..
..~P:~~~ .;l)y: .20 % ~and 1-5~; .a:c;co.unti11g for inu:tl~e fu.hctions,:qecteased rel~.ofinterler~1,1;. '
. . -~:~~ ma_!~~~. ~~~;t~~~~~i~~7-~~..!~~ .~!!.~Pi~~ t<EYF.4.;Tl;l2JmroJm.~_:r~P.Qrt,s.e (I_k4,.::?-)~,:
. _;,_TO~O,!l .:':'!~~g? ~-il~ h~~~~<l :m~~Q~;.q~r: c.v:~r Tb.A .(lk.;L., .1i..J ..<Wd l~F).,.. which ..may explam.
. ..:~Q:ei'l::t)1e .: patient assl).es a supjne po.s 1tioh. In exacerba,tions at thne of labor. . .
.. ..~~ .Q-f pulmonary f~ction, changes that may ~.-
. . ~~n ::py t<tr.in mclude: a decrease L'l. Tesidual 'Diagnostics
:~Oi'liW~ JU.nctiot!.al resi4u.al 6apacity, e,XpitatDcy
. ~r!:~iv.e .vqlurne, filld tot:;~.l lung capacity,i an The clinical asses.sn1ent of asthma sho1.;tld
.'i~#:e:~s~ in i.n:spiratpry c:;~.p.9.ccity; :and an employ ,both su:bjective evaluations and
. . ~n#l:{~ged vita,! capacity or forte'd exp.i r-atory . pulmonary function .testing. Thisa pplies even t'ci
, -~;t,\wl.e in 1 se<::en4 :<FEVI:). Iti.ge.neral; h.oweyer, :wo.m.e n with iniiQ. O'rwell-c.otttt:oiled disease
' . .ihe:~m.tnon..clip.ital measurem~nts ofpulmonary because pulmonary function a:ndasthma se~eritY
.,fJ..1l:i;e#5:>.n suth as respiratory .rate or FEV 1, do not. may chang~ .during the cour$e of pregnancy. .
. .. 0h@-g~withpregnancy, so any alterations in these Spir9metry i s the prefe!Ted method for pulm.oD.p..rj.:
s'h:9illci. he considered as abnormal and treat<!.d as fup.ction testing during outpatient visits: In
:suc!h, situations wh~re testing is unavailable p'e?-k..
expiratory flow measurement w;th a peak flow
AS'rHMA
. . . '1.
m eter may suffice. Ultrasound and antenatal fetaJ
. testing should be considered for women w~th.:
.' :Bf,~mdiial asthma has been defined by the moderate or severe asthm.a. dupng pregnancy.~. .
. .G~ballnitiative on Asthma (GINA) as. a chronic
.: ' ~lnn;i.mffiatory disorder of the aitways, whlc.h is Treatment
: -associated with airway hyp~et:i-esponsiveness that
.... ,:r";Sults in recurrent episode.s of ~heezirig, During p regn ancy, it is safer for w~men With /.
breathlessness, chest tightness, and couih.ing, a s thma to be treated with asthma medications

. Scanned 8y: C

than to have asthma symptoms and exacerbations.
The main goal of astlu:Ua treatment is to maintain
sufficient oxygimation. of the fetus by preventing
hypoxic episodes in the mother. 5 The step-care
the.mpeutic approa~h .e ntails increasing both the.
number and dosage of medications as ast.Juna
severity increases. Salbutamol is the recom-
mended rescue :nedica.tion. In cases of persistent
asthma. budesonide is the preferred inhaled
corticosteroid.
Asthma self-management skills can increase
ast.hma control. These incl:ud.c self-monitonng,
information coneern.L.-rg cctrect use of inhalers,
agr~ement with a plan fo.r long-term asthina
manageinent, and promptly addressing signs of
deteriorating asthma. Maternal well-being can
likewise be improved, with less need .for
medication, by identifying and controlling or
...,avoiding exp,o sure to irritants, allergens .and
to~cco: .smok~.
~; Q>ntinuiiig im.m1U1otherapy is recommended
forwcmeri\~:ho ~at -orn~ a maintenance dose,
who .are n ot having advers~ reactions to the
iiJ.J.~UoPJt; ai:.d.who .s eem -to be deriving .clinical
benefit. ...
...1. .. ' ; . ...,._ .
Di~e~e-:severlty and
Mild intermittent asthm..a : Salbut:.amol should
-be-1iiveri-as' -needed-, -With no-regular'daily
mecijca'ti()ns.
Mild .p ersistent .asth~a: First-line therapy
inclu~es a
low"dose inhaled corticosteroid.
Alte.rnative treatments sugg~sted are
-crotnolyn, ~ leukotriene receptor antagonist,
,or theQphylline to a wget serum level df 5 to
12pgjmL.
:Moderate p:er sistent a:;thm.a: First-lirte
tli.erap.ies include a low-dose inhaled
corticosteroid and -sahne~rol or II:ledium-dose
inhaled cortfcostetoid or medium-dose inhaled
cor~it:osteroid and sahneterol if needed.
Alternative regimens make use of a low-dose
or medium-dose (if needed) inhaled
corticosteroid with either a 'leukotriene
. receptpr antag~nis.t theophylline to a target
serum level of. 5 to 12 J.tg/mL.
Severe persistent asthma: Preferred treatment
is a . high-(t~se i"haled 'corticosteroid and
salnleteroi, .a nd oral corticosteroids if needed.
Alternative regimen include a high-~l'ose.
inhaled corticosteroid a nd theophylline to a
CHAPTER 57: PULMONARY DISORDERS
.....
target serum level of 5 to 12 JJg/ mL, plUs an
oral corticosteroid if needed.6
Labor and Asthma
Philippine Obstetrical and Gynecological Society (POGS) .
Accredited Hospitals: 1457
.Asthma in Pregnancy
Year 2005-2006
Year 2005 Year 2006
Bro:1dlialAsuuna in Remission 1464 1284
Acute AsthtnaQ9 Attack 499 397 '
(POGS Statistics)
The p.a tient's reg,u larly p rogrammed asthma
medications should be centir.ued during labor and
delivery. The.patient's 'Peak.ExpiratoryFlow .Rate
(PEFR) should be taken uj,on ad.1'liission,to delMhy
and :monitored as .l1'tbo.r -progresses.:;Altlli1:tlgh
asthma .is often quie$~ent durip.g . la:bbi!1~)1~ '
delivery, if s.ymptoms develop, ~EFR shourd ibe
monitor-e4 after .. asthma .:treatm~nts;.. Adequate .
hydration must be provided and . suffi~ient
analgesia e.asured to limi~ the. ri.S'k\'~'i6f"
Tr~atinent Options broncho&pasltl.- Chromesystemic cortico8t~i-9fds
during pregnancy .should alert the physi~''io .
st~ f.i.YA~Qrti$)ne -tP address possible Adrenal =
suppre~ion; -N-arc11tic--a1'1atge-gics th'a't " p~t&au-ce
histiiiiliile eiease s}iotild be .avoided.
Bacterial Pneumonia
The physician shou.ld be. vigilant to any
pregnant woman repOrting cough, phlegm, nasal
congestion or discharge, Q.r shortness or breath.
This last. symptom is a con{ounding factor because
dyspnea. as me-n~ioned earlier, may be physiologic
and is often normal in pregnancy. The physician
ne<::ds to sus4-in a high index of suspicion for any
pull!lQ!1a!}' pathology l.n the pr~gnant womart.
Medical attention is often not sought as the worn~
expects shortness of breath resulting from the
pregn a ncy, when in reality, this may signify
or pneumonia or some other disease process:
All .. of. th~ large stud~~s of p.n~urir~ a in
pregnancy' describe considerabte:~~fetal
complications, with the .majority of:' po.O't fetal
outcomes occurring ill mothers with underlying.
co~ morbidities, such as ch.ro'n ic lung 'dis ease . .
Seanned 8y: ~
86$ SECTION X: MEDICAL. SURGICALANO REPROOUC'fNE .ILLNESSES AFFECTING PREGNANCY

Although no congenital syndrome has been pneumoooccus and H. in]luenzae, superinfection

ascribed to the presence of antepartum
pneumonia, the fever, tachypnea, artd hypoxemia
associated with acute .p neumonia may be harmful
to the devel()ping fetus. The uterine response to
certain mediators of infection and inflammation
results in a high ra;te ofpreterm la:bor. 8
is most commonly due to invasion by
StaphylOc:occus aureu.s and gram-negative bacteria.
Gram-negati'Ve . infection$ predomina,te in
nosocomial pneumonia, while aspiration.
pneumonia involvesanaer-at>es O!l top of the gram-
negative organis!lls.

Predispo&ing Factors CUni~ Presentation and Diagnostics

A number of ana1:omic t:hanges take plac e in The clinical presentation of pneumonia as a

the chest during pregnancy, including outw:ard
flaring of the lowe;:- rib$, an inctease in the
. su~~sta:t angle, and an increased transverse
diameter of the chest. The dll).phtagm atso rises
by 4cm. These alterations reduce the ability of
the pregnant woman to expectora te. Functional
residual capaci~y lFRC) decre.a ses with the
e1evationofthediaphmgm... Theiiicrease.i,noxygen
consumption.that, o.CC\J,TS during pregnancy
triad of cough, fever and qyspnea in pregno.ncy
does net differ from a non-pregnant .P;'\tient. When
complications :-Qf pt)emnonia do develop in
the
prgnan~ patient, they usually are a consequence
of delayed diagnQsis.
lmag.ng ~dies such as a chest radiograph
are ne.e d.ed to -m -a ke the d i awosis. When
considering the use ofx-ray the effect of radiation
I

cQ~po~n;l:s .. tbis.-diop <in .FRC, :te~ucin:g tbe on a -developi.q:g fetus is always . a major concern.
to
pregnant .p atient'$ 1;\bility tolerate ~\ten .the . . Develo.pment<:U anomalies and growth retardation
sbo'rte$t:.~O<l:rot.q:tx>Jda'J:.most-'especially -~ ~the~: .have, .been:$h~wn 'bY. ,s-tudi~~:;,.w i t h radiation .
tl;rlrd t.riblester;. ;A<$ .the '-~~pit?-totY .rate . should threshtilds_of }!5 rad; A tyPicalhest-x~raydelivers--
rewfui'<\hotnlhl:o uringpregnancy,.itis iirtportant a dose :well below this, between 30 and 1oo rad
th~~ : ap.y :!'Sigp. .of. ~~ypnea be c onsidered as and may~ ~-sed safely in pr~gnancy. Precautions
patb,ol()gi~. . incl~de appropriat~ly . shielding the pregnant .
> ,-.. .. .. . .. . patient.with .a lead aprOn during the procedure.
. A.~jo.~:tJ~~n.p~~pQsipg~ptefmanbw,ome'Il; \; -- .. . . .
to sevete.p~ewnonic:inf~ns -is:.ad~an;ge in :the: Medical Mana-gem~.,.t
jmm:'Utl'e ~tatus .. Cf,iant~s . ln cen:..m~diat~d
immu)nty,".1ilitrce WiiJ,--rungru;"and io~icu1~.u s T1}e~4.o1ceor;antii;>.1otlc.~e.rapyin th~pf~i
.irif~u9iis pa.fti~Y.t>i1h6gerti6 itt 'th'~se :~~brii;en. patient With pneumonia is dictated by. tl).e ietentical . J
Srudie.s, have .p~s-mt.d a ._n urilber of pregnancy~ . pripciple$ as .in the. non":pregnal'J:t ;patient- the
spedfic iinmune status altera tions, including-a presence o.r a:bsen~ of coexisting U1ne~s. illness .
decrea~ed lymphocyte proliferative response, $everlty at pre~entation., and -.s ite of beatment
dect~ase.d NK ell :ac-tiVity, and a dect:eased (inpatient or O\ltpatient). On top of efficacy and
a'bsal:ute humber of helper T4 ce.Us~ . Lyntphokine sarety, ad.:dtd ctmsiderations inclu<)e fetal
secretion and lymphoprp.Ufer~tive tesponses to toJdcities, teratogeniCity, and e:xcretion in breast
~oanti;g~s -~ay be blo.ck;ed by maternal serum. in deter-mining the appr-opriate choice of
In addition; fet.:U lymphocytes suppress T-:."cell antimicrobials.. .
proliferation. these . hnm~nologic adaptations
. prO:te~t ~e-:d~velopirtg.:fetus from its a_n:tigenkally A .p rime consideration in the choice of
dis~hDnar inother, thereby promo ting its growth antimicrobials fo.r the pregnant pa tient is the.
b:ut ironically iricteaslng maternal susceptibility saf~ty ofthe fetus. Penicillins, cephalospdrins, and
to -infection. mactolides are safe. Penicillins are only .SO%
protehFbound and can cross :the placenta to
Etiology achieve fetal conc~n:trations . that are therefore
50% Of maternal levels. The cephalosporins eros~
For pa.t ients with -an uncomplicated,. the pJacent:.a.less effectively-but also appear to have
COnUn\Ulfty-acquired pneumorua, pneUmococcus, no adverse effed -o n the. fetus. Tetracyclines
Hemophilus inflit,e'nzae, arid atypial agents, are however, may stain .and deform the fetal teeth.
the mos,t common pa:tho.g en$. When bacterial When given at any time dur.ing the pregilancy. In
pneullionia complicates influenza, in addition to addition, bony d eformities may develop with in

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,~ .
~- ----------~--~----C~HA~
- ~P=TE=R~57~:=P~U~LM~.?=_N~
. A~R~Y~07.1S~O~R~D~E~R~S----------------~---
.
:.(: .
m: utero exposure to tetracyclin.es. Sulfonamides
~; administered shortly befor.e delivery can cause
i
~-
fetal kernicterus, and the safety of trimethop.tim
is ,aa.}Q1oWf!.. Chloramphenicol in the fetus, as i.-"1
~-
~.;
the adult, can lead "to bone marrow suppression
and even aplastic anemia Use of chlorampherncol
near term may ;res-ult in an adverse drog reaction
known as gray o.aby syn.d rome: whiCh is
cham.cterized by a.Sll.en 8J1lY cyanosis, flaecidity,
and cardiovascular -collapse.
Ideally once a specific pathogen is id~ntified,
therapy directed at the t arget or-ganism can be
started ';,.,.... usually the etiologi~ agent q.t time of
ptest;n~tion is l,lnlcnown, forcing .the initial use
of -e mpiric trea tlllent. TJ:le decision to add a
macrolide in.thi$ inst;m~ is -based 9n clinical
suspicion of atypi~ in!ectit>p.
Amip.~gly~oside;l s h9lUd qnly be ~se(l if th.e re
is evidence of serious gr.9.m.;negativ.e i,iifettion,
because the risk :of ototoxicity to the fetus is
considerable. S.imllarly, vancorp.ycin way cause
fetal n ephrotoxicity and ototoxicity; therefore use
of this agent m~st he carefully considered . .Serum
levels may' be monitored with th~se agents. .
Supportive therapy of the pregnant patient
with pneumonia observes the usual principles:
hydtation, antipyretic therap_y, .and supplemental
oxygen. T.he goal of .o~gcm .therapy is more
~ggressiv~; n>.ainte~~ce of the arterial oxygen
tension great~r than 70mm Hg is critical ~cause
hypoxemia is less tolerated in the pregnant female.
As respiratory a lkalosis , is commonly seen in
Scanned 8y:
869
infectious prQGesses such as pneumonia, this may
lead to a reduction in Uterine blood flow. Work of
breathing must be decreased whenever possible
in . the. pregnant patient with pne.umonia,
mandating adequate oxygenation. Jf respirittory
f~ure ensues, requiri.t'lg mechanical ventllation,
close monitoring of both mother and fetus is
compulsory.
ASPIRATION PNEt)'MONIA.
Predisposing Factors
...
-~
Elevation of intragastric press ure due to .the
~ravid ut~rus, a relaxed gasfioe~opbageal
spb~ncter due to the circulating prcgesterone, and
de"layed gast:rtc empt"jing, predispoSe the. pregnant
woman to ~spiration. These physiologic f~.ctors.
together .. with "$edation . a nd analgesia
adn:Unistra~o.~ and vigorous abdomi,nai"'palpation
:during e:xaruination.s, signifi~tly intensify the
threat Of .aspiratiOn. -: :-:".;.;:_,~:! .:. . ~;.. ..
ClliUCal Couif>e_. anc1 ;P~~ologiC"-";.~;;;:;:;,:lf+:J .:
l'danagem~nt ' ;",, ...
i3ecau~e ~cid . a$piration is ~n jmp()rtant
c omplication of obstetriC anesthesia/'SODie~"for.ril.
of chemoprophylaxis is often given prehi>etaijv..e!y
to minimize the rislc. A$p;.rn_1;i.Qp m'tlie p~t
. patient~ usually occur in the labor toQm-aHhe
. "tifi.le'o! dell,ve~i~ ~p;~P.1i.a~1on "h1~1U~d~~ cba~~iia
present in the orophlUyn:X{Staphylococcus aureus, ..
gram-negatives or anaerobes}, liquid gastric
~ntents, or solilf particulate matter from the
stom.a ch. t)s~ally, pneumonia resultin:g frorti
l.>act~rial .aspini.tion occ.ur.s at least 24 .hoU.O.Safter
the .e vent ..Particulate matter, when aspirated, will
lea,d to acute bronchosj>a:sm, cough, and .C:yanosis:
Aspiration or gastric fiu.id .leads to a different set
of clinical consequel)ces, including tachypnea,
bronchospasm, pultnonary edema, hypotension
~d hypoxemia , appJ:OXirDately "6 to\ 8 ho\rrs aft er
the event. The pHO'fthe gastri~ fluid' is important,
with acid pneumonitis does not occur at a lower
pit -
The occurrence .of respiratory failure in the
postpartum period should always bring)~ a high
index of clinic"aJ suspicio~ of asBif.ation.
Supportive management is indicated, pJi@arily in
the form of supple~ental oxygen, bro.pchofulators,
~nd yentilatory support "if n eeded. Ir signs of
infection develop,. antimicrobial therapy covering
~
870 __ ___;;:
.,~:.__ ________________
SECTION X: MEDICAL, SURGICAL AND RtPROD.UCTIVE ILLNESSES AFFECTING PREGNANCY
~- -------~-----------

gram-negative~, iram-=positives, and. anaerobes in pregnancy wa s eluci dated ear.lier in the

mus t Qe initiated, .t hough not ali aspirations discussion of pneumonia.
proire~s t9 pneumonia .
Treatment
:p revention is the major thrust of . ..
management. Regional 'anesth~sia preferred is. Adherence to _TB treatment is a recognized
over general. If general ~nesthesia is mandated challnge in _pregnancy with the magnified :concern
then the patient must be on NPO for ~ full ~4: of the possible advers.e effects of-the medications
h9urs. AJ:rway prote&on is paramount .e ven with on .t he outcome of t he p re_gnancy' and on the
re~ona:l .:a nesthesia.. and ~ricciid :press1;1re and developing fetus. Symptoms such as n au:sea that
rap.id s equence induction mu.st accompany may~ attendant to medication use m ay confound .
endotracheal intubation. the clinicj.an as this symptom may also be related
to the :pr.egnap.cy.
. ..
First-:iine medications inClude -i soniazid,
Tuberculosis ('fB) z:e:mams the siXth leadir).g rifa:tnpitin, ethambutol, and py.ra.zinamide are
cau.~ e o{ o.rb~clity a..n~l i:no.r tality Jn . the ge:hera!ly considered . safe '. in p r egnancy .
Phi,lipp~~s.~ Tll,_e lticide~ce of pre.: -ec1ampsia, Streptomycin should n at be used, as there is an
va~ :Pl~g, . ~d eatly f.etil death has been increased ris~ of v!'!stibular ~r <:tuditory damage in
shown tP .be l)igber .in. ptegr..ru1,t w6men With .T:S . th,e fetp.s. .Iso!Xi~9. may cause ~sient elevatio;:ts
~an~in1..tho~ Wttho4t th~ .cliseaJ?e. There l:s ai~o in tt.Ul.sa.nllna;i~s ahd are .generilly .:ihnoeu:ous.
an increa~ed l!kelih6od Of h.a~ing :P:rt~'!liature Althb'\igh: it crosses the pl~GeP.tai ba.:rri.er, :no
infantS' with:-low t>ii:th.w~ights .and~A!?,b~~-.~~.s... . . tet,aipg~tii~. !'!{feats,ilaye been.i"epq*. .Pynd,oxineo.
Statisti~Y.:.~~_gfi~an.t:JJ:tcrea~e~. . in -~~?:natal.. sho\.lld.::pe ad~ed t6 ' any treatm'et1-t :~egil:lleri- that
morbtdity and, adverse' nip:ternal outeo'mes h<3:-ve', con.:tain.s i so niazid' . to .' prevent : neurot oxic: .
.bee!!.r.~ported.. Congenital tuberculosis; resUlung cond:l~~s-:such~as'perip~e~ riei.:lropathy and
.from4h~matei"nal transfer. of.mycobacteria from . optic:neuntis~ Ttetl.tinen:e-dtiration~:for,new TB
. . . .. ~. .. .. . .. : "" j . . \ , ;. . . . . ~ : ,I

th~(t:Jto.~~I'! -~9:: ,t!;te,S~tli~~--: ei then.. tlin~'!;l-gh:._ $e . , cases :"9 l*t.s.~: Iii<?nths; 'lith m:q: i:Jion fus:for the
;~J:iil!-9Bir~~b~;:l:>Yi:'~~B~t10:zi. ~~:-;e~J.).;t~_xn~,n.a~~d. U:i~~n~~ve._ph~~f{~a<lrttpl~ qrU:gthe~py:in highly.-
-~nw.o.;.:ts;rnr~'.h'~tis,~~~~~.fWith. ~hiih:mo~t.r; eri9-?il;\.i.c. ~p.i:~~e?. 'w.i~li :~iey.+fi,~~il-:~- .:p~~i~.t3,!!~~.
:~te.:~ ... : . . .. .. .. .. -~~ ~: Repeatsp'Q.tum AFa :st;ain-.;p:~ 'dom:. on.
t:~~--~~f:$&~: :ffiji!?,:~!i.. E1~'r.~r.~ :-.~2V.~g:t~~!lJ::e .
~~i;u;Iii'-~ese:nta~o~ ~4-n iagri:os is n).ai~tena.n~ p~se w hich employs'two (rifa:rp.picin.
plu's jsoQ:iazld)or three :d..-r.Ug ref;i.io.cn. Treatment
.: . .': Th~:rn.ostcotilm:<>~ 'symptom~,inciude chroiiii:: shptiH :nof oe. discontim.ied f.f. pr~gnangy ~
. c~~gh.~ -W:ejg~t lQ.s~. S:We.at and ;C~tll~, bo~y Or if diicoveiedaft~r "treatment initiati01;i..10
0
.
.:niruaise ~d, . _fever. A co_ 1.fgh df mo:t~ tp.a.--1 twq
. we:eks.shoul<il.alert the, diri;ici.~n-.to.the.pb~sibility It :has <be~n s how.t). .that treatl:;l:i~nt adherence
9 (.. 1;ub~t.~ulo.s}s~ A. siglliflca nt _per~eP:tig~ <if may be improve a.with the direc'tly- obser.Ved .
.:: Pr~i4~t : w.o~t;n may.l~e . asypfo!P:a;t~9. . .An tita_ttiient short-.ourse~(DOTS) :s trategy. Irr cases
~- _,iJi;l;poria;Pfili.inito .co-~sid~r is _th.at fall~r:e._'to gain where .thepa tien:t has had previou~ treatment or
:.=:~~~gll(jD.ay)~e th.~ o~y. <;:lUe t hat a di~gposis.cf has risks o f dr ug-re s i stance., specialty
. :r.e ... ';
'be :corts1G.i:'red.
should. :. .. . .
.. . . . . . : . consultq.tipn m;:ty be 'neeited :as 'treatment rna.y
employ .more or secon9.-line .agents, with longer
.... .sp~t:u.m:.!n.ic.roseopy remain~ tl_l~ test or choice durations.' . : .' ..
fdr the initial work--up for TB -symptomatic
,pa'9~nts, Paqents must b e encouraged to c9liect Pulmon~cy Embolism
thr-ee early m~HTiing sputum s~ples v;r~th at.lea st
two being po'sitive fo r the patient to be considered Veno;J.s thromboembolic disease (VTE) is a
sm~-posjt?.ve: ~putum-mdudion \Vithhype.r tonic 1ead1ngtau se: of morbidlty . an~kmortality dUring ..
(3%}.,$aline may be used in. Pi1Uents unable .to pregnancy..-VTE affects preg'nantcwomen-fi.ve.times ..
bdr:~,'g .~:p ~p.~t:u:l?- . TB cu+tur e ..a nd." th:est. more frequentiy .!:han nori..:pz:egnant women of
raclio~phy :ar.e recommended .for patien:ts who c f\ild b~aring ag~, and has 'b'~en r ep o rted to
are smear:
. negative.
. Th~ safety of chest.radiogr~phy
. complieate one in10 00 toone in 2000 -pregnancies.

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1 ' .
;
J,"W":
CHAPTER 57: PULMONARY DISORDERS 871

Risk factors forVrE. include rpatemal age over tachy pnea, tach ycardia, and palp itations-, . a re
35 years, parity:of three orgreater, weight over 165 normally present among pregnant women. These.
pounds (obesity), and a personal or fa:tnily history symptoms tend to increa s e .as the woman
of deep venous .t hrombosis :{DVT) or pu,lmonary approaches t erm and delivery. This makes the
embolism '(PE}. Several o~stetrical complications diagnos is of VfE on clinical grou.nds , which is
ha,,e also. bee n identified to be. associated With difficult -even in the n on-pregnant population, even
increased. ri::;.k of t..."lrombcembolism, including less rehable.
prolonged immobilization or
bed rest, instrument-
.asSisted or .stlrgical .d elivery, hemorrh~g~, and The diagnosis ofVfE durir:>.g p regnancy is often
sepSis. Recent studies have shown that fue risk hindered by an unwillingness t o expose e. pregnant
for Dvt is highest in the antepartum period, . with pati~nt to ionizing radiation. However, in most
..
r a relatively. even .d istribution throughout the ca:ses, the cUnka( benefit of objective tests t6
pregnanGy. However, the possibility .f or PE is coillttni or exclude suspected VTE .outweighs..- the
highest immediately following .delivery, especially risks as di~~ostic testing for VTE can
-'i?e safely
in 'the case of instrument-issisted or surgical perfott,ned ih pr egnancy, and therefore ihoukl. not
deliv~. be delayed. EJX':p<)$Ure of radiation d.oses of les$
than a totalof :5' rad (50,.000 ~croGy) has not been
Pathophysiology associated with s~~Can..t .risk of fetal inj:urj.
..
,f Although there are :r.eports that exposure .to
~- -P.rt;:g nancy i s. asso.ciated with a ionizing.t adiation durUig pregnancy. may in;:;:;ea3e.
hyperCC?a,gUlable state _-;lue to a combination of the I;e~tive risk:Of.cb.iidtumd. t:an~er, the-abso~ute .
t-
j ven~u~>~tisis anddclt:red levds of circ_ulda~g - risk Temain~ .remo_te.._ . . .
-cloUi~g ,_f~~~ors. urtng pr-egnanc y an -U.I.e
,. ,~_~_- :.~::..,"';--~':_-.:,1_,,."'::_~...:._ : ...
"~: _puerperi:u.m. Multiple dotting factors are ele~ated A pregn;;mt patient. wi,th symptoms-:-~~?,(~P,VT
.
& . '
in the 'blood du'r ing p.regna.ncy .and the . should unde rgo testing ..w.~th coinpres s;~.ve
. . o; ' . .. .... '"""':i. . ~

~ . pu~rium,~~~luding factorS I, II.~ Vl!-r VIII:_IX:. ultra$o:und.. ;er,impedance .plethysmob'.aphy~ D-

<.. 8.nd:)Cy!Vefs"offue(anticoagulan:_trJ>rotein-s; ootii dimer:.tests .should: ;not :be~:Sd indeAAfi~eq.#-:Y. to
f , ~ .. : ,. - t.,}"': ....r~-< ,;~r:,_
the nnboU..na arid total .kids. decline :with . assess .for DVf..du..Tlllg ..pregnancy a:s:the:'gtjtVJ.d
t'
';!
i:x;lcreasm~;~~stationf- although _protein. C ~ctivi~ stat~. ~ts.elf, : as. welJ, as. -!U~ny <>~~t;-~~'.ir-~~cal
~,.. .appears t~ .be same .. Pl~telet ..a:~hvatiO?l- . 1~. -copc!Jtiop.s, rn.<;~.Y' el.~~te D-4iJAer lev!!W<m'.\fue
.
f inerea~d. pe':lsibiy a.s .-p:ait .of :-fue .-acute :Phase ...absehce'.6tveho~~ iliroin.i>Oe.ID'b9t~m; iesillt-fug in
l- .response-:-FWnn generatibn-"Ismcrease<f':'an(f :..... arugn"tai.:s'e"poSiB.veE.te:"1n .aadiflolJ., -~' .~egati~e- -
t fibn.iiolyHc. aetrvlT:Y 'is.. -. iieci'eas e~I. m.'ost . prea:Iarv.;; -varur~T--t4~ -i5~clin1er..11as P:oi-:~e:n.
! sl.c1bst?.ntiaUy i.ri'th(; tbii:-d.'t;:r:il:U~te:r:.' ; . ?stab~he~ .. for .'pregn.a:n~ p~tients, .an:d in,a.y be
'J
. . . .. .. ;.: .. . , . .. .. . . ... diff~rertt from 'vhat .has been reported in non -
t...: 'nl,e'physi~ and honnonru- ch~ge~ as~atect . Prein:ant pa.tiei;,ts.
with pregnan<;y a lso" .c'ontribute ... tq th.e . .. .
hypercuagulability. Early in the f'rrst triniester, . . Dia gnostic tes~g for pulmonar}r eiabolis m
~1e.....-:ited .prog~sterori.e leve~s.. cause an i;J.creas.e iri shou4i! in.clude ~ .v~nt:iiation-perfusion (VQ) scan-
..~.i-<:nou~ 'diste'n~ibility-and capadt)r,..leading to : pr helical CT.: Bo.th-tests can
be performed safely
i~cr.easeci. s~asis_ Anatorrtieally, the enlarging . ~uring pr~~ai].q. If. VQ .'s c ~nni~g i~ 'U:~e d ;
uterus may :indue~ a s elect).,;e c6mpressive -ef,fect . . perfusion scan,ning' rca.y_.be used alorie-'frr~t, and
orithe common iliac vein: Theie-is.~on! significant a ventilation scan performed if a perfusioli defect
venous stasis in the left deep venous systecr. t.lui..'l is not dearly a PE. If CT and VQ scan do not
the right during pregnancy, due, in part, to the p rov ide sufficient . diagnos tic info~mati o n ,
right iliac-artery compressing .t he l eftoommon iliac pulmonary angiography m ay be n ecessary.
vein. .Conse.q uently, there is a noted left-sided
p re:ponderance of the :d e.ep vein thromboses
associate'd 'wit~ pregnancy .

Clinical Presenta~onand Diagnosis

Treatment

Heparin is
'.
the n;1ainstay of. therapy fq"r a cute
vrE in pregnancy. Heparin does n o.t cros s the .
l
Many signs an_d :?ymptorns that are typical of
placenta .~nd, -a lthol,l.gh: bleeding at .t he
uteroplacentaljunction is a possibility, it-does n ot
j
VTE, including leg _s-..velling and pa in, dys pnea, carry risks .of. t cratogenesi_s .o r fet al h emorrhag e:.
l
!

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~
872 SECTION X: MEDICAL, SURGICAL AND .REPRODUCTIVE ILLNESSES,!\FFECTING PREGNANCY

The major risks of heparin use :are matemal, :and of pregnancy has been suggested because fetal
include hemorr:hage. heparin-induced tissue or amniotic fl.uid CQIDpOnents are not
thro~bocytopenia , and heparin-induced . universally found in women who present with
ost~penia. signs .and symptoms attributable to AFE.

The bleeding risks associated with heparin The . diagnosis of AFE has traditionally been
appear .to no different for pregnant and rton- ma.de at autopsy when fetal squamous cells are
preguant patients. Suppartive care should involve found in the maternal pulmonary Circulation;
nu:~d resuscitation, and careful po$itioning in 'a however, fetal squamous c~Us are commonly foun~
lateral decubitus poSition to displace the gravid in the circulation of women in :labor who do not
uterus off the IVC and .mrodrnize venous retum:11 developthe syndrome. In a 'p atient wb,o.is c ritically
ill, a satnple obtained hy .Mpiration .c)f the distal
If acute DVT or PE is diagnosed during port of a _pulmonruyarterycatheter that conWns
pregnancy. the patient $hou1d receive five days f etal :squamous cells is considered suggestive. of .
of treatment . d~Yses of intr-avenous but not diagnostic of AF syndrome. The diagnosis
unfra.ctiortated heparin. (U!i} subcutaneous is basically one of exclusion based on Clinical
he.parc:m or low-molet:ular weight heparin manifestations. Other causes of hemodynamic
(LMWH) . _then maintained on subcutaneou~ instability should not. be neglected.
h~padn l;Jr .J.MWH .. As . there is increased
:degra~'::ltian . and :clearance dJ.lring pregrianty, The 'initiating .ev-ent is poorly undea-stood.
both .ttnftf;.ctio'ilated heparin and LMWH are Howev~. lisuatly'durj.ng labor or other proCedure, .
Iike~ito require &her dosing; 1'herisk prortles- amniotic f.luid and debris, o.r s.o me as yet
.for :t )H and l'MWH' appear tQ be . similar. A . unidentitied tu bst~nee ,:. "ente:r.s}.; the maternal
pregn;liit:p_atient .~th- a Ovt.or. ,PE, should 'Pe . .circulation; this . ]::i}ay . trigger a . massiye .
antt(>agula.cted for the duration . of the ana phylictit: reaction~ activation of . the
. pr~~.ano/and at. le~$t . six weeks postpartum,. _ccn;iipietnentcttstade, o.r l;>oili. Ptogre.ssicmusually
or
or X .thiee=
.
:to .six.J npnths,
. . . ..
,J~~h:ich.
.
ever :i$).l>ngef.,
.
... 0CCU@.:m '2 :P:h'ase~; J>h~se J..cQ~enc~s 'with :
pulin"oriaty-.a;rtezy -vasospasm with .p plinQnacy .
'. eo~:~:~~ri.vaw~~tt()~S ;the.;j)l~~J:ita;.;an.d;_:!.. hyper-teh!iion .a nd. eleiated .J:Jght : v.eptt'icular .
are rcl~lbte1y ~9~tr*hl~i(:ate'd in pttgnttncy; press,u re cau~e . hyp.b !icia~ :H}r.po:xia c~u~es .
\Vaft'Mirt"JS'thQU~tm'beS<tfe'dUrll\gthe~:firSt:'six . -tnyoeardial capill~f....d.amage...an.~.:,pulmo;tacy
wek~ ofgestatio:ft, b'!lt n:r;;ttertii;tl -expo-s:ure capUlary damage, left heart failure, and acute .
:be~een siaild ~e weeks of gestation has b:en respi.ratcr:i distreiis syndrome. WoJU~n who
as$0clateq with waif~..n embcyopathy ih 4-5% bf surviv~ .these events may enter ph~s~ l,l, whi~h .is
fetuses;i~ a hem9rr11Agic .phase cl:laracterized by massive
ble.e di'qg with uterine ~tony and PIC. Fatat
~fa po~tpa.IAAm PE is diagnosed, warfarln cart . con~umptiv.e coagulopathy may however b.e the
~ :uiluated wit;b the .:futta~enous heparin, bul: tv initial presel'ltation. . .
.:b.eparip. sln:>uld 'be <;:ontin~ed unti.l the
.:in~rnati6ria:ini>~ .ratio {IN~} ls greater tha.'. Clln:tcal Pres.eritation an(\ .Diagnosis
.2J) for two :days or for five days of .ffit:J::a.venous
ili~r,.py, .w:~c)lever is lon~er. Ain:niotic fluid e~bolism (AFE)u~ually occurs
d~g 'labOr but has' oecutred during abortlon,
OTliER ~PmATORY DISORDERS aftet .abdominal trauma~ . and during
amnioirtfusion. A woman in tpe late stages oflabor
Amniotic Fluid mbolism becomes acutely dyspneic .wjth -hypotension; .she.
may exp~dence seitures quickly followed by
Amniotic fluid embolism (AFE} is a tare cardiac arrest. JvfMsive PIC-associated
obstetric emergency :in which it is postulated that hemorrhage follows and then death. Most patients
aniniotic .fluid, fetal. .cells~ hair,:. or other .debris die within an hour of onset. . Currently; no .
en.ter the m aternal c1rcillation, causing defmitive diagnostic test. exists. The United Sta tes
Car.dioresp~tory coltapse.lt has been proposed and United Kingdom AFE registries recommend
that the process is akin to anaphylaxis thari to the following 4 criteria, all of whiCh' must be

C .
embolism, and the -term anaphylactoid .C::IInrlmmP nrP~~nt tn n:J.ake the <;iiagnosis of AFE.

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~! ----------------~~C-HA~P=T=E=R~5=7:~P~.U~LM~-~O~NA~R=Y7_~D~IS~O~~=o=ER~S~------~----~---- 873
t:.

[\l Acute hypotension .or cardiac arrest Jn pregnancy , respiratory physiol~ is

f Acute hypoxia . changed by physical and hormonal changes that
~ Coagulopathy or severe hemorrhage in the may significantly change bre.a thing during sleep.
f. abSe,nce of other exp~ations The high circulating level of progesterone during
All of these .cx:curting duiing ll).bor, cesarean pregnancy increases the ventilatory d-rive, which
t!elivery; dilation and evacuation, or witl-p.n 30 has a potentially protective effect. Obesity
minutes postpartum with no other explanation predisposes individuals to sleep-related breathing
of .fmdings disorders and weight gain and increased nasal
obstruction during pregnancy are considered
Arterial blood ,g as {ABG)1evels show hypoxia/ contributory to sleep breathing disorders. The
hypoxemia and decr-eased pH and .increased enlarging uterus alters dhiphragmatic function,
PaC02. Hemoglobin aru:l hematocrit may remain thus resulting in reduced functional residual
wit'hin .the normal reference range : capacity and potentially causing shunting and
. Thro~bocytopenia is .r:are. Prot::J'umnbin time (PT) hypoxemia leading to hypoxemia du-ring.
is pr'()long~ ~causee'lotting:factors are used up. hypoventilation in sleep. 13
Values are institution $~ific~ but intervention
is indicated when the PT is l.S times the control Studies h ave suggseted that pregnancy may
value. Administer fresh frozen plasma (FFP) to precipitate or worsen sleep apnea. A study on
nortnali.ze the PT. Chest ra,diogr.aph p(>st;ero- snoring pregnant wom;efi v.t:ith a clinical di~osis
anter!or and late!'al findings a-re usu.a:tly of sle.ep apnea found intrauterine growth
nonspedJlc, but ei.ider1ce 9f pulmonary edema " retardation in all cases, but most have ~ported
may be :OQ:served. A l-2 ~lead, ECG may show good fetal oUtcOme. Snoring alone is not assoc4ited
tachyca.tdt~. ST .segment and T-wave changes, With fetal risk. - "''' .:. -- ~;;,,.. - ~
. .. ~-: .. ~ rif:K:~~~ :
and fmd1ngs consistent with right ventricle
strain. . , . Pregnancy, if complicated by obst~ct~~tki~p
apnea, is associated with potenti~ advex:~ effects
~anagehtftit for 'bOth the mother and the fetUs: ltl gener:a.l~
' a pneaand hypopnea-are uncommoif-~~~:(egp~;
Tr~~)~n~ is mclmy supportive. O'Xyg~ri may beCause .Of the te~piratory 3timuiatQg,,Sf!~:b pf
be ad.i:D.iniStered to maintain. normal saturation progesterone . Nocturnal hypoxekia'-~1:ght
and b:i~tion ~y be net:essa.IY An arterUll.lli:te.,_ adversely arre.ct ~e fe~s and poor fetal w'wth
to---aoou;rately: -mea~m&e- blood -pressure -and -to -has- be_e n documented- in patients-with ~thi~
i)btai:;n-ABG~rea.dings-can be it:lse.rted. In addition, condition. Tr.e atm<!nt with mrsa:t c-ontinuous
:a pulmonary artery catheter can be use d to positive pressure should be institl.lted after
monitor wed,ge pressure, catdia:c output, appropriate investigations, such as polysom~
oxygenation, and-systtmic pres~ures. Crystalloids nographiC studies, are performed.
and pressors' are given to address the hypotension.
c oagulopathy may be treated 'w ith FFP, for a . TOBACCO DEPENDENCE
prolonged aPTl', cryoprecipitate for . a fibrinogen
level less-than 100 mg/ dL, and platelet t.Icls fusions . The World Health Organization has recognized
.for platelet coup.ts less th a n 20,000 I J.IL. tobacco dependence as a chronic relapsillg disease
Cardiopulmonary reSu$citation is ins titUted if the that requires medical a~tention. Smoking is merely
patient arrests. A perimortem cesarean delivery a symptom of the dru.g dependence. Each cigarette
sh,ould __be done if ,efforts to r~suscitat~ p:rov~ contains over 6000 chemicals of which over 60 of
u n successftil. . them a r e carcinogenic. Reducing tobacco use
amon g pregnant and parenting women is a top
9bstructive Sleep Apnea public health priority. Smoking accounts for 20
to 30 percent of all low birth weight ba bies born
Sleep complaints are very common among in the United States, and ma ny consider smoking
pregnant women; however, limited polysom~ to be the single mos t important preventable cause
nographic recordings are available tha t of low birth. weight. Besides low birth weight,
systematically investigate the cause s of these s moking during pregnancy i~ associated with
complaints. .materna l a nd infant morbidity a nd mortality.

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 .874 SECTION X: MEDICAL, 'SU~GICAL AND RS'RODuCTIVE ILLNESSES AFFECTING PREGNANCY

Additional risks associated with tobacco use evaluated to determine its efficacy pr safety.
during pregnancy include SIDS, pretenn birth, Nicotine gum and patches should be considered
ectopic pregnancy, miscarriage, placenta previa for use d~ring pregnancy only when
and abruption, intrauterine growth restriction and nonphannacologic treatments {counseling) have
other complications. failed, and if the increased likelihOOd of smoking
ce$sation, combined with its potential benefits,
Brief Intervention outweighs the unknown risk of nicotine
replacement and potential concomitant smoking.
~ .
The brief (5-15 ;nlinutes.) intervention iS most
effective with pregnant women who smoke less lf the cUnician and pregnant or lactating
than 2:0 cigarettes per day. This is tbe patien t decide to use ~kotine Replacement
recommended $tartitl:g P9irit for i.den:iifying all Therapy {NR1'} {Category D), the :phy~icilm should
pregnant women. who ~moke and assisting thoSe consider monitorin,g blood nicotine levels to assess
who are readY to stop. the leV'et.of drug delivery. 15 ln addition, medication
doses that are at th~ low end of th~ e1Tective do$8.ge
Five As of Smoking Cessation: range should be considered, pr.c;:fetring delivery
$ystems ~at produce intermittent, rather than
Ask: A patient's smoking status .shoUld be continuous drug exposure . (~! g. oi~otin~ ~m
CQP:~idered :as tQe. fifth \rit~:ti ~ign an'(! must tather tban nicotlfte patch). The relative ratio Of
routinelj be.nsked UpOn. e a c..lt visit . risks "to benefits~ irt ..tteating tobaccO depe11dence,
. is.unclear :b ecause noQe of theSe Jnedicatioils has
. . i\d~ise: It has: been ..shown. that... a .; 3.- minute.: been tested :in pregnant w.qmen .for efficacy.
di~l,ls&ion; led: by't:he . physiclan~::~(jn<tbe <benefits, ' Additi1)hally,. sfnce.:small amoUnts' ot.
tbese
of smokingcessation,greatly influ.ep.ce:;J;a~mokers . ~edications .are ..passe d through-breast milk~ they-
tnotivatiofl tri quit. . . ll'la)' pose roine risks for nursing infants. '

~~~!The $Ill<>kei's. ~djn~~st~...qUj.t.,~~tbe . :V4CC~ATION DuRING PREGNANcY

evait1ated. Oncea patiettt .has 'eXf>r~ssed her . .
. willingness :to..-do.:.$ 0... t.'le,,pllysic~'~'ll~t~pm-ride',- . Risk'fol":-a".developipgifems.from'vaccln.at:lon-of -
s\ipport. lt'or .the ~6:kerwhci l~ un~K().r1is:J1t the m~lher .du.iin~. Pr:e;gna~cy prim~rlly is
thepte4X>ntempla:tion .s~e., iilloifu~ti'o~ ~-a~.!!!~ .~P~~b~ti~!:~~-Q...-~Yi4~Il~~.. e~i~l~L .QL.tisk:ir.om .
.m<;>~tei'..aqillfatteiij.pf's~owa &J>:f.o~ed! v~.:~ID.f!.ting :P-regnan t wo.t nen . w.itb inactivated
virus .pr b aCteria l vaccines or toxoids Live
A$$ist: Problem-solving me~o<is and coping $ldlls vac~ines pose a theoretic~ risk to the fetus.
must be tx{)lore4. .identificatic;m ,.c)f .~ support Benefits of vaccina ting preg:mnt women usually
within the smoker's :fa:nilly and P~le Of CO'b.tao.t s outwe~.gh potential risks When the likelihood of
should .be .d one .to ir.n:prove .t hances or &uctess. disease ~sure is high, when infection would
.Pregnancy-s pecific .'inf()n)ia tio n :a nd setf'..:hetp ,po~ a n $'k to the '.mother or 'fetus, ~d when the
smok:i.og ma terials should be made available, vaccine is ' unlikely to cau se harm. 16

Artarige: Follow~upvisits should.be schedriled ~d
aceess to s moking cessation programs or clinics
~loied.
Pharmacotherapy
. The u se of nicotine replacemen.t products t>r
other pharinaceuticals as smolcit1g cessation aids
during pr.e grtaricy h a s not peen s uffideiUly
Women in the second and th ird trimesters of
pregn;;utcy are a t increa.se'd risk for h ospitafuation
from influen~a. Thereiote, r outine influenza
vaccination is r eCommended .for all wome n who
will be pregnant {m any tiimesterf during influenza
seasort (usually November-Ma rch in the United
Sta tes). The Phili ppin es has a bi.. m od a l
distribution of the influenza season during the
rainy months and a t year-.~nd.

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 875

POINTS TO REMEMBER

Hormonal and anatomic changes may ~use physiologic ayspnea in pregnancy.

Optimal management ut :asthma durl~ pregnancy Includes objective monitoring of Jung function,
avoiding or controlling asthma tri9gers, educating patients, and individualizing pharmacologic therapy
to maintain normal pulmonary function.
Salbutarnol is the preferred reliever while ipl:ialed budesonide is considered for persistent bronchial
astintia.
Immunological changes occur with pregnancy predisposing to pneumonia. The etiology of.whiCh is
. similar to non-pregr.ant patients. Safety <if the fetus must be considered ln making the ~ntimicrobial
choice.
. Prevention is the most important aspect of aspiration pneumonia.
Quadruple anti-tuberculOus treatment .is safe in pregnancy. The benefits outweigh the risks of
continued treatment
Pulmona.ry embolism may :be diagnosed safely using conventional imaging studies such as va
scans and helitaiC i. Heparin (unf:j'actionated and LMWH} is the mainstay treatment t.'lai needs to
be continued post-partum.
. _, -Amniotic !tuid embo!ism is a .diagnosis of exclusion is cases of immediate post-deliverycardi.ac::
. .' aitest. . ., .;< .. ;.~::_;;.:;;... " .

Obstructive sleep ~pnea may become more evident in a gravid patient.

l '. . Srnoklng cessation a<ivice from the physician exerts a si~nifican~ impactin triggering a quitattempt.
Vaccination should berecornmended for pregilancies during the influenza seasop.

:. . . ~.... !.

7 . Philippine Obstetrical an<l.: OynecologicalSociety (POG$).

1. Craw RO. Notmal C$"diopulmona.:y physiology during
pregnancy. Clin Ob.st~tGynecoll996; 39(1): 5 -16.
2. Garcia-Rio F, t>ino JM. Go.mez L1 et at Regulation of
breathing and perc~ption of -dyspnea ii). healthy
pregnant women. Ch~t. 19915; 110(~}: 446-453.
3. The Global Strategy for Asthma Management and
Prevention 2007 Update.
4. Abou-Gamara A.and -Refaat M. Bconc.hial ssth~l-a .i n
. prt~ancy ASJOG . 2005; 22~~230, .
10. Philippine Clinical Practice Guidelines on the Diagnosis,
5. Murphy VE, Clifton VL and Gib:son .PG. Asthma
exacerbations during pregnan.c y: .i ncidence and
associationwith advers!: pregilancy O\ltC<?mes. Thorax
2006; 61: 169-176. . 11. Buller HR, Agnelli G, Hull RD, Hyers TM, Prins MH ,
6. American College of Obstetricians and Gynecologists
(ACQG) .practice bulletin !or -management of asthma
during pregnancy. Obstet Gynecol200S.
Statistics from 145 Accredited Hospitals, Year 2005-
2006.
8. Mandell L, Wunderink R, Anzueto A, et al. lnfectious
Diseases Society ot Amerka/ American Tho~c Society
Consensus G\lide lines on the Management of
Community-Acquired Fnrumonia in Adults. Clin lnfeet
Dis 2007; 44: S27-72.
9. E:fferen LS. Tuberculosis an.d laten.t M tuberculosis
infection in pregnancy: facts versus iears. J Pediatr
Obstet Gynecol2007; 17-23. .
Treatment Prevention and Control of1'uberculosis 2006
Update.
Raskob GE. Antithr ombotic therapy or venous
thromboembolic disease: the Seventh ACCP Conference
on Mtithrombotic and Thrombolytic Therapy. Chest
. 2004; 126:40 1S-428S.

Seanned lly: C ... ~ c.........:.. .;.......

1376...:"'"". SECTION X: MEDICAL, SURGt~ANb .REPROD!JCTIVE iUNI::SSES
" . . . AFFECTING
.
P~ .

12. Hirt;h J, Warkentin TE. ShaughnSSY' SG, et el. Heparin
and lowmo1ecular~weight hepa.ri.n: mechanisms of
action, t>hs..-macokinetics, do3ing. monitoring. efficacy,
and safety. Chest 2001; q. 9: 64~.94-S.
13. Pien GW, Schwab RJ. Sleep diaordus during
pregnancy. Sleqi. 2004; 27(7): lA<lS-14.17.
14. Amerii:ar. Colle.ge of Obstetrics and Gynecology.
Educational B:ulletin 'No.. ;260, Septdll~ 2000.
15. US OHHS, Public Health Service. Clinical :P ractice
Guideline:1'reatingTobacco Use and~ June
2000.
16. Ge.n e ral Reco'mmepd.a tions on hnmuniul.tion
Recoinmend~tiona of .the AdVi~xy Committti! on
InunUilization Practices-{ACIP) . MMWR ~ba 2006
{55J RR-1,

.
.. . . .. .

. .. - -
' .. ...

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 58

ENDOCRINE DISORDERS

ANNA iiELEN IGNACIO-ALENSUELA, MD

Diabetes Mellitus in Pregnancy

Classification: Pre-gestational Oiabele$
Diabetes During Pregri::ncy
Diagnosis: . Overt o i,dbetes During Pregnancy
Gestationai Diabetes
Perin~; Outcome
Gestational Diabetes: Feta! EffeCts
Adverse Matem.al .Effects
Overt Diabetes: Fetc:il Effects
Neonatal Effects
Maternal Effects
Management
Gest9tior.al Diabetes in Pregnanc;;y
Ph9tt:ma<X>logic Treatment Qp_tions and Glycemic Control
Diet
Insulin
Oral Anti-diabetics
Obstetrical Management
Postpartum Follow-up

Overt Diabetes in Pragnancy

Intensified Therapy During Pregnancy
Preconception Glycemic Control
Management During the First, Second and Third Trimesters
Fetal Surveillance
Labor and Delivery
Postpartum Care
Contraception

Thyroid Diseases
Thyroid Flinction During Pregnancy

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 SECTION X:. MEDICAL,' SURGICALANO 'REPRODUCIIVE-J.-~
ILLNESSf:SAFFECTI~

PREGNANCY ''
' ., .,

Hyperthyroidism
Types. ' :,.: ,
Gestatibnal Thyrotoxicosis and Hyperemesis Gravidarum
Graves' Disease
Diagnosis
Pregnancy Outcome
. :.. Effects ofThyrotoxieosis on the Mother, Fetus, and Neonate
Treatment.
. .- . Me.d''~J"T. ~:r:ea.tm
: e~:t :.
. :...:' : :~u~icat Tr~~ttn~ht
. Thi(o.id -~il'n in Pf~g:nancy .
. -, .. . }1yt)Pthyr~iq)~m
.
. ..
.. . 'Diagnosis
Pregnancy Outcome
. . Treatmem
. .; , .. . R~dioiodin.e Treatm ent-:o~ring Pre_g nancy
.. ~

'-.
l.'
Parathyroid Diseases :. . -:
Hyperp~rathyr~;>idiSm .
Mp.nife.statioo.S,.artd- Compli~tions in. Pregnant Wor:nen
Complication$:in Fetuses
Manag$ment o flhe. Mothet-and"Neonate
..:. : . . . Hypoparathyroidism
.. : . . ~

:Diseases of the .Acir?rial Glanqs in:P.regnancy

. . ..: .. , Ph~.ockromocytofl}a:iA P,tegr~ncy. .
Primary Adren~llnsufficiency(.A.ddlsoh~s Disease) . 1-
.. ~
- eushing'-s-Syrrdrome-= . .
Pfi~~ry Ato'o steronism
.=. . . . .

Pituitary Diseases
. . .
.. Anterior Pituitary Gland and Pregnancy
.;_r . Prolactinomas
. Effects .of Pregnancy -an Prolactino.ma Gr0wth .. _.
_

. . ...
Effe.cts -of Hyperprqlac.tinem'ia ar1d Its Treatment on Pr~g nancy
.. . Management of Prolactinoma in Pregnancy
Acromegaly
. ,. Diabetes Insipidus
Sheehan's Sy"ndrome

'.
. . ' .
:

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 CHAPTER 58: ENDOCRINE OISOROERS . 879

DJABETES MELLITUS IN PREGNANCY history). Women with a history of GDM are~t an

Diabetes mellitus i~ . the most common
endocrine disorders oi pregnancy. Gestational
diabetes mellitu$ (GDM) accounts for
approximately 90% to 95% of all cases.
Pregnancy is . characterized by
hyperinsulinemia and insulin resistance in
response to the diabetogenic effect$ of n,Ptmal
carbohydrate metab<>li.s:m.. 1 During the first
trimester and .early hi the sec.on~ trimester,
increased~nsulin sensitivity occurs due to the
relati.rely higher level$ of ~strogen. la-conti-ast, in
t..l)e late second and eaily third trimesters, there
is increased insul'in resistance and .reduced
:sensitivity to insulin action. Aviuiety ofhon;nones
lilce p!acentallactogen, leptiil,, pt'bgest.etone,
prolactin, cortisol and .adiponectin are
instrumental in these char;tges.
GDM is defmed as carbohydrate intolerance of
variable severity with onset or first recognition
during pregnancy. The definition is applicable
regardless of whether insulin is used to treat the
di~se~or if the condition persists after pregnancy.
It does not ,e:x;clude the possipility that
uJ)r-ecQ.gnized glucose intolerance may have
antedated the pregnancy. 1
GDM and type 2 diabetes share impaired
ins:ulin s:et:retlotl arrd insulin resistance~ Ittsulirt
resistance resUlts in decr.e a5ed glucose uptake irt
skele,tal muscles, adipose tissue, and liver and
suppression of bep~tic ~lucose prod~ction. Tpe
riSk factors associated with type 2 diabetes .and
GDM are .c omparable (eg, obesity, ethnicity, family
increased risk for subsequent development'oftype
2 diabetes (SOo/~80%). .
DIAGNOSIS
Overt Diabetes
. ...
Criteria for Diagnosis of Overt Diabetes during
Pregnancy: American 'Diabetes Association, 2004
1) Fasting plasma gluc;ose Of >125 mg/dL
2) Glucosuria
3) Ketoacidosis
4) Random plasma glucose level greater than
200mgjdl
S) Pre~nce of the classic signs and symptoms
~ polydipsia, polyphagia, polyuria and
unexplained. weight loss. .
6) .High inde~ of suspicion if wi~ the following - "-
strollg family history or djabetes, previous .
haVing delivecy of larg~ infants, UhexpJained
fetal losses, persistnt glucosuria~ .;;~<~7' '
Gestational J>iabete:;
Screening for Oestational biabet~s
D~spite more th~ 30 y~ars of r~~$~~t,rt!
is. NO CONSENSUS regarding tnt! optllfiaJ
approach to ~enil:).gfor GDM. Scree.-JngJ}igh-
risk'women-- (wbmert"w:ith~ n:tarkedobesitY;strong
family his wryor type 2diabet~s, priorGDM; or
glucosuria) may be beneficiaL Ot..~e!S advocate
universal screening. The following is suggested:
1) Perform between 24 and 28 week$

CiasslficaUon of Diabetes {)unng Pregnancy

Table 5.8.1. Class Hication of diabetes complicating pregnancy.

Cla:>s Onset Fasting Plasma G!ucose 2-hour Postprandial Glucose Therapy

A1 Gestational <lOS md/dl <1 20 m g/dl Diet
A2 Gestationlll .> 105 mgldl > 120 m g/dl . Insulin

PREGESTATIONAL DIABETES

Class Age of .Onset (year) Duration (ye ~) Vascular Disease Therapy

B Qver20 <10 None Insulin
c 10~9 i0-19 None In~n
D Before 10 >20 Benign Retinopathy InSil'lln
F Any Any Nephropathy Insl;llin
R AnY Any Proliferative Retinopathy Insulin
H Any Any Heart In stili~

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 SECTION X: MEOlCAl. SlJ.RG.ICALANO REPRODUCTIVE JLlNESSES AFFECTING 'PREGNANcY

2) Do on pregnant women not known to have .Fetal Effects of Gestational Di'abetes

glucose ip.tolerance earlier in pregnancy
3) Do a one ot two step procedure
3.a One Step Procedure
T.a...~e a .fasting blood sam. pte..
Ask the patient to ingest 75 gm.giilcose.
Extract 'anot]:l:er blr;xxi ~:ple 2 hours
. a.Jte:r . .gluco~e inge~tion
An l"BS v.alue >lUkmgoio:anda 2 hour
post.,glucose vatu.e of > 14.0 m!t'lo are
di.?.:gnostic of GDM.
3 7b."'I:w{)-~tep Pr-o_cedure
A 50 gram glu~oS-e load js p,clinll}.is~ed Withoqt
regard to the t:laie ...o( day :br time: of last meal
(giQ:~se 4l:allenge *est}_. .100- ~. :om! .gl~
tol~ranc;e. ~est .{QG1if.is .d9.P.ei-if re~~t :o(tbe .so
. ~ gluqJ~ _lOa~ -~~ ab.no'Iml:~.L .<th,e :J;09 ~
_glucose 1oM is . a#.:p;U.n.ister.ed ;atlet..(i.n bv~r;i::U,ght
.f~~g; ' Thete. ~~$. _~1?- m~eh .aebate1.'i.ltrrthe
~~ptabk.'$i-es'holaWJJue'fqtfue$P:grifutJ*Pos
challenge -test: Twe c ut-o.fi v~lu~,s :oha1re :be'e.n;
~tudied. .(l)i~le -5tL:+1 There: Is .:go:pi:1.1'!;ti.el. r;if
.eVid~f,.~ Oeve.LB) :tQ,s)low th~:t;ithey.i~actpta~le. .
Ajhres4o.lfl::-.ori-:t~'mgtii;t;~9::6ti;!~~rj~id~tffie~.;:
139 % of'wow.~n ana 'O~lh~,.. 2~2-s~ wiJ.r -~
put. ~tn:ii.eiJXjsi'PV~<fO.~'GI?M~~et;,atl.PDtn+-(jf:ni';.: .
1) Stillbi-rth. Risk is increased at 3 - iLfold.
Increased risk of fetal death durin,g the 13.st 4
to 8 weeks of gestation has been foun<i in
associatipn with fasting 'hyper'glycemja
(> ~OSmg/ dl). .
2) Aberrantfiiaf. growth (macrosomia~ growth
restricti.q~)
3) Metabolic {e.g, hypoglycemia and hyp:<:>cal-
ce.mia) ,hematologic (e.g, biEnibinetnia. and
. p olycytheinia)., ~d resp'i.rator.y oomplica.ticns
;~ that 1n.c iease .neon~ta1 intensive cttre unit
.adiilission:rat6ana bfri:httaumi (eg, Shoulder-
. :dystodaj js likewis e iricreaseQ:.2.3
4-) 'Congenit4l ~:z:nmna#es an.d .spon.terneous
qborlions: in:o:re ..seri-ous COmplications in
pr~ge~t:atio~ diabets $a:.1. in .GJ)M.
Sj Long~.t~mi c.ajnpiications, such as Qb->-Sity in
adciesce.il.ce a:n:d .later .in 'life, higher rates of
dia:'Qet,~s -~~ pctentia:l ~tellecfuai..ini~ent
ofth'~t.'
.... : ._ .. ..
. T.hei-e :I~ a'. ;~oted.incr~as~d frequ-ency. of
' hJ"Pertensfon~ari!J!. the< n~ed::for: .ce:sareani dcli:very;
.

-~~~i;~~.J:~~~:~fi~:;~;:;!;r~~
.aiftta$.~1fg1l):'eio:.J~t~'1ciwm..b :poiii~ve'for:g:pM
a,ftec~ l:oO @tl Q'G rt.: . Fetal"-E!fects.'gf Overt Dia{>etes (Table SK3) :; I

Ad~erse Pe.nnatal .Qtitconi~
:Matem_aJ_ hyperglj-c~mia with tes'\.lltant fetal
h:YPeiinsulinemia.is centr-al to th~ pathophysiology
or' diabetic. complications in pregnancy.
rj Peri:n.atal lO.Sse$ are about .2--4 peit:ent 'w;ith
improve:(tfetal surve.illar:i,te, rtebnatal!intI?.si9'e .
. car.e and ma.temaJ. niet:abOlic t:Qntr:ol.. It was
hypo.the=si.Zed Ulat osmotically-induted villous
edema.Jeaq' to imp?lred fe!:Bl oxygen transport.
Pli:J.ce,n~a1 insu.f,ficien~y also: .oc.c:urs with
increased frequency in women with -overt

:Table 5~.2. 1\.meric~ College or' Ob~tetriciaii.s ~d Gynecologists 2.0.0 1 Crlteria f~r Dia~~~sis ~f GDM..
u s ing the lbO-g Oral Glucose Tolerance Test.

Ti.IP.e Measu:rel;I\ent Pla-smaGluc::ose

National 'Diabetes Data 'Group (1'979) Carpenter andCoustan{1982)
. rirg/dL mm~l/L mg/dL. .mmol/L.

-Fasting 105. 5..8 95 . 5.3 .

. 1 hoU.r 190 . 10.6 i~Q 1-0.0 : ..
2 ho~rs 165 9.2 155 8.6 ........
3hours 145 8.0 140 7.8

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 CHAPTER 58:ENDOCRINE DISORDERS 881

-
. diabetes usually in association with severe
preeclampsia.
2) Abortion is associated with poor glycemic
control during the first trimester. At increased
risk..are those -with type 1 diabetes with initial
glycohemoglobin Al concentration above 12
percent 'Or persi$tent pre-prandial glucose
coneentration_abQve HiO mg}dl.
3) .. Mttljormaiions. Women with type 2 <fu.ibetes are
less likely to have preconception care and
counseling, often becaUSe the diabetes has not
yet been diagnosed, and thus.1 they are at even
greater risk of ~g a birth-defect~ child.
4} Jiydr.amnios. Possible explanation is that fctai pregnancy. Maternal mortality is increased 10-fold
polyuria was bt(Jught about by fetal
.h.ypex:glycemia.
5) Preterm deliuety at 34 weeks or less in 9
percentofwom.en with pregestational diabetes.
..
:. . , ;.
6) Inheritance of diabetes- older m_aterru~!,age
and maternal type 1 diabetes .are important
risk factors. Offsprings of overt diabeticS have
a low risk of developing type 1 diabetes.
7) Altered fetal growth. The incidence of
macrosomia rises significantly when the inean
maternal blood glucose concentration exceeds
i30 mg/dL
Maternal Effects of Overt Diseases
With the exception of diabetic ret:i.nopathy, the
long-term course of diabetes is npt affected by
as a result of ketoacidosis, . underlying
hypertension, preeclampsia apd pyelonephritis.
The effects are:
1) Diabetic ll~phro.pathy
2) Diabetic retinopathy
3) Diabetic neuropathy

Tabl~ S8.3~' CQpgwitalm.alfon:nations in in!:m~s of women 4) Preeclampsia

-~'. '~c~~~~:,~~~- ~;t~ '
with 9Vert ~tes. 5) Ketoacidosis
,. _,, , j ,

:.- ' ;:.--3'.~.~ ~~ ..

6) Infection
Itllt:J.O of ID.cldence ... '"';'.: ~~ ~'"-~t}!! .
-:~: ; ,. ~~:

2.52 Management
8/1

2
. . ' - - - . . ._ .-, :~;.;. ~-~ .,;;lcA!r.4--:." .

4
3 Pharmacologic Treatment Options. and GJ#Etffic
3 Control for GDM -" .
5
' 4 1) Insulin Therapy
4 2} Diet
23 3) Exercise
4) Oral anti-diabetic 4tugs
From. Mills and colleagues (19.7Q) and the American Diabetes
Ass9iation (1995)
Although. treatnlent modalitie$ for achieving
targeted lev.els of glycemic control in type f
diabetes. type 2 diabe~, and GPM di.ff.er. diet,
exercise, insulin, and oral anti-diabetic <hugs are
Neonatal Effects of Overt Diabetes the chief means of r educing blood glucose
c0ncent!"ations.
1) Respiratory distress~ gestation~ age rather
tnah overt "d.iabete$ is the most significant Insulin therapy is usually recommended when
factor governing the development of respiratory standa-r d dietary management does not
distress. consistently maintain fasting plasma glucose. at
2) Hypoglycemia attributed to the hyperplasia of less tb;an 105mg/ dl or the 2-hour postprandiat
the fetal IS - islet cells induced by chronic plasma glucose at less than 120mgf dl. Rec.ently~
maternal hyperglycemia. the American Diabetes Asso<;iation (19.9) has
3) Hypocalcemia. . = '
suggested insulin therapy .when diet .al...[.e fails
4) Hypetbilirubinemia-impllcated are preterm to:mainta.in fasting blood glucose (.!.t,or ~1ow 95
oirth
and polyCythemia with hemolysis. mg/ dtor 2-hour postprandial blood gfuco:$e levels
5) Cardiac hypertrophy. at or belowl20 mgfdl. . .

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 882 SECIION X: MEDICAL, SURGIC-AL AND REPRODUCTIVE tLLNESSES AFfECTING PREGtWJCY

Diet and E.Xerctse: Modalities that Enhance How long is diet therapy mainta~ned before
Glucose ControHn GDM ~nitiating phannacolobfc treatment?

Diet is the illatnstay of treatment in GDM Consensus and hard data are lacking. The
whether or not ph arma.c ologic- . therapy is faiiure to initiate insulin therapy jn a timely
introduced. Dietary controhvith a r eduction in fat manner may lead to fetal hyperins"Clineinia and
inlake an.d the substitution :of complex associated complications. Premature initiation:of
carbohydrates fot refined carbohydrates seeks to insulin therapy without knoWing whetherglye:emic
achieve and maintain the matem~ blood glucose control can be acllieved with diet alone may~use
profile essential du$g gestation. Two current unnecessary drug treatment. When GOM is
:approaches are reco.mmended: deer~asing the di~osed after 30 to 33 weeks. of gesW:tion, and
pt<>portion of catbo.hy~tes to 35% to 40% in a minimal time is available for achieving ta:(geted
daily regimen bf three me:ils and three . to four glycemic contr.ol, phar!J?.~"co~gic thempy should
snatksl,u 6r iowering th:e glycemic i:rideX so that be initiated. There is greater flexibility U1 treatment
carbpllydra~es aCOUllt fot .approXimate~ .6 ()% Of modalities when GDM ls diagnosed early in the
dailyintake. 'rh~ass1gmnent6fdaily calcrie iri.~e Ll}ird trirneste:r.
iti similar fot women with either GOM .or
pregestation~ diabetes and is .~cq.ated l;)~~~d
on pre-pre_gnartcy l:)ody masi:~. ,ltii:J4 '{BM!t.v.s In Oral Antidiabetic ..Agents as 4ltetnatl;o.e$ to
genera.l, for norma.t..weight women (B'Ml 21}-!25t, Iri.stditt Therapy for GDM
3.0 kcal/kg sneuid be prescribed; 'for overweight
andol>ese..woiQ.n (BM:t.. 25-;.-34};. ~oties.:should , . Avarie~y.of.~ralagents ..may. be altenia;tiv:es to .
berestricted;to:~S.kcal:J.'kg;::'OOdt:i'o.Pm-otb.idl,t:o~s.e:;~, : ... insulin . therapy~ .for.-. wom:en witlnGDM:; .Mo.~t .:o f"::
women . (BMI;.~ .34).,,, r;alories-.sho.l.lld: be' re$trict:ed . . these ,dr-ugS.have. not been studie<l in .pregoal):cy:
to 20 k~fkg .c;r less..C_h lork.te$ttictions 'of '~O%. or only ~Y so. The most data regarding
. in obese .pati:~rtts . are associa.t~ with the .same safety~. p~cy .fo;- -C?ral ~tidia~ticdrug$ ar.e
mte"of~~~to~mia.as.m:;.the,;g~taLpopwatl(;il. ~. . .. -with t he ..~se ;.of. ~etfonnin .~d'. glybl.U:idc. Ma..~y
.e'perts , .and authoritative .. ~ocHeis . hav.e.
A.m:o~er,ate~e.rcis~~Pto~~:~fpr... ,p~gu~p.t.- ,- reconun~rid~ .::Using .'them ,as: an'.-alterila,twe; .-to
:d~~ti ' wOni~ti> who' ,are viilll~g' ~d <~t>l~' mfi.Y ' in~ttltn..!MO.i.. Others have noHiri:bly ad~ the
imp.r.ov.e. p.os.q;m:ndtal .blo.o.d .. glue.l)s-.e 'le~(tl_s__au.d u..se.~ .otal.~-g_ent$..in . pregxlancy.and:rtny;nend
insulin sensiti'Jity. 6 7 Some .Woll)ert .ate les~Lable futtber. .~v~uation. 6 15 16 1'he use of.or.al~ei).t$isa.
. 'ttl ~-erCise owing to issues . of . soei-oecoil'O'i.lliC pragmatii! altem~tive to insUlin thei;apy iP
limita:tions, obesity, and multipa...-:ity. pregnancy because:of ease of adrilinist;nltiOti Md
patient,satisf'acticn with a non-invasive treatment.
Insulin Therq:py During GPM

U"Q..man b;iS '"ljn is reC:Oin:~e'n4ed :during
. pregnane)' ~u.so d'aUt :U$ingi:n'stilin anruo~w~s
.are lacking.~ The Jeula:tiofi fot .the insulih dose
in: obM women is based on pte-pregnancy BMI.
For .non.obesepati~nts; . 0~8 'Ujkgis usedand for
overweight and obese women, 0.9 t(l 1 Ufkg is
used; then current :m.atemal pregnancy weight is
multiplkd by .the amount of insulin. The total
insulin dose is .p ivided so that two thirds is
adprl.tiisteredin the rnorrHng; which is further split
in a ratio of2:1 (intermediate .a,nd tapidacting),
and one third is administered With supper and
.bedtime in a ratio of 1: 1 (ra.pid-.:actin:g and
.intermedi~te)~ Ifa:fter 3 to 7 :days-the GDM patient
has :n ot ~c-hieved the d~sin!d ~teV.el of glyeemic
control, .the total insulin dose should increase by
10% to 20% and thereafter adjusted when needed
Is there irwreased risk;{or fetal a.rwmaile$ With
the wse cf orat anti-diabetic drugs?
For a drug to be potentially effective and safe
in pregnancy, it should not cross tpe pt~centa or
should not he detrimentai to the fetus at
c6ncentdl.tjon~.that are clinically indicated for. thc
mother. l-t is iinpossil)le to determine jf. the
reported rate of anomalies was due to the use of
the drug or the preexisting hyp.e rglycemia
(Piacquadio) et al: 19.91). A . meta-analy~s .f ailed
to show an increa.s ed risk for.-.feta} .anom.alies with
s.ulfonylureas . 17 Metformirt seems to . be
unassoci~ted with congenital malformations in .
patients with polycystic ova-ry syndr;o me. and
reduces the occurrence of GDM and SpQnt.al)eous
abortion. 1820

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 CHAPTER 58:-ENDOCRlNE DISORDERS 883
~~
~ ----~----------~~~--------------------------------------------~------~~

Obstetrical Management in GDM Good glycemic control achieved with intensified

therapy prevents microvascular and
G'eSta:tlon!d c'diab~t~~ l');At requiring insulin macrovascular c-omplications and improves
seldom requires early delivery or other pregnancy outcome and the overall quality of life. l
interv.ention. Antep11rtum fetal testing is
recommended for women who require insuli.TJ for Optimizing clinical outcome for various diabetic
fasting hyperglycemia an.d are managed as if they complications in pregnancy occurs at different
have overt diabetes. ' levels of blood glucose. A decreased rate o f
congenital anomalies was observed when .the
Postpartum Evaluati-on postprandial threshold was less .than 140 mg/ d.L
or the pre-prandial threshold was leas than 12 0
The American Diabetes Association in 2003 ,Ln mg/dL. 1
the Fourth Inte.' i:national Workshop-Conference on
Gestational Diabete.$ recommends: Intensified Therapy in Pre~ancy

lJ Wonien diagnosed with GDM should undergo
evalUation with a 75-g oral glucose tolerance
test at 6-12 weeks ~ter delivery.
2) Women whose 75-:g test is normal -should b:!
re-a.s.Sssed at a n:Uru.mum of
3-year interval.
A suilunazy of these recommendations is seen
m'.Tabte;s8. 4.
Table 58;4 : ReCOlll:ll:i!."1d-!d postpartum evaluation.
F~nal Workshop-Cotlference on O:es.tatiQI)al
~~~~~endatiQn:
w~~oiied~th GDM ShoUld undergo evaluation with
.a75-g oraldueo.se tel~~~ at6-12 wee~ after deijvery
. ,liif~ea - - --ma.oe-tes"Meltrfus
Fl:i'StiiigGlO:ct>se
otGlucose .
TQ1erance
FMtir.g < 110 J'O.g/dL llO-i25 mg/dL. - ~ 126 mg/dL
2 hr < 140 mg/dL ~ 140-199 mgfdL > 200 mg/dL
Women whose 75-g test is normal should-be ~;e-assessed at
a niinimum of 3-year inte-rvals; ADA2003
Pregnancy in diabetic women is associated \i..ith
an increase in risk to both the t:etus and the
mother. Early 1n the pregnancy, t here -i~ an
emergency to no~ali#e the bloc:>d gh.ttose to
prevent currgenital anomalies and . bl"'Q'iltaneous
abortions. As the pregnancy progr~sses ..the
mother. is at an . iil.<;.t-eased risk ofQl'.kS.fl'Cqpe:,
hyp<)glycemia, .or. diabetic ~etoa.ci<:losis~,allfor:..W)llefi
need emergency attention. ~ter in tb~pt:~~~
she !sat risk for accelemted tetinopathy~-Witlithe _
-. risk of blindnes s, pregna-ncy..:indl.lce d
hypertension . and preeclampsia::\e'Clatnp.$ic;l;.-
urinary tract infections, including py;elonepnntis.
and polyhydram'nios~ The gr:eatest .cqilc.em:~~~it.he
increased ri"sk of sudden .death in-.ute:rO;ror. the
fetus. An. or.these. dte.aded:cornplicati.ons.;ean ~ -
0hvra.t-eaor--arreasr m.rn.1m:rzeawTt:11-~cal-erui .
plannmgotthe :Preiiri~6Y-:ancra:u~iltiori i:O gliJC:Oi
control:
There are several components to $e treatment : .
of diabetes in pregnant wo_m en: the administration
of insulin, exercise, and diet.
Role of Exercise

Gestational-diabetes di_ffers from a pregnancy

in type 1 diabetes because the fonner is:a disorder
.Manc;.gtment of -Overt Dia-betes in Pregnancy primarily of impaired glt\cose clearance. As . a .
and :Deliverg result, therapies that overcome peripheral
resistance t<:> insulin, such .as exercise, are
. ldealiy, if a diabetic woman .plans her preferable to insulin. In comparison, in women
pregnancy there is time -to create algorithms of with type 1 diabetes who are already taking
Care that are individualized, arid a woman can be insulin, the benefits of exercise a re not so..clear.
given choices. When a diabetic woman presents Exercise can contribute to the "brittle~~s" of
in h_er f1.rst few weeks of pregnancy, .there is no diabetes ~ with the ri sk .of e~ercise:..i~uc~d
time for individualization; rather, rigid protocols . hypoglycemia~ Women :Who exerci$e~(;before
must substituted urgently .to provide optimal pregnancy can usually continue under the
control Within 24 to 48 hours. s upervi~ion of their .obste~ricia.n. However,

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884 SECTION X: MEDICAL. SURGICAlANCf.REPROOUCTIVE ILLNESsEs AFFECTING -PREGNANCY
exercise is not r ecommended in women who a re
dec~mditioned .a nd did not exercise before
pregnancy.
Diet
ihe optimal -diet takes intt> account caloric
iT'ltake, carbOhydrate content, and the distribution
of :meals thtoughout the day. The appr()priate
,.caloric in.take depends .o n the pregravid weight,
With the following general te~mmendations:
-30 kca1/kg/d if the worean "is at her ideal body
weight . i
...24 kqil/kg/d if the WO!Jlan -~ 20% to 50%
above ideal body weight
12-18 k-cal/k,/diftlie wotna...T'l is> 50% above
id~ bOdY.weight
.36-40..kdl1lkt!J"d ifthe w()man is > 1.0% below
ideal body weight
. .. .
The recammeri(lcd~'distributio~~ Ofrcalories, is..>, .. c. Fetal sunteil!ance .such.as . biophysi~ ptofile
4~lci.'tO SOOAh~Sf.bolifdmtef20o/<Jl-i)f"t>teinj~and~~Q%f"'': .
to 4()!14Jat/ A d8ilJ>~sUpp\ementt:6N'ert.qus. :sulfate.:"r
and fo~te is~$!:1 reeottimend~d:
The -starting:Jnsulit),dose, is-.,c culated-.to:, be. ,.. d . . Hospj}~liza:tio~ is recolllJA~nde(:J !or those with
0~7 U}kgj4, di'vi4ed:' into - ~ ta Jour inJections
of sh'Ort----am1:.-;inter:~~d1l).te"'actit'tg in~ulh'l ;
Massiv~Jy -obe'~e wo:tri.en'ntay t;le'e<l-Wtialtl'crses of
LS tJj-kg/d t:a 2.:-o ,Ufkgfd t9 overcome the
combined in~ulin. nsistance of p rgnancy and .
ohe~t;y~i1 Only hti.ma,ll insulin should be used m
pr~t -wotnt)'l;
Despite the clea,r benefits t() tl)e fetus of strict
glycemic control, there ls a hazard of
hy.p ogly.cemia. Majo;t 'Conrpiication.s of
hyp.oglycetnia c$.-n usttally be pr;evented with
careful motlitb.tin_g and ..edueatiO'n .: of the mother.
Very strict ~ycemi~ control {mean bl()od glucose
% 56 tngldL) may be deleterious to the fetus and
should. be.avolded.
Manage!llent DUring the First, Second and Third
Trimester of Ptegnancy
First Trimester: Matemal glycemic .c ontrol is best
.achieved in. the hospital using multiple daily
insUlin injection and adjustment ofdietarv ;nt::olo
Snanned &y:
Diabetes tends to be unstable in the first triJ;nester
followed by a stable period and then by an in~
in insulin requir--ement from about 24 weeks' due
to increased production of-pregnancy hormones,
which are insulin antagonists.
Second Trimester: Determination of alpha
fetoprotein at 16-20 weeks may be D}isleading.
because of the lower values associated with
diabetic pregnancies. Interpretation is alt~ed
accordingly and used in association with
ultrasound at 18-20 weeks in an attempt to detect
neutal tube defects an<;! other anomalies.
Third Trimester: The following are recommended:
a. Weekly Visits to monitor glucose control and
t-o evaluate for preeclampsia.
b. Serial ultrasound at 3-4 .week intetv~ . to
evaluate fetal -~rowth and amniotic fluid
volume .
de.tentri.n:.ttion is .-started.usu;;dl.Y-_; befiveen:2q .
and 32 weeks. depending on. risk fac.Wr$. for
fetaJ death. Ant~partum testing . is.
reco,m~ended. at .. least. :weekly,. while -other .
ptOtO'CQls -:s tipUlate : at-least tw:i te week:J,y.
testing.
hype~~itsion an:d .wh~se -~bet~~ is poorly
. controlled; -~his.. should be~accomplishe<(at38 .
week-s w.lretr gestational age is certain. If
uncertain, ledthi~ .. spl).i.pgomyelin ratio is
measured at aqout:38weeks atid if it is greater
than 2~0, delivery 'i$ af'tecteq. Even if tl)e ratio
isles~ than 2.Q, d~!l1V'ery .iscarried outifsever:e
hypertension develops ..
Feta.l Survi!illance
The high perinatai mortality once associated
with a diabetic pregnancy has decreased
significantly, largely due to improved glycemic
control. :.Jn. the .p.a;>~, ~~explained fetal .death,
occurred in 10% to 30% of type- l diabetic.
pre,gnancies, typically after the 36th weelc of
gestation in w<nnen with, poor glycemic control,
asi;ociated with macrosomia, .hydr.am~o.sf
preeClampsia, and va.s cular . disease. F.e tal
surveill~mce, there(ore, .-i s of utmost importance..
in optimizing a good outcome for bolh mother. and
fetus. ~ltrasonography is the most.u seful tool for .
the assessment of the fetus. It- can be used to ...
1 ' ....... : ...... ~~... ~estational.age; 2) screen for structural
C
 CHAPTER 58: 'ENDOCRINE DISORDERS
.,.
anomalies;-. 3) evaluate growth; and 4) assess
(lmniotic fluid volume; and 5} .d etermine fetf:l.l
status dy.na-m ically through Doppler and
biophys'ical -studies.
Guidelines for antepartum surveillance vary
and u s ually depend on the clinical situation and
the discretion of the physician. In women whc
have diet..eontrolled gest;itional diabetes, fetal
surveillance i~ notinitiated usually un:til 40 weeks-'
gestatio~. because these wom._en are at very lew
risk f()r complications. More .rigorous ntonitopng
is ~pmmended for women who have additional
indieatio.ns for c1oser fetal surveillance. Most
ceilters defer testing untiJ the 35th week .o f
gestatio.'l ifthere is exceUent-glyet:mic control, but
resting is started much earlier in women who have
poor c.ontrol, .nephropathy, or hypertension. In
tbese women, antepartum testing ls begun at 26
to 2~ w~~!'.S, when fetal survivalblikely if delivery
. were'to':occur. AntepartUm fetal testing should be
.pet'fqr;gi-ed tWice per week. Do.p pler unib;iical
artecy~\.-:~locimetiy has shown il'lcreasedplacental
resistance in women with vasculopathy and poor
glyc~IQ.iC -eontrol, whic;h incre.a se the risk of
intrauterine .growth retardation and
preecl~ps~ 21
' '''. .
.J.
The foU()wing general recom..tilendations can be
ni'a(fe': ms\illii-rs sfill fequiied."l>efore-acuve1a:tSor
ati:d . c;an: be gl.ven suhcutan'e ousiy or " by insi.iim=-ri24 to -12hours.ulyceiri.ic.coiit:ror is.
intravenous i..,Jusion; with a :goa;t of maintaining
.b lood glucqse concentration s between 70 mgfdL
and 9 0 mg/dL. As the mother enters active labor,
insulin resistance decreases rapidly {because
expulsion of the fetoplacental unit leads' to the
cessatiop of production of somatomammotropin,
whiCh has a short half-life), and insulin
requirements drop to zero. Thus, continuing
insulin therapy is likely to lea d to hypoglycemia.
To prevent hypoglycemia, glucose should be
iilfu~d at~. rateof2~5mgfkg/rn41. Capillary blood
glucos~ should be measured hourly. The glucose
infusio.n should oo doubled for the next hour if
the blood glucose value is less than 60 mgfdL.
On the other hand, values. of 120 rng/dL or more
require the administration of r egular insulin
~ubcutaneously or intravenously until the blood
gl~cose value falls' to 70 m gfdL to .90 mg/dL. At
this-ti.qle, the insulin dose -i s titrated to .maint;:i.in . increase cat.diovasCl.llar, risk, rnay .~e. ;u~d only
nonnoglycemia while glucose is infused at a .rate
of 2 ..5 mg/kg/min. Bolw~ doses of glucose should
~
Scanned 8y: 1:_:.:}
'885
not begiven because they can raise maternal plood
glucose concentrations and in.crease the. risk of
neonatal hypoglycemia, fetal hypoxia, and fetal ol"
neonatal acidosis. lf a cesarean section is planned,
the bedtime NPH insulin dose may be given on
the motning of surgery and every 8 hours
thereafter if surgery is de1ayed. 22
Cesarean deli'V~ry has been commonly used in
the overtly diabetic woman wjthin class B or C
White classification to avoid traumatic delivery oi
a large infant at or near term. Those with advanced
di-abetes and vascular disease where h~.b<;>{
induction remote from tetrn may not be succes sfiil,
cesarean delivery is suggested.
Labpr induction may be t.ri.ed pro-vided the fetus .
is not v:!rJ large and the cervix i$ favontble ft>r
induction. o n the iy ofdeliV~.Y. ~insulin
should be u~d to -m eet tbe .insulin needs of the
mother because insulin requirements m.ar:kedly
drop after delive.ry. 'Hydration fo~;;itl:t~;fl~~pe..ti~
mother is important dUJ;ing_.l abor and.'aft~i>:"'{a,.gil].at
or cesarean deli1ety. Intraveaous hy~m:?~x#?.i4!b
crystalloids and glucose to . . D:l,_ai~tain
n ormoglycemia is very important. Vigilance
againsf.infection:isalso a must. . .. !
Postpartum -C<ire
Insulin requirements drop sharply- -af'ti!r
deliVery~ ana me new-. mother may poT require
somewhat more erratic in lactating diabetic
women, with m 0re frequent episodes of
hypoglrcemia. Because the risk of life threatening
hypoglycemia is increased in the immediate
postpartum period, especially if a woman is
lactating, preventing postpartum hypogiycemia is
t..."le primary goal.
Contraception
No single contraceptive method is .appropriate
for the -diabetic woman. The ~strogen in. the oral
contraceptive piU can increase the. risk of
thromboembolism-~ myocardial infarction 'and
..
str.oke in .the diabetic woman . who is already at
risk fer vascular disease.
"""''"
. . ,
Contemporary low-dose pills, whic~do not
by Women without vasculopa thy or addi4;nal risk
factors such a s a strong history of ischemic he art
 886 .SECTION ~,MEOJCAL. SURGICAl.ANO REPRODuCTiVE IllNESSES AFFECTING PREGtiANCY

disea.Se. The low dose pill can also be .given tt> The following is a summary of these changes:
rece.n t gestational diabetics without an intreasM
risk 9f developing type 2 diabetes. 1) Moderat e enlargement as a result of glaridular
hyperplasia and increased vascularity. Even
Progestiri~nly
contraceptives can be used . its volume inc reases during pregnl.'.ncy.
because of minimal effect on carbohydrate Pregnancy, howev e r, d.Oes not cause
me.tabollsm. impressive thyromegaly, s.o any goiter or.
:n odule should~ approached ~s . patholOgicaL
Intrauterine d~vices are no.t .rec()m'fn.ended 2) Sharp rise in .total serum th~e (T-4) and
because .'of the possible increas ed risk o f ~>1Vic triiOdothyronine {1'3) concentrations as ~ly
inf~ctions. as the se<:.ond month of pregnancy .
3) CQn;siderable increase i n the Serum of thyroid
TaYRO'J.D DISEASES bjnding globUlin (TBG) . .
4) Higll serum concentrations of hCG .during
Thyroid dysfunction -o ften is overlOOked in. eady pregnancy.directly activate the tsH
pr-egnant women bec.a:u.s e of nort- specUic r ecepto.r .
sy:tnptomsandtht hypen:netaboUc stateQfnormal 5) No alteration in thyroid re.l easing l:loftDOne
pr~ey. Compo.unding ;$e diagnosis1'\.u1her is :(TRH} secretipn during pregnancy u tRii
the e:!teiationmthytQid phy~ology tl\at ~o~ eros~ the pl_ a centa. .
occur8 dtu:fug $es~tion. A - clh~~ - must.first 6) Unchanged c()ncentratiort in. tAYTPtro.pin:ot
eonsid~r thyrQ'id :d~fUnction :a po:ssi'J>Uity, -t1len . th.yroid stiJn\lhPI1g .honnone .. (TSH). It is not
.4if{eriil'tiatt:no~hysiolpgie;~mutges.{rom,t:tue-'' botind l?Y -cattier, proteins .and does not tt(>s8 . ..
d1$ea:se; .Al>hoJ1na1Jtiea~in:: ~illt.t.i~rtud'-'thyto:id,, . - . .-.the 'P~t:enta. , .; , ..
funCtionCan-aav.er-..ely,affect. the:fetus.-~y~li>Y' . -.
w~y .of -t he ttan:~pl~aentaJ: pas~ge of.'a'bnonnal . During._mO'~t:of .pr:egnancy, .ser:umlevels aHr~ ..
I)lS:tern~'l :h'Ot:D:lli>pe eonceritratim$:, ~Yrvld .- thyr:oxin:e and .triiodot hyronine a$ V."ell as ..
.. st,i.rb~tm,g~;hotbion:e- l!f$llll:tecept~~-an'tibodie~:~ . . thyrott:op.i n are
maintained within.artarrow~J;lonnal.: ;.
-or .j>res~dbed;:a..ntithy.roid ,medi:eati:t>rts ..4nd :'' . ninge .....so .ther.e .. -.is . no.
Qvert ' functional
in.dUectly>by>Wa.y:~of~thi:z, altered :,mate.maJ:;gta.\r.id ~'< ... hyperthyroidism.
phy~iology.
. ' ~- -. - .....
All-fonl.ls-of Ulyroiddi'~se--ar-e 4-$-,tUne$UlPre
c~mmpn h1 femah~s than in .t:na,les. Tbyr.o id the prevalen<>e of hyperthyt.oidis m ~duting
di$ea~s also irite"r!erc with the :p~y$iology .o f . pregn~cyran,gesIrom O.lo/oto{).4~~ Witb.G:ra.ves'
r.eproqucti()fi. ' aot.b hyperthyroid.t~.m . ancl di~ase accounting for 85 per~ent of cases.25
~ypothyroidism significa-n tly td'fct estx-og~.n
.metaboll$rit. The pregnant wo~an wi't:ll thy:roi~
di'~ presents .~peci~:lproblem fu di..agnosis B11d 1.~J.Gestci.tio~u.l "':hy~cto.xlcosl$ :qruf
. ma.ijagemnt.. ~yp~remesl$ Oravfc.farum

Tbyrol!i Function. During Pregnancy Resec;u-ch strongly suggests that the high serum
co.n cent.r ations of :hCG during early pr~gnancy
Several ~terations in thyroi(l .physiology .occur actiVate th e .TSH receptor. The stit\ililatt>cy effect
during nofrtlal i)t egb.ancy. T:hes e changes t::tke of .hCG .results in a wide sp.edn.tm :o f .Clinical
place at diffetent:t imes <Sf gesta.tion;ai"e reversible scenarios ranging from a .s light decrease in .
postpartum, and collectively ;s timulate th.e materna l TSH concentrationo(l8% of wo~en
maternal thytoid.gland. Tfiyroi4hl s~ulation is wlthout thyrotoxic 'Symptoms) .to _g estational
sti)?_ported further by the findings o f increased thyrotoxicos is . (elevated .serum Jr,ee T4 and
serum thyroid stimulating honn.one (\fSlt} and su:pruessed serum TSH levels}.
thyr.o glqbuUn_ concentration's . relativ-e
hypo'th~ia, aJid oecasionalgoit~r.fo.rmation' Hyper-e mesis gravidarum is a syn~r()me
i n'p regilant women from ar:eas of bOrderline itxlln~ affec\ing some pregnant women and is-. d~fl.iled by
sufficiency. severe nausea .and vorp.iting leading to .a 5% loss

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 CHAPlER 58: ENDOCRIN!a OISO~OERS
-~~--------:!,.
:::
>-.,;;-------.---~~--.._.--------"-------- ...\

of body weight, dehydration, and ketosis. Of
women with hyperemesis gravidatum, 60 percent
have a subnormal serum TSH level(< 0.4 mU/L), free and total T4 serUm concentrations. TSH
and nearly 50.pertent have an elev"Sted semm free
T4 concentration. ln addition, the ~everity of
symptoms experie.n ced hy .a woman -with
hyperemesi~ grav:ida,ruJ:Q. is po~\~vcly correlated .
wifu maternal free T4'levels~ D.e spite the apparent
correlation, hype,remesis gra~9arum d~s not
seem to be dir.ectly related t.Q thyroid function.
Only 12 'percent of sucll women have an elevated
~ 'f3 indeJt.
Some irtvestigators b~li~ve that . another
compound stimulated by the . increased
concentrations of hCG (eg, esttai:Uol) Iilay be the
cam~ative agent. Whether s~ptomatic or not;
gestational tp,yrotoxicosis usually resolves
spantan.eo1.lsly by 20 weelts' g<:statifJn when ~CO
. declliles. T.eatment With .a ntithyroid. m~dieations
is ge~erally not .rt~cessary. If'.gestathmal
Wpoto~~osis c~ntinues beyond 20 weeks, a
repeat . :e.valuahon foT other ca~ses of
hyj}erth~otdiSn:l Should ~ cvnsidered.
: . . .';:::...,......
' GiaveS':diseaseJs the most COD).ni.On cause of .
. :h~~ism d\iring pregnancy.lS ...Similar to
other autoi:i:nmu.ne. :4isea..~. the:: activity level of
Grave$' :disease. may fluctuate duritl.g gestation,
with~bation dj.lliQ.Ifthe. first -tli,i:riester and
grad\t~improv.cmen~'d!lrlng-L~e.iatter half;
Laboratory stu<lie.s also are helpful, rev~ing a
suppresSed serum TSH level and usually elevated
receptor antibodies are usually present with
Gr~ves' disease and may aid in confin:nng the
diagnosis.
Diagnostic signs include:
1) Tachycardia e.Xeeeding the increatle associated
with normal pregnancy.
2) Abnormal elevation oi the sleepingpulse rate.
3) Thyl-omega).y.
4) EY.bphthalm~s ..
5) Faihite to gain weight despite normal or
increased food intake..
Pregnancy Outcome
The risk of ~nipUeations for the mother and
the child is related to ~e duration a nd et>rttroi of
mat~rnal chyperthyroidism. The frequenoy of
pretenn !abor is high. ln ~dditioul;.unt(~ted
women are twice as UkelY to developfp~sia
duririg pregnancy. As for t.he fetus/ ;'sti'l.Ibi'rtll:is
more conun:on runcmg untreated womeri:.' Fih:aliy,
:studie G ~ave indicated that children-'boin to
. inothers wjJh uncontrolled h~rth~idismr;are
mor .Jikely to 'be small 'for ges~tio~'aie-t.afitt to
h~ve congenital malfoimations.: u'tfreta:lea -to
thion.liqe tb~r~py.
-r - ,.,.,,,
---'.-~ ~

Patients"withGraves"lli.seaseaiSb m~y..experien:c-e Effern of Thyro.t~~.Qi$. <>.rl th~ N.e.~Mi.~

an exacerbation .shortly after delivery. With this
possibility in :mind, tPere are several different
clini~ scena,rios by which a woman may present
with Gtives' tUsease during p!"egnaricy. . First, a
woman with ~table Graves disease receiving
thionamide therapy may experience an
exacerbation durittg early pregnancy. Second, 'a
woman in remission may e:q>erlence a relapse of
disease. 4stly~ a w:oxnanwithout prior history may
be diagnosed w.ith Graves' di~ase de novo during
pregnancy.-
.Dtagnosis
1) Hyp.othyroidi sru may develop .w~~h i6ng
. standitlg eiposure to antithyroid d,rUgs in
utero. )he fetus m~y develop a goiter.. the risk
is extremely s.m ali.
2) No .a dverse .e ffects on subsequent neonatal
gro~ anq d cveiopment.
3) Thyrotoxicosis in infants with miPifestations
including goiter and exophthalmos .. Matsurrt
and colleagues, pre~ente.d evidence that
neonatal thyrotoxicosis results from . the
tr~nsplaceptal. .passage of mater.nal thyx:oid-
stimulating.. antibodies. This .'transplacental
passage can .c ause fetal demise.

The thyroid examination is often ~fere11t from . Tre.atmen.t

that of normal pregnancy, hyperemesis
gravidarum, and gestaUonal thyrotoxicosis . . . . The goal of therapy is to contt;"ol ~ternal
Women with Cr~ves'.disease u~ual.ly have a goit~r disease, w.h~le minhpizing the p~t~n~a!;-Jer fetal
(with ,or with.o.u t b~it). but :the .aceompanying hJP<>thyt:'Oldlsm a nd hypen:hyroiClism. Epllowing
autoi~une syndromes of <:>phthalmopathy and js a Gu~ddine . suggest~d by Shane .O,. 'tal. in
possibly dermopathy are stiU quite rate. 2006. . .

banned 8y: C
8'8'8 SECTION X: MEDICAL, SURGICAL AND REPRODUCTIVE ILLNESSES AFFECTING .PREGNANCY

Guidelines Cot Clinical Management of Maternal
Hyperthyroidism During Pregnancy lSbene (), et
al. in 2006.) .
1) Use the lowest dosage of thionainide
(preferably PTU) to maintain maternal toW 1'4
concentrations in the Upper one third of
normal to sligptly elevated range :f or
pr.egnancy. Nonnal ,ra,nge :Qf total T4 durm~ .
pregn;mcy,is estiJ11a.ted to ])e 1.5 t.iriae,s the
non~pregnant stitte~
2) Monitor maternal total T4 serum concen~tioiJ.
ev~ey 2-4 weeks, and. tittate tbionamide as
necessari;;Mbnitorlng serUm TSH.may ~me
us.eful latr..
3) Mea~ute TSH rP.ceptor antibodies {thyroi:d-
&t.iinulatmg"immunoglobul,in$ or TSH ~ptor
b~ding .inh,ipitory bnmuncglobulih'~) at :2 6-28
w.eeks to. as'Sess d~k .of '!e.t;ll./:tleonatal
hypetthyrc$1dt~m. TSH . rec:e:ptor antibody
,., m:e:S:su.remen~ i.s etuci'al i-A .hypotleytoi(l
' :levo~~y,r,:>ldn..-:tr~.ated .w.p"men' :With a?"Prior
,P:: bistary'"Qflimv~s~at~a$e~.~~c.~do-1i:ot::~ppeilt .'
tl:'yroto:!tie. . . . .. .
. 4) P.e'tfonn fete! uitra~und at 'wee}$ .2~28 to'
~~ PQ~P,aJ,:f~~.re~pqtJ.~ to..:fu.ioilanli~~
tri:attneilt:mi~#(etof:TSil~ptol1an~es .
Ol):!e~ 'U\mid.ft#l~tipn, . : .
S) Cdn$iatt; l~:Yti>ia~etqi#yat-pet.fii~tt:~~Y"JAga . . comp1icatibnof~J'tt(>~'or fuadequa;rety.treJtted .
d~ses ot'ij.lionamt4e {PTO > ~6~.'~gf'4:6F ~l
> 40-'tng"/d)'-m-e-:r equ:ired, or if:"thepatient the--,~'igns and sytnptpms' ~(~..hyperthyroidism
.~nt;~l~~te ..tf.Jp:nami'd ~th~ta:py.
6J ~Aar~nergic blcking agents and tow t;toses
Of' iodine maybe ,Q.~ pet;iQpeiatively :t o control
hYPe'i:thY:rilid state. . Treatm~~ttt oJTh~ofd
""7l Check.feOO tor<r blood 'a:f.delivety Jor'TSH .a nd
~- ' I) Hydration: 5 lo 6 liters of 'intra\Tenous Owd
l . Propylthiouracil (PTU) ~d meth~te both
. cr.o~.s th. p}~cenW. aJ.tho~gh .f>To ctos;st$le.s s
readi}y tiui.n methima zol. .Th1;se drugs,
th~~efo:rb,:cfu~ diuse 'fetal hypothyroidi$rQ and
goit~i':. Neonata\ thyroid abnormalitie.s,
howe:vet., can also be c:aused by thyrotropin
. blocking antibodies, which also cross the
placenta so ,it is di(ficult ,t o ascribe these
complications to the us.e of these drugs.
2: Methimazo.le . has a:lso been 'implicated:i-n th~
c:at.t~~ti<?n ~f ap!asla cutis. The starting doSe
...is 300-450 .tng daily as .recommended. 'Thts
may be mcrei'sed. until the pi'egrian't w.o man
is only minimally thyrotoxic clirticallvand the
total serum 'thyrOXine level is reduced tO the .
upper norm~ range for pregnancy.
SUrgery
Subtotal thyroidectomy for the treatment {jf
G.raves disease during pr~gnancy is r.estrve(l for
specific situationS: 'Wlle1t pet'Si~f6ntly high dotages
of thiooamides :(Pro >600 tng/ d, MMI .~ lng/d)
are r~quired to corttrol matenial .disease, if a
pati~nt i$ alle.tglc or intole.r .ant o! b.oth
ili,icnamides. if a patient is rion-.compliant with
medical therapy... q;r if compre:ssive symptoms
cccur..in:ihe mother \>eeaus~ .ot.g<:>iter .~;:as The
t.iiPing or ;s~ is crucial. .Hist:;>ricaUy, it has
been recommended that $\l.:'g17 o\lf d\lrin~ the
$eCOlld triinester, l,lefore .:gestatio~ w~ 24, L.;.
an at.t empt to !Jlinimlze the .ri~k oi mi~ge.~
Rac!!CHZdf:ve IocRne Therq.py
R.adioa.~tive .iodine.th~rapy is cantralndleaU:d
:for..th-e tt.eat~cnt: :o f Grav.e :stcdisea'S.e d \,l:npg
pregrtancy.
Thyroid Storm.ln :Prep.ancy.
_
'thrroid s.to:ttn .is 'a .rar~ Ufe-'t'~r~att:ning..
thyri>~Sis. 'tb~ ts .xn~k~d augm~~tion:.of
usually triggered bY ~bor, vagm;:,.t or ~~ean
de1fvet}r or.mfectiop.' .
.
stomt
j>er day
2) Hypefth~nnia cc;,nt:rol:. cooling .blanket~ alcohol
baths, etc.
3) Propa:nolol (us~ with caution, if there is heart
failure) IV, 1,-Q ~g e:very ,6 hour$
4) Pr~pylthiouracil (PTU): 1 gram PO.
5) Potassium Iodide - 1 gram PO.
Hy,p othyroidism
Overt hypothytoidis~ :complicating pregnancy
is ~ricommon because it is often, a::;soclated with
.iri.feftilicy. '.Oesp~te the :assodation .between overt
'hypothyroidism and infertility. hypothyroid
wnm~n m ~v become pregnant.

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 CHAPTER 58: ENDOCRINE: DISOFWERS 889
..:

Screening studies have shown that an elevated
serum TSli concentration is found in 2.5 percent
of . pregnancies. In an iodine-sufficient
environment, hypothyroidism during pregnancy
is caused pnmariiy by Hashimoto's L'l.yroiditis and
prior radioactive iodine treatment or -surgical
ablation of.Graves' disease,23 N-evertheless, the
elli-"Jctan.sheuld k~ep .in .m)hd the less coii1lnon
caU~$ (eg. overtreatment oHt,yperthyroic:Usm with
t hkmamides, transient hypothyroidism .o wing to
p ostpartum thyroiditis, medic,ations that alter the
absorption or metabolism of 1evothyro.xine, and
pituiWYfhypotbalam:ic dise~se) because the
dUlgnoSis .$1d mali.agement oUhese patients may
~-different.
disease .(9%) and the general population (7$1. An
assodation between maternal hypothyroidismand
impaired cognitive function among offspring has
also been described.'l"
Treatment
The .treatment o'f hypothyroidism during
pregnancy depends on the timing ofdiagnosis, the
severity .of disease, and possibly the GaU~ of
. thyroid dysfuncti6n.25
Gqidel.ines for Clinical Management of Maternal
Hy-pothyroidism DurL'lg Ptegnancy (Shane 0, et
al. in 2006.}

J>lagnoia 1) Clleck sen,u n TSH level as soon as p~ancy

is cmifrr:med. .
. Only ~0% to 30% o.f patients with ov.e:rt 2} For newly <::Hagnos~d hypot:p.yroid- women.,
,, h}-pothyt'Qidism dev~op.syrn.ptbms C()b,sis~l)tWith initial levothyroxine d~sage i$ -.b;t~~ .on
-disea'Se'{howevet, wherea:; most patients with ..Se;verity of hypothyroidisJ]l . Fox: . .Qve.rt
subclinice..l disease are entireJy asymptomatic. The hy:pofuyroidisi:n, administer 2 ~8tJau4 M:.roH
.~pl-6Sis. p.f pri.iruuy bypo~y~i<llsm .i s fi;lade by is< 10 r!:!U/L, :initialdcse ()fO._f;mg/~i~..X:.}le
dOc{lmenting an elevated s.er1,1m TSH .sUffipient,. .. ....~. , ~;~ .
.Concentration. 3) For previo~slydia.gnosed hypothyroid ~QXnen,
m()nitor .serum TSii ~very 3-4 wee~. dluing
P:::~ O utc,o nie fit"st half -of pregnancy .a n.d e.~~~ ~~,; 'ireks
there31ler.
. . . .
. ;; ...
. . : ;
. ..~ "'~- . .
-~- '. '\".:t"= '
'';:.t.he ,ukelihood that either mate.t:nal sr fetal 4} Adjust.."'levothnoxin.e
. I dqsage.~~
. -~~-~ "m~J;ain
,.,.~ , . _,t:-:!=' -...~-~- - .
.ec:)~plleatfuns will .3 rise depends on the s everity serum 1SH ~ 2 .5 mU. L. . J) <..:.
tt
of :disease and adequacy. of-treatment Maternal .5) Monitor ~~m :TB.H. ~d ~Ja.l T1 leyel~ ~
complications include: ~ - ' weeksafter~everydqsa:g~a~justnn~nt; Wh~n..
leVdthYroxi:rre dosage a:chieve~r eqUUibtlUnl,
1) . Gestational hypertension occurs ;more..often re~mme moiiitoring.TSH ~one:
in overtly hypot})yr.oid women {36%f than in 6) Levothyroxine ingestion :>hould be se~ted
women with subclinical dise.a se (25%) or the from prenatal vitam.i.ns. cont;aining .itvn, iron
gental poptila,tlon (8%} . . and calciu.i n .supplements, and soy pro<fucts
2) . Increased u~ of c esarean section because of by at least 4 hours to ensure adequate
fetal 'di.stre!>s . . abs_o rptiOh.
~) . Pl~n~ abruption, fu"leniia, and postprutuin 7) After delivery, red,~ce. lev.o thyroxine to
hemorrhage prepregnancy dosage, and check serum TSH
4) Very preterm .delivery (< 32 completed wee~s) in 6 weeks.

. Al:th~ugb the relative ontitibuti6n of maternal ..

. v.e rsus fetal' thyroid ho.rlijo.n e . to neurologic Levothyroxine dos3:ge should be adjusted to
development is not fully t,mder,stood, fin,ding~ a
maintain maternal s.erum TSH concentration 2 . 5
. suggest that materrtal hormone is .hpportant mU I L.or less. Kaplan proposed a set ~{guidelines
durirtg th.e tin~t trime.s ter, before thef.eta.l thyroid for adjusting levotbyroxi,n~ replaoement'acc~rding
gland begins to ftJ.nction, and later iri .gestation. to the elevationdn ~erum TSH:
The children of hypothyroid women also can be ~ . . ~~\."
~dversely . affected. Re~e~ch has shown that t he l) Senirn T$H conc~ntration < 10 ~U/L:.fP~r~ase
incidep.e e of low-::birth~weJght neol)..ates . is .0. OS m gfd. .. .::
. markedly . increased in cases of .overt 2 ) Serum TSH .con~entration := 1~20 m:U/L.
hypothyroidism (22%) compared with subclinical increase 0.075 mg/d.

Scanned 8y: ~
~
 890 SECTION X: MEDlCAL. SURGfG_AL ~.R REPRODUCTIVE" ILLNESSES AFfECTING -~REGNANCY

31 Serum TSH ton~entratiOn > 20 mU/ L, increase 300. rng per day late in pregnancy and the
0:1 tn.gfd. inGrease.d renal losses o"f calCium du~ to
augmented glomerular. flltration:
Thyroid function shouid he ;re-evaluated by
s~rum TSH a.'ld total T4 measurements 3 to 4 HYPERPARATHYROIDISM
weeks after every change in dosage.
Pri.ma:ry hyperparathyroidism occurs rarely
RadioiOdine Tr~c:tment: Dudng Pregn.aney durirt.g pregii.artcy; .the tru:e fucidence is unknown
.becau~e hy.~rparathy'::"o.iditnn may refuain
Ablativ.e tat#.oioiline thera,py during pregnancy . as ymptomatic and go .. u:ndiagno:sed in
can caus~ not o;:lly maternil.4ypothyro.idism but un.co-mpllcatcil -pregriancies.
also dest..nrction of the fetal gland.
.'. Hyper.parathyroidisrn m:~ pregnant patient-can
'Postpartum Xhyroiditis meancoaside:table morbr~ty. for the mother -and
the fetus. Complications have been .reported in
Postparhi:tn thyroid .dysfunction is an 67 percent of raothe1s and 80 percent of fetuses
a utbil:i:lin.line ~sordet in-whichthyroid.mic:;rosomal and neonates27, complicati<;ms that art ill large
aut:paht:i,Dodl:es .apparently Pl.l:I.Y. a: centniJ: role. It part due to ln3.kt:nal hypercalcemi~
is tho'q.ght "t'. he .caused' by an .. iniliati~g
. in:flainm!;lt:ory ~~e:;nt "fo'l lo'wed by a spedfic ManifestaW:m.Sa;nd.Compli-cation.S,fflP regrtwt.t
auxorea6tion fioril the i.ID:tn.u.n.e s ystem. Wumen:
llistoid.giciilly~ :it-ls::..a: de~tr.uctive;..JymphOcy.ctic
thjr.t:.OiQ.a'tis\\; :<t.'fh-e''.:m'a!joliit:y:.:..of";;.'\V.oirf~ril .-~with'~ .., , 1'}' :'Nausear.Vomlting,' ortabd:o.riJ:fu<U'~i ,
po~. $yroi0. dys functi0n -.haV:e a:. :pOsitive 2 ) -'Renal~t6lic .. . . .
as~y'f6'r- nllcrosomaL'a.uto~tibodi~s: ' . 3) Mu~CQ:lar w~akness
. .... . : 4 ) .. Mental .sy.mptc m.s
A~t~t:hY.r():td +Uedi:eati.on~s - sn'Cl! . as 5) Skelet:alpain .or fatigue , .
-prop ylttuotua.-qil and .'me~~le ,ate :jrteU:ettive 6) fi}'peremesis:graviQ.arum, >"ei~t-lo'Ss,.seizure;
):n~-th~<~)i;f0t6~c:!plia.'se;~f:tli~.sropnditioreand!;.may~:.:~'' - .~orbther~sy~ptoms-i.rr:iic~g'fpree1afu'Psia
ev.e)1:'l;i~~t~~:Uj;>':~Hiv.e~p;pmnt'~rt.~.',$\l'b'#quep:t . : . .
'h~Y;i(}Id~....Tt:eaoneirt.iS.ustiali.y~not:giv~n. Comp'lic.atton.s-~tn. Fetuses . . .. .... -~
~~r- -:~~r:e -sY~Ptp~s~ <due:to :e xte"siive thyroid . .
b;olinotte;-.'j! iidr.ener.'gic.:f>i0.e ker m.ay.be u :se.lu-1.- The most frequent s.e riq:us 'complications in
Duri~g. tlte 1-~Y.;Pl?thyroid :J:Yh~.se, . thyr6~ine fetus es ..incl4-4e stillbirth, miscarriage, and
replacem~nt is ir..it,iatetl. 'rhyro.:icine should be : neonatal tetahy.
eontinuei.l::tirim t~ ~to -:1'8 mtintlis after delivery., ... .
t hen- ~Q.~ally Withdrawn. Man.~g_emcn..t of the. M.(:ither and.'the -!feariitte
. .
: Apptoxim~1i~Y two thirds of th~ee. casesreturn Treg..tment qpticns for hyperparathF1>idism in
tijl-epuy to.a . euthyteid s.tl;tte, l!>ut .tP.~ ollier-th,iid pregn,a.ncy .'be4'inuericeq by t:h syniptom~ and
su bsequently expet.ienc:e hypothyro~d~sm which severity of disease and gestational age. Optimal
may,. re.qUiFe thytoxl:ne replac~ment. manaJ.r~me.Iit req1.J_ire.s l:!. multidisciplinary
appr.:oach; su~gecy s ho1,1ld be.perlonned only by
PARATHYROIP DISEASES an ex-perienced parat..~yrcid surgepn.s}nipfumatic
and se1.r.~re d1sefise s hould be t reatM. s urgically.
Parathyroid hormbile is .a p.roteip. hor:mo~e preferably in the secor;Ld trimester,. w.l;ler~s mild
:n~spqnsiliie for the fl1aitltenanee of extracel1t~1ar a symptomatic <iisease .diagnos ed in- the t:hitd
Uuid calcium -concentration. Tt al~o acts .directly trimester m:ay continue.to ~ observed until after
on bone and kidney and indirectly on the small deliverY:.
intestine through its effect <;m the ~ynthesis of . .
vitamin D to.-~crease serumcalciu,rn.:za Parathyroid . For -..votnen with dangerously .elevated. 'serum
hormone l~v.els ?.re .i ncreas.ed :in.pregnant womeri. calcium levels; or in those ,w ho ar:e. mep.tally
This -is 'bt;ca~se of ;fetal calcium .n eeds of about obt:Unded~ emergency treatment in cludes: J

Saanned 8y: ~
 CHAPTER 66: .ENDOCRINE DISORDERS
. ~..:.":'
1) Intravenous hydration with normal saline to
evoke diuresis is the .first step. Urine flqw
should exceed 150 ml per hour:
2} Furosemide given in ~nventional doses V~.iU
block tubular reabsorption of calcium.
3) . Aqjunctive therapy includes mith:rat:nycine,
wbic:h inhibits bone resorption, calc.i tonin
which decreases skeletal calcium release and
oral phosphorus.
N:eo~tal hypoparathyroidism secondary to
matetnt~lhyperparathyroid!sm is us~!y transient
and is treated With ~cium supplementation and
calcitrlol These neonates should be fed milk
formulas high in cslcium and low in phosphate to
nUnitniZe ~e risk of hyPoCalcemia.
. Hn.oparatbyi'oldtsm
.~:..~- t
P~Uents usually are known to have
pyp<>~thyr.oidi:sm or aparafuyroidism before
pregnancy~ and the therapeutic dilemma revolves
arotmd adjustment of i:he treatment, which may
wmrmdcly.
~ - c~ri:sequently, there is no established
therapeutic regin;ien for the treatment of
hypopar~t)l~roidism durill~ . pre.~~.ncy? but
nmneiroU:s .J jrinciple.s .exist that help to guide
t:reatmepnree~rons: untleffl'"eatmen:t' teswts m disease) 1s cnaracte:ii;Zea oy tlie.llijpai:fiiien:t a.I::
niaterii1il1iypocaiCem1a;.'incfea:ses-the .iisk of
prer:natur.e labor . and of neonatal secondary
hy:perparathyroidis.t:Jl; and may lead to neonatal
skeletal - de~neralization, subperi,osteal bone
resorption, and osteitis fibrosa cystica. Conversely,
ov:ert.~atment may le~dlO maternal hypercalcemia
and neoootal hypoparathyroidism and nrises the.
P<>tential con<;:erns ofteratogenicity that hc;ts been
shown using older vitamL D preparations.
DISE,~SES OF TH~ ADRENAL GLANDS IN
PMQffAljCY
The hypothalamic-pituitary-adrenal(HPA) axis
and .t he renin-angiotensin system (RASJ are up-
regulated during normal pregnancy. Pre.gnancy
represe.nts a state of relative hypercortisolism,.
res~lting from the interaction of the matei;n.a l HPA
axis and the fetal-placental unit. Consistent with
a physiologic. role, the RAS maintains normal
soditlm b alance and volume homeos tasis.
Scanned By:
891
In normal g estation, hypercortisolisttf~and
relative hyperaldosteronism are not usually
clinically apparent. In contrast, adrenal.disorders
that do occur during pregnancy contribute to
significant maternal and fetal morbidity.
. Pheoch'romoeyton:Ul in Pre~Wancy
Pheochromocytoma accounts for
approximately 0. 1 percent cases of hypertension
in the generi:U population. It is associated with
.sustained .or p!U"Qxysmal episodes of hypertension,
pallor, headaches, and palpitations. 29 Other
presentations include chest pain, dyspnea,
abdoinirial pain, se~l"e, or_even suddendeath..38
Althou.g h a'n tenata! diagnosis is a~socjated wit.~
improved outcomes, pheochromocytoma can be
missed because oJ u~expectedly normal .blood
P ressur.e
- . . . . gestation.
during .. . . 30 u(:>'W'"er
~~ ... """ a .de!JlY~ 1 ~
diagnosi~ ~.as been. associated with maternaldeath
caused by c.etebral e dema associated ~with .
cardiogenic shock. 30 Untreated ~ .p):l~Qch1:o
mocytema is associated witb .increased~!~tat:and'.
maternal morbidity a nd -~ortality~ ::....~~~.....:.~:-~-. : :. ::~~~.
: "' )
:Pdmary Adrena! :insufficien~y..(:='-:ldlson;a.
Dlseas~) .;:. . . ,._ .<. . ,,,.: ,
'P rimary adrenal insufficiency lA1i:~p"I~pt
acutely or with a more m s idious ~t :c;>fi :chr.oriic
.sympto.m s. Primary AI . {so ~called Adtilson's :
ardos te'fone .."or c.6 rtis61 . secretion and-
adrenqcortica} atrophy arising from ifl.sensitivity .
to ACTH and angiotensin II stimulation. The exact
prevalence of AI occurring in pr.e.g nancy is .
unknown.
AI in ptegn; mcy wa:s.associated with maternal
mortal;ity rates of 35% in the 70-year period before
1930, which Unproved to 18% between 1940 and
1947; Gestational AI has been as~ociated with
high rates of intrautetjne growth retardation, low
birth weight, and fetal ~ortalit:y. 31 There d oes not.
appear to be .an increased risk of pretetm abortion.
or congenital anomalies resulting. from AI alone; :
when patients iare. treated adequately. 32
Cu$hlng''s Syndr.o me ;:;.;
The clini~al presentation of cU:~Jrings
syndrome i,n pregnancy is s imilar to .tha(in the
general population, except for the preservation of
~
 ! .

892 SECTION X~ MEDICAL, SURGICAL At-10 ~EP.ROOUCTIVE lltNESSES AFFECTING PREGNAN.CY

menses before conception. The 'CaUSe., however, . PITUITARY DISEASES

differs between the pregnant and non-p~gn:ant
state.33 The association of pregnancy with Cushing Anterior Pituitary Gland and Pregpncy
syndropte is rar-e .b ecause of the. inherent
amenorrhea. Its rarity _m ay be explsined by the Pituitary adertom~s are common in women,
ru:wvulation tbat usually accompanies severe constituting 5.7% of intracranial (malignant and
hypercortisolism. ~ Solitary.adren-;:u adenomas are nonmalignant) neoplasms, with an .ageadjusted
the most common cause_, whereas adrenal incJd~nce rate of 0.82 cases/100,000 person-
carcmoma accottnts for ~pproxjn)ately .i()% oi years.~ These ade.nomas may caucs~ proble;ms in
caSes. women beca\,lse -of oversecretion .bi hormones by
the tumor and hypopituitarism. Hormonal
Cushing's syndr.ome in gestat{c,>n ls ~s~iatf!4 dys.f unction caused by p ituiquy adenomas inay
with niatem3l morbidj.t;y, inckldi.n:t p,reecJamp;aa,. affec;tfettility and p.rt!~cy outeom.e ifp~cy
l;typemension., diabetes, wound bteakdO.wn.., does en-sue.ln add:ition, the pregnancy itself alters
ppportunisti~ in'fection$, . and .. fracture. hormone secretion and pituitary function,
tlypereortisolism effects oii the tetus ihe.lude complicating the evaluation of patients with
in~se.d rat~ of spontari:eous abortion, perinatal pituitary neoplasms. The ne~d forpreveutmgbatm
death; Pr~mature bi:ft4, a.nd inf;raUte$e -gro,wth to the developing fetus influences therapeutic
retardatiOn. t..s.a result-o f this fet~'l'and materocl -decisions for th~ mother.
morbidity,' early dl!B:g~osig _;find tre.atment ~f . .....
cUsbin"(:s.synd.tome ln J>re&n?ncr are crlti~ Pr.o lac.tinomas
,.

. .

Pfi:I!laiy hype.r at4osterottism {P.A) 'i's mre ift .f u women-With prolactit:lotnas, thestim:u)atoty
p.regnar;icy, with :apprc5;,;:bnatl!!~Y 31. ca,ses eff~t of the hormonal inili.eu ?f pregrumcy nray
te'p0rteit3511le'majorityrif..repor:tedc asesatis.c,,a'S, .. ~sult in significant tumor enlargement during
a resUltof-a drenal adenoma cor hy.peqi;lasUl:,. PA..jn ..gestatic)n; '
p;tegnlU:lcy.. 'is . ~s-~()(:~a:ted .. ~:typie:ally .~ with'
4~~;AAd:.:a~~~:W:itb:ltr~~~~-.~ .
~. .--~@ :,,.. ition.o ( case$ ll6t2.2LiiLB..~t
. .~ ~-~=':"-~:-c~~-~ - : - $~..- ' . " -.
.
reV!ey.r.,;.~.QM.w~oodcoll~e$. : .. .. P.auent$-:may . The risks of s~Fgery vet.su$?tne<lital therapy
pree..ent With sympt~;>ms that include h~~he, fot .prolac.tin.oma should pe;e;cplained in detail to
fatigue weakne.$n, cljziine.s:s, 1Ui~hnu.le c~ps. each patient. F'Dr patient:; with microadenc)Jilas
:In a .serles Qt- 27 ~.ses pr.ogt:C$~g ,t 9 . d~li\ltf, orlnttase1lar .tnacroadenomas, br.omoc:rijHine or
pt~gpartcy : was .haracte~d by :nt.Qd'~rat~ 't o -cabe.tgQl~ne therapy generally is. prefei:nd to
$evere)i.ypertension in 85% and protelnuri~ jn _ sur:gety 'b ecause it is. sa:fe for the fet\i$ when
52% cif paiientS.35 .H-igh rat~s of pret~rni de'livecy diseontiriu~4 ,earlj in ge~tation. and it :poses only
\5.2-%) were p~ia'Uy a;~trib~ta;bl~ t.o. emergent a stQall t isk.-.o f ttitnor.enl~geJilent for !he mother. .
-d~ety'fot'.<\ses with Un.~o!ltro'U<1 l)y,pertens19n. such patients should be seen each trimes~ and
H~rtension may.ii:Dprove dp.ring. g~~.tation in PA assessed f(>r symptoms such as headach~ or.
becau&e.~leyated _progesterone .l evels have vis.ual probl.ems; visual field testing needs to be.
antiinmetalocorticold effe.c ts at the renal bibule~ 36 done only when clinically indicated. PI'oiactb1
Di3.,~osis . is . ~a.d~ by lm~gh;rg .,wjUl MRl -~-r . . levelS may no~ a:l.:Ways incr,e'ase,.with::'p~cy~ .
ultrasonography. . B~th ~e preferable to ct iti induced turiwr enlargement; pe.tio.dic
ptegnant:wptnen, with theappropriate..preca.utio:ns measuretne nts of p rolactin levels are . of little
at'ld limitations. Medical:thet:'apy is ihdi~ted for bene'fit. Wheh there is evide:nc e of tumor
cas.e s that have adrenal adenoma that are enl.ar.gemeht during p regnancy, broinocriptine
identified late in gestation or those. whq :have therapy should be reinstituted .immedjately and
adrenal hyperplasia. Adrenalectomy:i.fl'the second the =dosage 'irtcrease d: as rapidly astolerated. =
tJimes~er m~y. be considered for cases wi.t h PA Experience with the use of -.br:omocriptihe .
ca;used
. .by
. adrenal.adenoma.
,. ..
thr-ou.g hout gestation is limited to .onJy slightly

Scanned 8y: ~
 CHAPTER 58: ENDOCRINE DISORDERS 893

l]lore than 100 women, but no abnormalities were prolactinomas also apply to womerl"""'\Vith
noted in the infants except one with an acromegaly.
undescended testicle and one with a talipes
deformity. Because bromooriptine crosses the
placenta, howevc:r, it should n'>t be us.e d any Diabetes Insipidus
ionger than necessary during pregnancy. :Such
therapy must Qe monitor-00 ciosely~.lf there is no Diabetes insipidus is a rare complication of
tesponse to bromo~tiptine, switching to pregpancy. It may cause impair:oient of labor:,
c,abergoline..~ssp~enoid~ ~\lrgery.. or delivery possibly . cau:s ed by diminished or sbse.nt
(if t.'le pregnancy is tar eno'iigh ad\railood) sho\ild . endogenous oxytocin. Transient diabetes
be considered. Although suckling stimulates insipidus maybe .enc.ountered more likely in acute
prolactin secretion in normal women for the first fatty liver 0f pregnancy.
few we~ tO months })Pstpartunl~ there .a,te no
data to suggest" that b~"5t{eeding can cause
tumor growth. .There seems to 'be no rea:son to
disconrage nursing in w~men with 'P,r:olactinolrias. Shee.h an'.s syndrome consi~ts of .pituitary
necrosis second;uy to . i&eheni~ occurring -within
Acromegaly hcu::-s of delivery. lt is usually secondary to
hypotension and shock from an cbstetric
. Rep!)rts of pregp.ancy in pati:ents . with be.r:p.orrh~&~ Pituitary enlargement during
ac;rom~~y are uncox::unon3~l. perha;ps. because .. pregnancy .a ppa:rei)tly predisposes to. tl;le risk for .
30% to 40% of such patients 'h ave ische~ with occlusive spasm of the .arternes to
P.yperprtl~ctinemia. 'Correction of hyperprolac- the a.:nterior pituitaiy. a:!:ld stalk.. TP~i'~~~,.: of:
tinefu.ia With bromoc;riptine tru;\y be rteces;ary to ischemia . and ~t:rosis dictates the
Si:il>se<:i~nt
pe.rmit .ovu:ie.tit;>n and p0nc.e;ption .jn tnese patient course. Modern obstetric teclini(Iues 1tave
~1ieilts~~1--J'he considerations regatcijng tbe .~~ . r.sulted in ~bee~I)~s syndtonie .beingJolind .
of brotnt>bti'pune
. ,..
';(
and ca.beigoline in woinen with rarely hi tlltrent practice. . . :.;~,,;:.;; ...'::,. r,~.
. _,_,~ .. -~_,.\ ~~- ~# _;:~" ~- - '

.
,.~~1 .:'- ,;~ ~"5-:J t.. :
r. .;.:i'"

P01NTSt0:REMEMBER-
.. .
~ Pregnantyis cl)aracteiized by hyperinsulinemiaand insulin resistance in response to the dia'betogenic
effects of normal carbohydrate metabolism.
. The risk factq.r:s assQ~ted With type 2 dfabetes and GDM ar.e cOmparable (eg, obesity, ethnicity,
family history). .
Criteria .for diagnosis of overt diabetes during pregnl'!ncy includ~s fasting plasma glucose of >125
mgidL; glueos~na; ketoaCidosis; random pl.asma gluCose level greater than 200mg/dl; presence of
the classic sig()s and .symptoms of polydipsia, polyuria and unexplained weight loss, high index of
suspicion if With a strong family historrof diabetes, having deliv.ered large infants, unexplaine<l
. fetafiosses, persiS.tent.glucesuria:
r t?estationah:1iabete~. :1.$ ~. efin.~d -as ~"roohydrate
intolerance of variable severity with onset of first
reeognition. duFing pregnancy regardless ot whethe( or- not insulin js used for treatment
There is NO CONSENSUS regarding the optimal approaCh to screening.for GOM.
For Low Risk Patients: 'Blood gltJcose testing is not roptinely requfred if all .of the following
characteristics are present memberof an ethhlc. groupwith a low prevalencecf gestational diabe~s;
no known diabetes in first degree relative; age less than 25 years; weight n<;>rmal before pregnfln~y;
no history of poor obstetrical outcome. . . . -~
. . ~

pcaii
Scanned 8y:
~
-894 SECTION X~ MED1CAL; SURGICALANO RE'PROOUCilVE ILLNESSES AFFECTit:'G PREGNmCY .,

For Average Risk Patients (Women Of Hispanic, African, Native American, South or East Asian, or
Pacific Islands Ancestry), perfonn bloodglucose.t~ting al24-28 ,.;:eeks.
For High Ris.k Patients {Women with marked Obasity, strong family histo-rt 'Of :tYpe 2 D iabetes, _
prior
GDM, or glucosuria), perform blood .glucose testing as soon as _possible. If normal, repeat blood
glucose test at 24-:28 weeks or at any time a patient has -signs and symptoms :$l,lggestive'.of
hyperglycemia. ..
There has:been much debate with the -aGCptable threshold value for tf:ie 50 gram glucos~--~hge
test.

The infants .o f GOM women-are ~t a :3:to '8-tota mcreased risk.fo~ stilll?lrth -and .aberr~nt'.fetal grOWth
(mae~:osomia.and .growth restriCti6'n} and metabOlic (e;J. -hypqg~cemi~ .a nd hypocalcemia), hematolOgic .
(eg, bmrub1nemia and pc!ycyth~Jllia), an4 respiratory oompjtea.oons.'thal increase neonatal jotensive
care.uriii: admis~ion rates and birth _~_urn~ {eg, shot.ild~r'ystoo_a).
Qqhge.1ital anomalies and spontaheptls abOrtions -are mote serious .comptfca.ti-or.s in pregestational
diabetes ih~m in -GoM:
The!'e.is a_ nPt.~d in~ea.se .frequei)_cy o f hypert~nsiori and me .need'for .~sarean delivery.
-...~ Fetal ~ff.eds -M overt-Oia.bete_s -mciUde .P.erih~llosses, abortioh; -preterm delivery, mafformations,
uoexplaln:ed fetal demise; hydratnliios;(;Q~nital :ano!i'laft~.
': f

.A~$Urem~n.t.ttitgJ.ycpsylatetll;le!flogl~birl-Aic- (libA1c) ..~!'J. :~ini-~l'1YPr~nancy. e?~Q'l~t?--th~\ev.el .- _.

:. ofgJYceiJ;liC~-co-ntiq'ffunrl~ftl:re'-~iidd :tst~tal :erganogenesis; -- ~ - .- ; ' . . _.
Ne_ooa w effectS---Ofvoveit; -aiaP'e-t~.s, inchlde :respiratO:cy -<Hs-tress~ 'h_ypo:gly~einia, :hy~leem~.
hypE;!bilirobiilemia, :~rcl~ hmrtroi)hy; 19ng..,ter:!!'i eogrimve'devekip~ent.- - irille,r~hee of;diat~tes; .
-.and!neofl<if?l maerpsom,1a... . . . .. . . '
~- M~rernalifffect$ 'of .Q .vert-.Di~asestWtu":! :tne. ex~P.tion qf:dia~thr~n!'lpafhy,:. ttJe,!png~term wurte
o{'aiC)'betesHs notaffected:.by:pr.~~ncy:~- . : :
.G6o.91y~emic:~ntrot,achiev~with,inte;'1si-fle<Hherapy pre'?ents~microvasrolar.aoo"ma-C1o'Vascuffir
cotuplica+jons- and- -impr'O-ves-~pr-egh'ancy"oot.cbme:c:ind--the- ovetalt quaiity i:if Ji:fl'l. - -
Th~ P.u~e Qf inten;ifled th~r~P. is to 3Ct'1~ve .th~ -ta(Ye~w;teyei-Qf--9\ycemi~ ~~tr~i.th~fdimirriShes
.' the raie.-Of hypb~tycemia and:k!3t~is ,and max)m~-es ,petihat:il: O.~CO~- - ,.
Although .tr~t.rn.e.nt -m odalities for .-aehi~i!1g tar;get~ - ~~is 9.f .91YcefUic. cpntr:ol in .;type :, d'l<l~te_s,
~ 2-diaoote.s, 'and .GOM -:differ, :diet .ex~te,tse, lnst4nn. ~~d -od! anti-{H?betic drugs ~r.e -the Chief
c if\9 blood-. gh-'~~ "'\Cen~lkms.
means of--redu_
: . .pret~ lhe. m?i_
.
n ~~Y 0.Ltr:c!.tm~orirt
. .
GgMwl)
. e~r.:or.:r\o~:P.M'flml~~ic_
. ther:~py ~!?.:introduce<~:.
A inOd(:)r:at~ exercise -pro~frain :for p:tegtiant'di<;l~tic. worri'en who are willing and able may -imprqve
. po~tprand!al bl0od :glu:0_seJevels ~nd-.lnsulin -:sensitivity. :
Insulin !he~py is us.ual!y n:~commende:d when stqnd<:r:ddietary ryl:?na~ement d0.e's not eonSistenl:ly
_main~in fasting..pi;:J$ma .gi\Jcose~atJe;ssl:I}Qn -10~mg/- dlpr:the 2.,h0!Jf.pO~tpra;"ldi<,:J~-plasmcrgl~cose at
less .than iZOmgJ- d):
Consensus ancj ha;-ddata are :1~ct<;ing :r:egatoin_
g how long diet th:er:apy ,shpuld-be maintained before
jnitiating phatmacologi-c- trf;atmenl
.. . . . -
The Amer.ic<;m Diabetes Assotlation:recommends the-folloWing .for follow-up :qtGDM:
o Women .diagnosed with -GOM- stiould .undeq;jb .evaluation -with <:!' 75..:g oraYglu-co~e toierance .test
at6-12 weeks after deliv_ery.
. .
o Women whose 75--g test is:riormal should be re-assessed at a minim~m of 3-yec.r intervals.

Snanned &y: ~.
 'CHAPTER .58: ENDOCRINE. DISORDERS . 8 95

,. Exercise can contribute to the "brittleness" of diabetes, with the risk of exercise-induced hypoglycemia.
Women who exercised before pregnancy can US!.!alty continue under the supervision of their obstetrician.
Howeve-r, e~ereis.e is not recommended in women who ate de-conditioned and did not exerdse "before
pregnanoy.
The s1arting in$ulin dose is calculatedto be 0.7 U/k~/d, divided into three to four injections of short- and
intermediate-3cting insulin.
Massively o9ese women may need initial doses of 1.5 U/kg/d to 2.0 U!!<g/d to overcome the combined
insulin .resistance of pregnancy and obesity.
D.eclining ins.l.ilin requirements may occur at 9lo 12 weeks of gestation and again at 38 to 40 weeks of
gestation. ~:
Fetal surveillance ls of .utmost importance in optimizing a good outcome for both mother and fetus,
especially in the perilous third -trimester.
Caution is advised against the use of sympathomimetic drugs as tocolysis in preterm labor and
I ~lucocorlicosteroid :as these can worsen maternal glucose control and ca~se ketoacidosis.
, _:
Ce~~~an delivery has ~en commonly used In the overtly diabetic woman within c!a.ss B ~r C White
cla$sification to pvold traumatic delivery of a -:-,,rge Infant at or near term.
!
I
Sinte t~e ris!< of life thre<:~tening hypoglycemia is i ncreased in the immediate postpartum periO<;i,
especially if a woman is lactating; preveni:lng pOstpartum hypoglycemia is the primary _goat~tj:.v?:'<Fi.t):

No single contn:~ceptive method Is appropriate foi the diabetic woman.
-
. : . .:.. ,,,,_.
_.; .,, ..:. '~i (. , -''.'1".~r:

I ~-. .. . . JpY._!'()id dysfunction often is C?VeriOOk?d :Jh pregnant WOmen, however, because of non~specifiC SYrft"PtortlS
:- '' ;_..-.an~d. "-e hype
: - rmetabo.lic stoe of n""'rm..a l"pregnanMI
_1 . . . ' . I'

!
t1 ..,,. ~'-i.': ~n;:rnaliti~s- m~tern:~thyroi~
in function ca:
adversely affect the fetus directly
transpl9centat passage of abnormal maternal hormone concentrations. thyroid stimulatnr9:!J1ofitl~:~:;.
by:~~x~.Qf;"tpe',

. .. (TSH) receptor antibodies, or prescribed antithyroid medications and indirecUy .by way ofthe atb:ired
!~ .maternal gravid physiot()gy.
!~'

n;e.~~eV.~ieoq~ othY.Pe.ribyroidisr:n .dUdng..p.r.egnaQcy r.ailg.es frp_m 0.1--% to.0.4%~.wi.th..Graves~-di~se

accounting for 85% <>f cases. Graves' disease .js .the most common cause of hypertnyroidlsm during
pregnancy.
j .. Hyperemesi~ gravid<;~ rum is a syndrome .affectitlg some pregnant women .and ls defined }>y severe
nauseaand vomiting :leading to a.so/o loss o~ body weight, dehydration,.and ketosis.
Diagnostic signs ofGraves' disease include tachyr.ardia exceeding the increase associated with normal
pre_9nancy, abnormal-elevation <?f. the sleep.if19-pulse rate, -thyrc:negaly,. exophthaimos, failure-to gain
weight despite normal or increased food intake.
Maternal effects include preterm 1<?bor and preeclampsi~ while increased incidence of stillbirth, small
forgest<;~ tlona l age, Cbngenltal malf0rmations are fetal effects..
The goal ofthera py.4s,to control matemat disease, While minlmizing the potential for-fetalhyp(>thyroidlsm
and hyperthyroidism.
Subtotal thyroidectomy for the treatment of GraVes' disease during pregnancy is reserved for the
foiiQwing situ~tions: when p~rsistently high dosages of thionamides (PTU >600 mg/d, MM.I >40 mg/d)
are required .to control m aternal disease, if a patient is allergic or intolerant of both thionamides, if a
patient.is
.
non-compliantwith medical therapy, or if compressive
. . ,. .
symptoms occufin
. the mother be~use
of goiter size. . .
. .
. .
m. -~

.:.t~

-.

Seanned 8y: ~
896. SECTION X: MEDICAL, SURGICAL
-..
AND
. REPRODUCTIVE ILLNESSES AFFECTING PREGNANCY
..

Thyroid storm is~ rare llfe...:threateniog.compl!r..ation of recognized or inadequately treated thyrotox~osis.

There .is maTked augmentation of the ~igns and symptoms of hyperthyroidism usuaHy trigg:ered by
Jabot, vaginal or cesarean delivery or infection.
Treatment of thyroid storm includes.hydration witiY5 to 6liters of intravenous fluid per day; hyp~rthermia
e0ntro!, Propanolol (Vsed with caution, rfthere is heart failure) IV, 1.0 mg every 6 hours; propylthiouracil
(PTU): 1 gram PO; Pota$sium Iodide- 1 gram PO.
Hypqiliyroidis.m is feund in 2.5% O.f pregnaf!cies.
Maternal effects include Gestational hypertension, fetal distress, p.lacental abruption, anemia, and
.postpartum hemorrhag~.

Fetc:il and neonatal effects include. increased inCidence oflow..:birth-weight neonates, lrnpaired ~gnitive
. funtuon
. . ,~mpng .off$pnng,...:and
..
del~y in mentai . and motor development
.
Lev~thyroxini3 dosage should be adjusted to maintain a maternal serum TSH concentration 2.5 mU/L
~ .
For newly dlagne.sed hypothyroid women , -lnitial levothyroxl.ne dosage is based on -severity of
~yr.ord~rrt; For.pvert hypothy~q1dism, administer 2 mg/kg/d. lfTSH Js < 10 niU/L, initial dos.e of
0.1 mgkimay b~ sufficienl ~... .
At*lti:V.~ ~tac:!j\3~inet~hefP.py <luring piegt,a!)cy can cause not only ,tnat~mal hypothyroidism .but also
destn.i~tip~H>f.:th_e fetal 91and~ ..
. . . : . . . . . . .
Currenfiy,:.:there:.is:.no..~nsen.sus:~o .theappr~:pr@tt;!.timing of:sur,g~!)'.Sorq~.experh recprrimend qperati ng .
during:l;lie.secol19 "lr.iffie!?ter, b e:fore 1~ '\.V~ks'. g es~tion, tO .niihimizethe fisk Of miscarrlag.e.. .
. Th~ :~e .tit~i~~nc~..~f:prt~~ry hyper.p.a~yroidisi'D.~ uo~P~fl. .because.:hyp~rparathyroidism may
remaif:i~ptGIT\aticr'and.go::tmd~hG>Sed.in :'Vhcompticated pregnancle.s; . . . .. :
. Mater.tofi1pfiatiGns.)ntJud~: ~?usea; :Y;cmit:t.jg,.~,abdott:1inal,~in; ..ren~1 c61i~. mu5cylar we~I<Oess.
: .ll)en~:#,hptorns;-si<ete:@lJ:i.alin)r.'fa~u~:'O~erdinical rhanife_~~ti91Js include.hyperern~~~sravjparu m,
.. W;~.~~.b!~~-~!:~-~~~~.. ~~ :!b.~-~!.!l.~~9~~ .rn.I!:i2i~JQ.9 :gr.~e_a:-n.).P~!~:. . . . _
. :Th~:,tngS#fr~u~nt $erio~.s:~mplications .-ir).-fetupE!.s:incltJde-stitlbirth; misca h)~g e;:.and.n ~98atal 1gtany:
T;eatrrl$i':lf:~.ptionsfor:hy~-r:parathyr.oidismin:'pregn~ncy :are !nfluencectby the. symptomsand -severity
of-disease-ana: gestaupnal.age.
S~lmptqmatlt ?J no .s evere.-~Js.ea~e should :.t;e "tte~ted surgically, preferably J(J the .secoqd lrimester,
wh~re?S :f:i:lild"asyrnptomalic.'dlte.as-e:diagn0sedl.n the thircftntn~st~r may:Goritihl..!e to' be bbserve'd until
after":o~~vew. . .
.. iher~;iS'!ib estabtished-t1etap~utic regimen.for the trea,tm ent ofhypo P9 r:athyroidism d uriligpr~ghancy,
but i:lumero11s principles :exis~.lhat help to guide treatment dec,isiohs.
PheQChro.mocytO:ma- aGG0llnts-,for-approximat.e\J 0~ V>fo g:JSe$ of hyp ertension in theg en~ra l population.
Ther~'tl9-ve.been at.teast.2b0 cases diagr\osea In preg nancy; and 'the estimated preva!enGe at term is
~ppt.0~Wnately 1 ih 54,0r:JQ. ,. .
Pheochromocytoma is as$OCiated with sust ained or paroxys mal episodes pf hypertension, pallor,
heaf!athes, and palpitations. .G;tner.pr.es.entations .include.ch~st pain, dyspnea, abdQmin.aLpair), seiz:!Jr.e,
or even . sudden death.

Untre-ated,phecchromooytoma.is .associated with increa?ed 'fetal and maternal morbidity and mortality.
Adrenalectomy .is the _pr.efer(d -definitive treatment of pheochromocytoma fol!"owing adequate a:,. and
~bJ~ade for at_ least 2 V{e ~ks before surgery.

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 CHAPTER 58: ENDOCRINE DISORDERS , 897

,.
Primary medical therapy is Indicated for cases diagnosed after 24 weeks gestation because of the
attendant difficulties and risks of surgery performed at that time.
The optimal timing of adrenalectomy is late in the first or early in the second trimester.
!n the t.'iird trimester, a combined cesarean section followed by adrenalectomy for cases managed
conservatively with medical therapy may be considered.
Vaginal delivery is not recommended because of the potential for exacerbating a hypertensive crisis.
The exact prevalen~ Of adrenal insufficiency (AI) occurring in pregnancy is unknown.
AI in pregnancy is .ass_ociated with matemal mortality, high rates of intra uterine growth retardation, low
birth weigh~ and fetal mortality.
The optimal antenatal management of AI occurs in a multidjsciplinary clinic that inCludes ~n
.endocrinologist whose primary rotes .an~ to provide a diagnosis, monitor the adequacy of corticoSteroid
or rnineralocartico!d repJacerrient regimens during gestation, crisis, and labor, and to ensure continuity
during the postpartum period.
a
During gestation, a diagnosis of primary AI should be considered in. case with classicsymptoms .o f
exciessi'le fatigue, malaise; weight loss, vomiting, orthost.asis, abdomina.! pain, .hyperpigm~ntation, or
biochemical disturbance.
'AlthoUgh criteria for diagnosing AI in pregnancy have not been. developed, the.previously reportedllM1:,
. third-trimester plasm-q ~rtiso11evets and responses to the SCT in normal pregna.nt ~omeri :aoo'fh~ ;,.-
...... . resultS fri:>rn the low-dose cor:tiC9tropirl stimulation testing cited above provide usefullnfo~tion.:::::':::;h;: . ..
:_..:... The.. a..c ute treatment of adrenal Ciisis includes prompt, rapid glucocorticoid. replace~~nlw . 'i tff::' .
'-~-- hydro<;Oqi$cne, too
mg to. 200 rng Jv.
as a single poiU's: Thereafter, a bolus of 50 mg to 1 o.omg
is given
. :- ever'{ s to 8 hours during the acute period, based oo maxim'a l cortisolproduction ra_tes of2o o:lngldta::. - ,~ ~ -
1.. -.:~ -400 mgld. . : ; .:~;-_: .~..:~:~il.,....
Routine glucocor:ticoid and .mineralocorticoid replacement therapy can be.continued until tlie:,onset'.~'
labor; provided thaUhe patient has no symp toms ..of lirider-replaeement
N~r.m~fvgi.n~l <J~i)y~ry)~ af~~sof!~ple ~X.P.~~~ilqn for-wo.rnenwiTh A[ Ces-arean section Is const(j~ered .
for lnc!:e<;~tions similar to those in normal pregnant individu al~ .
Cushing's syndrome .i n gestation is associated with maternal morbidity, including . preeclampsia,
hypertension, diabetes, wound .breakdown, opportunistic infecticns, and fracture.
Thti\ CRH stimulation test:i s us~;:ful pr:rnarily for the differential diagnosis of ACTH-dependent Cushing's
syhdrome-~
It is rCOmmended that surgical tre.atment of Cushing's syndrome be done in the second trimester of
pregnaney, with medical treatment as.a second choice.
Primary hyperaldosteronism (PA) is rcrre in pregnancy.
PAin pregnancy i.s associated typically with hypertension and associated with .hypokalemia. Patients
may present with symptoms that include headache, fatigu e, weakness, dizziness, and muscle cramps.
AQrenalectomy in the second trimester may be considered for cases with PA caused by adrenal adenoma.
The benefits of successful surgery include nc:>rmalization of blood pressure, whlch can be expected in
approximately two third$ of non-pregnant.cases, together with the n ormalization of serum potassium in
to
a majority of cases. These benefits have be.balanced against the potential risks of surgery or medical
therapy in pregnancy. i

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~
898 . ILLNESSES AFFECTING PREGNANcY~-
SECTION X: MEDICAL, SURGICALANO .REPROOUCTNE .

Forpatients with,prolactinomas, the choice of ther;:~py r:nay have important consequences for decisions
regarding pregnancy.
For patients with macro-adenomas, surg~Jcures a much smaller number.with a consiciera!Jiy.greater
risk of caus11}g hypopituitarism and ~y affect iertiilty.

1.1. Cefalo RC.. A ~~pariS!>n of glyJ:n.iride and iilsulin in

L Langer D. M-anag'em~nt of .O.~sta~onal Dial:;etes:
Fnanna~logicTreatment Options t1.:1d'G1yteuiic Cpntrol
.2oo6; PP 53-si.
2. Merlob P, Hod M. Sh9rt-term implkations: the neonate.
Jn: Hod Mt Jovanovic-!,-. D1 Renzo -GC,-:e t aL {edit~):
T~k''ol.Diahete$.:an~fP:regnancy. l:.ondoU: blartln.
Dunitzj ~00~; pp. ~8:9-304. . ideat: ~plc of "bench to bedside.""' P~ ~
. 3. Langei:' 0, Ypg~v Y, ,Mo$t 0, ~t:aL Gestationa1 diai>etes:
the:COM<r$.~Jf.~~s.of. not~tin.S,. J\i::l:J -Ob::;~C;t.Gyn<::t:o;I. .
2005;.~-92.: g;89:-e997- - .. . .. : . .
4; Yog~~ Y~ B.eu~-Ha.rOush A, -~hen R , et al. .Diu:m:iil.
glycemiC .Ptdt:ile in ()b-ese ld. nornuiJ.,wct~t no~
d~ab.eti:c pr~~ant wo:i n.en_. ~ .,J.'O'lf.stet, P;yne~oi
2004~!91;
. _. . . i6.5S...166o_
.. . .
5 .Am~can. ~~g 9f;Ob$tetnc4s ..a,nd '~~lo-gi.~~~.. . 16.._ ~;o'van's>_vic L. 'The use of oral:ag~nts -~g~
QJ.liu~:~,~~~It~~enJ ou~deJlli~s -fo~.-f?)j~~~~ .to tr~t :gt:Sta:tioJ?.R} dianetes. Cu.Jj rr.ab .Re:p 2001; 1:
69-'-\:tu.
Gynd:olo.,gists:~ No . 30 . .ue.st~t~Otl.-a'T .l?..i~b.et~~.
Wa'shiii:gWfi;DC!~edcanCC!!:tgh>fOb-stan~~a
Gyn~~logi.Scy;~~l:.
6 .. ~eri~.u Dk~tes t\s&:>ciatio.~ Position s~te'm,ent, on
ge~tional dietes .mellltu3 ..Diabetes Car. 20Q-n; .
27(Suppll); S8'6-S90 ..
7 . Artal .R. ~xe r~~se: th~ alte~a tiv:e ~h.erap.~{i~
intervep.tlon Jot gest~tional diabetes. C1in O.b~t:et
Gynecc-! .2Gv~; 46:-479-457.
8 ;- carr K, Idama'TO, Ma.sSon EA. A ra.Ldomiud contrOlled
trial of insulin lispro .given ~fme or ~ter meals in
l)regriant -w0 ~en :with typ~ 1 dil; bet!!s: the-:e:ffect -o:n
. -~ycaemfc exrur.sion. J Obstet.Gypaecel2004;_ .24:.382-
386 .. .
9. ~eece ~A. Homko c. Miodov-nik M, Langer O .. A
consensus repor.t of. the diabetes in pre~cy :study
group of' North. America Co:nfen;nce. J. Mat~ Fetal
"Neonat !>ted 2P02_; 12: 362-:l64.
1-.0. SaadeG. Gesta!;ional .dia~tes rzu~llitus:apill -Qr'a'$ho t?
[editt?rlaiJ o.bstet o.Ynecol200S;105: 456457.
women with gc.Stat!oru~J diabetes .mel!itus. Ob3tet
Gyn~ccil Su.rv 200 i; S6; 126-1~7
. 12. Gabbe SG, Graves ~R. Management of diabetes
l:ncllims omplit:ating pregnancy. 0 bstet Gyncc:ol:2003;
102: 857-'868. .
13. K-oren -G. The )..\se of glybUride iri gestatiimal tfuilictes:
2001; 49.: 7.34 .
14~ RY.~ EA,. 'Glybuiide wa.s:a:s sale .a=d cif~~'inSulin
:in.ti6u~:tion:aldlabet~:E'Vil}-en;ceB.a'seQ. MCdic:ib:e:2001;
6:.79 . .
ls~::coustanD.ILO'ni14ypoglj-Ce:mic~~~:roi-~Obf~ ;
. .;COntanp Obst-t'Uy:n~oi'200i; ,45.-'63.
.'
17. Gut#n: s; K0 ~r ~ };{a:gt~ ~. et a1: 'Dfe sareg of oral
h;i>Qglyc~c a,&ents mthfitst triilrest~ ofprqancJ:
~ 'm.eta~ysi~;,canJ Clin: Pha:rmac61'200:;i;. ib: 179-
183. . .
18. Gluecl5-.CJ. Goldenberg N, Wang P, cl :::l:'Mdf.onnin
dt=ni.mt Jri:l<'g pancyiredue.s in~u,lin. li1sUliil ~ee,
. in_s~ 8ect.etton, weight, teSt<)St~nea.ri4dcvclopment
of gestatii>n~l cii~'!>~te:s:- prospe!=tiv.e lo:n'git;udinal
as;es:shl.ent of:w~tn:en With ,)?cilycystic:oVary- syndrome
from P..reconce.ptio n -thro.ughout pregnancy. ~Ulil
Re.p!-"'d 2004:; .19: '5 10-521.
19. Glueck CJ, W2,ng P, Kobayashi S, et aL Mctformin
there.py ' througho~.t pregnan.c y reduces the
deve'lopinent of gestational diabetes in women with
pcilycystic ovary eyndr:ome. Ferti1Steril2002; '77: 52()-
525.
20. Jakub<iwicz DJ, Juomo MJ, Jakubowicas. Effa:u of
m:ef~ornjin on early pregn~cy loss in the _p<;>lycystic
ovary syrt:drome. J Clin Endocriilol Metab .2002; 87::
524-529.

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 CHAPTER 58: ENDOCRINE DISORDERS
------~-----~~---------------------------''--......-
~ ~::i'l
;::~
21. Jovanovic L, Nakai Y. Successful pregnancy in women
with type 1 diabetes: From preconception through
postpartum care. Endocrinol Metab Clin N Am 2006;
79-97.
22. Jovanovic L. Glucose and ipsu!in requirements during
labor and delivery: the case for normoglycemia in
!)iegnancle$ complicated by diabetes. Endocr .Pract
2004; 10: 40-45. .
....
23. N~e D, Burrow G. 'Thyroid disease and pregaancy.
Obstet Gynecol Clin North Am 2004; 31: 893 .
24. Pop VJ, Brouwers E'i>, Vade:- HL, et al. Ma ternal
hypothyrox.in!lemia during early pregnancy and
suQ~~equent cbild dev~lopment:. a 3-ye~ follow up
study. Clin.Endocd nol (Oxf) 2003; 59! 2.8 2.
25. Mandel SJ; Thyroid di~ &rid p regn;mcy. In: Copper
DS (editor): .Medical Manii.getl;lent of Thyroid Disease.
New York: Marcel Dekker, 2001; pp. 387-418.
~6- MesunanJH. Hyperthyroidism in n~gnancy. Best Pract
:Res Clin Endocrin9l Metab 2004; :to: 267.
27. Scht!att PF, Cu.-ry SL. P:ri.tiw:y hyperparathyroidism in
.'7
. .. . pregnapcy: evidence-based management. Obstet
Gynea>l Surv ~2; 57: 365--376.
:;!8. Kovacs C, Fuleihan GE, .Calcium and bon e disord(:rs
.., during.preg:,e.n...--y -and lactation. .Endocrinol Metab Clin
N Am2006;2l...:$.l.
~~29. Lyriian OJ. ParoXy.smal hypertension , pheochro-
. inocytoma, Md pregnancy. J Am . Board Fam Prnct
2002; 15.(2): 1'5.~158,
30. Cemiako~a A, kriibb M.lloski:ns .C, et al. Postpartum
pha eochrom ocytomiL int J ObstetAnesth 2003; 12(4):
3()()-304..
3 t. Gradden C, .1 8wrence D. Poyle PM, et al. Uses of error:
Addison',s di sease in pregnancy. Lan ce t 2 001 ;
357(92q3): 1197.
32. Donnelly JC, O'Conpell MP, Keane DP. Addison 's
disease with 'Sl,lc~essful p.regnancy outcome. J Ohsi.et
Gynaecol,2003; 23(2): 199.
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' 899
33. Lindsay JR, Jonklaas J, Oldfield EH, et al. Cushing's
syndrome during pregnancy: personal experience and
review of the literature. J Clin Endocrinol Mctab 2005;
90(5): 3077-3083.
34. Oh HC, Koh JM, Kim MS, et al. A case of ACTH-
producing pheochrcmocytoma a:;sociated with
pregnancy. Endocrinol J 2003; 50(6): 739-744.
3 5. Okawa T.. Asano K, Hashimoto T, et al. !)41gnosis and
man~ge ment of priinary aldosteronism ih pregnancy:
case report and review of the literall.u:e. Am J Perinatal
2002; 19(1)~ 31-36.
36. Matsu.m oto J, Miyake H, lsoz:&ki T . ~t al. Primary
ald9steroni:.m in pregn&.ncy. J J:lippon Med Sch 2000;
67(4): 275-279.
37. Central Brain Tumor Registry of the United States
(CTBRUS). Statistical re_p ort! primary brain tumor& 41.
the US 1997-~COl. Available at: http:/Jwww.
cbtrus;orgf. Accessed AprilS, 2005,
38. Musolil:jo NRC, Bronstein MO. Prolactino!DAS and
pr~a.J)cy. In: Br~nstein MD (editor:);.l?iWitary.:t umors
a nd pre,gnan~y. Norwell {MA): ld;U:wi.t, A~,ad'emic
Publishers; 2001; pp. 9.1-108. . ...
39. c:lierl T, Ziegler R, Kasperk C, Piegnancy mpe~stent
acromegaiy. ClinEn doc:rinol (Oxf} 2000; ~: 262~263 .
4<>. Neal J:M. Successful pregnancy i:Q. a wom~. vrith
acromegaly treated with octreotide.- Eriii'6crl.tior~
2000; 6: 148-150 . . ::-~~<'-'")" ;;':-_':1-.'f;:< ~
41. F.~-~~~c!_lt .~,_ <?a.P.~!l~ B,_
A!'-It:Y/1 c:t .~ .~~~~~ ~
treatment throu~out pr~$0~9' in .!'Ul.acto[Ilegalic
woman. Clin Endocrinol (Oxf) 2001; 55:411-415.
4 2. Bron s tein MC-, Salgado LR, Musolino NR. Medical
management of pituitary a denomas: the &pecial c ase
of management of the pregnant woman. Pituitary 2002;
5:99-107.'
43 . Ser'ri 0, La..t toie G. Successful pregnancy in a woman
with acromegaly treate.d with octreotide lopg-acting
release. Endocrinologist 2003;13: 17-19.
:~~- -
pctlii
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 .---- - .

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~
 59

INFECTIONS

RICARDO M. MANALASTAS JR, MD

Basic Concepts

Determinants ct" infections

Normal Microbial :Flora
Pelvic Infections are Polymicrobial
Rooi of !nfecticns

Microbiologic Test

Anti-microbiatTreatment

Effects on Pregnancy

Infected Abortions
tli~96<)5.is ~na Ti:eafmenf
Intra-Amniotic lofections
Diagnosis and Treatment .

Puerperal S.epsis
Diagnosi s and Treatment

Selected Viral Infections

External Genital Warts
Genital Herpes
Human Immuno-Deficiency Virus (H!V)

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 ~02 SECTION X: MEDICAL, SURGICAL AND R'EP.RODUCTIVE ILLNESSES AFFECTING PREGNANCY

BASIC CONCEPTS commonly caused by more than one kirid of

tnieroor.gani$m. Anaerobes often accompany other
Clinical infection-is directly rela ted.to the dose aerobic bacterial pathogens. Most of these
oC micr<>bial contamina tion and virulence of the organisms are part .o f the normal flora in the . .
.orgamsm, and inversely related to the immune vagina. There are important diagnostic and .
system of the host. This basic concept is not therapeutic implication:> -oi this basic concept.
disti.""lC~ to female pelvic infections but it has Diagno.s tically; other organisms must be tested
unpqrtant appUcations to its understanding. for when another is found . .Just because only one '
Clinical infection refers to symptomatic disease i~ddentified by a certain test di)es not necessari.ly
fr~t.n the presence .of micro bjlil organism (S.). mean that other organisms are not present as well..
.~:o~g the tht~c deter rtilnal),t s in the ab.o:v e It ou.ld 'Well be .that the test ju~t dlnn(')t detect
,. eqU:ation_.it iiS the d.os~:pf~crobialeant:anUnation_ the pie.$e!l<fe .of bt;>th. Therapeuti~ly, }. regimen .
~~ ~rte~ pract:ical;ly amenablet::>.m:a:n~p~tion .must often be tailored totlle several }:iotential
~l?Y , *he .p'hysici~n. i-n .:fact, mo~t m~asw'es ::~uspect~ paih6g~ris. " '
\lll(!eitaken, te they preventive like clippi~g oU~air
. hi.:t he :operative site, skin disinfection, washing of The asce-nding route is the predominant
: ~t4<; qp,e rative s~te with sterile solutions, mechanism in female pelvJc inJections. The
;m.e~us surgical teehPJq~e. insertioQ. of drains; endometriuin, fallopian t\.,\bes, ovaries and ~lVic .
...p~yta.ctit antibiotics, etc.; or therapeutic like Ca.Vity arc nprma.Jly sterile. the mu.cus plug in t.h~ .
a~.J;i~uon of ah abseess., debridement of ~n cervix functions both a s mecha"Q.ical as well as .
~.ted -wound, curettage .o f an infeGted abortion, to
physiologic ~er the ascent of nlicroo:rgar.i.Sp:l.~
: ~cision-.drainage - of a ..tubo-ovarian ahs:cess;: nortnally present in .-the ectocervix: and vagina.
d~"JiVc~ of'fetlj:s ih' intra~amniotic .infection~ . . :our.ngpr~gp..ancy~the<int~ctamnidti:c:membranes:,,.:., ;.
. hy~tomyforsevere pue~rals~.psis; etc.--:are ~.., . . . ~tve this:f unctiori:aswelL When this protec~e:.. ....
.~aU -m~ant to .reduce the dose of microbial mucus plug or intact amniotic membranes ':are
. ,~Jit~~matio~. .Bydoing SQ, L'le-eql)ation shifts somehow disrupted -or -b y-passed-; . such as..in .
'in -ta~t: of. decreasirtg-'the ris k,dncidence ,.and; .. incomplete abortion, ptem~ture tti ptur.e . of . .
~~'sttiity- ~f t;litiieaF infe~tian. - Ar{ hn.portau t-- membrane s . and following . vagit?-al .delivety;; .. ',
lmp"iidlticm,"ofthis'basi~' concept is thati.removjng~'., ~. mkrootganism$-can .bettansportedinto'theupper ..; '
tb:C~ldeuS' :of Tnfeetjon'; whe:never .reasi'ble:w~ll genital tract and cause infectl9n ~ Pathog~ie
.~tiiiatfY~fa<e-ilitak resolUtion of the hifect1on: organisme . that: are: not part (:)f.the norma!Jle~
.,:M tib'i9tics, alone may no~ always be s1.1fficient if can be deposited.. into .theva ginaor.. dire~tly -iJtt6 :
ille ctose .of microbial eontamination is not the upp~r genital tract by various tnellriS.
~uced. Unprotected 'Sexual contacts. instD.tmentatlpri~
. both diagnostic "like hystero.Salpin,gp~phy and . :
:. 't~~ fel:nale genital tract is colonized by .a therq.peutic, like completion curettage are S(jme
n~~l microbial flora. The vagina of normal common ~ples .
. , '"WQ.'mencon~sa wide'variety of.n iicroot g-cJlisms
'b~~-,~st in a dyn;;unic homeostasis. StJch nonn~ M"~crobiologic 'fests o.fFemale .Pelv:ic Infectl()J1S .
0

.11p~--n"$ists Qf gram neg~tive a nd gram p ositive can be M islead-ing and Unreliable

:O.~$ms , both aerobic and anaerobi~, as W (!ll
u ::SOttie fungal ~d non-pathogep:ic protozoa. The
'J)te(f~ptinance of add-producing lactobacilli,
-ri~luithed by glycogen~rich epithe:iiu.m under the
ihlh.t~nce of estrogen is the most important (actor
. t hat,maintainsthe homeostasis. Disruption of this
.pr~'ttt1ve homeostasis can lead to clinical
i.nf~tion, which in many instances is caused by
ol"ganisms that are part of the normal flora that
halJ.e -,hecome pathogenic.
.. .. ~J.{ost female pelvic infectib:n s .are
p(>lymicrob~al. Unlike infections in ()fuer areas of
the body, ir.fections in the female pel ..: ~ ~- ~
Scanned 8y:
The female pelvis is .a deep seated space .that
is difficult to a ccess when obt?ln1ng specim:~ns
for microbiologic tes ts. Onless a transabd0m.i,naL
route is used, most s pecimens obtained through
the vaginal route are bound to be contaminated:.
by the microorganisms residing in the vagina.
Hence, it becomes difficult to accurately interpret
the results of tests done on these specimens. It is
often hard .to distinguish betwee.n true pathogens.,_.: .
from mere contaminants, unless the idet;1Ufied -
organism is not a mem be.r of the normal.f!,ora; like .
~- --
w::.
".
.N.gonorrhea. The other issue about microbiologic : ...
~--~ -c ale pelvic infections is .
the need to .' .
. 0
 CHAPTER 59: INFECTIONS
-~--------~--------------:-'-.,------------ . ~~, ~
.;a,.
use the apprppriate culture medium especially
when attempting to isolate and identify the
patho~en. some organisms have special nutrient
r equirem.e nts for gtowth. Inability to grow them
in general non-specific nutrient ~ulture media
does not_'A}ways mean-the organism is not present.
Ifmay well be fua~ .t..'l~ appropriate culture medium
was not used. This is$ue ina} i:>e reeol~'ed by clo&e
coordination wit.h the microbiology laboratory prior
to obtaining speci::nens for the su.sp:e cted
pathogen.
B&oad s'pectru~ emplric ethnicroblal thera"py
b . ofte~ 11ecessary to treat femal~f }'elvlc
~ecUo~
0 completion of 20 weeks is termed an abortion. It
.an
' As the
off-shoot of preVious basic concepts,
.thi$ one adv:at~s the l.l~ of a treatm~nt regimen
that c::cY.ers.alJ .potential pathogens. By etnpiric is
meant that .a regi~e~ is ehosen. based on
:epid.e.tni~logi~ as well a~ cUnicaJ. data on the
comro~n::pathogen~ and the sem~itivities of these
pa~'O.k~ns to antilnicL"obia:Is, By l>ro~d .
specti1uri is llleant that the ri;:gim~nJ eitbe.r IP6no-
. tb:er,apy ()f .c ombination th~rapy, mil .hs:tve
a.n.tiiJ!!c;;ro}:)j.al djicacy against a wide r~ge of
.org~$~. })pth-gtatU positive and ne~tiv.e,' as
~n:~~~n;)~s.
'~~~:~~and its :phy$l()lo.g lc .c hanges must be
qb.- .~~0 <:*-~l-~~g~p~~ m cb.,oosl.ng :tlie type
.aDa;aJit'iiLJ:;f...~tiitlictobial~.age:rits..:Used~tor
~e~tlcnis:.m. the ~obst~bic :p~Uent
. 'l'era{Ogenesis and other adverse fetal effects
are. obvious cOnsiderations in choosing .t he tYPe
ofantimicrobia,b used for pregnant patiep.ts. ~ss
obvious b~t equally critical for succt:'ssful
trea.t ment of infections are the ,p hannacoidnetic
Qpseque~e.s of the various physio.logi~ changes
in pregnancy.. The changes include the eXpanded
plasma volume, i.r)creased glomerular "filtration
ra,te, .alt~ratio~s. ii;lliver enzymesaotlvity and the
varion.~ gas~\)-intestinc:;.l cpanges .in differeht
stages ofpregx:iancy. The over.;.all phann.acoki.netic
.effeCt is the iower serum levels of ~timicrQbi~s
in the pregn~t patient, most marked in the iliin;l
trimester and the puerperium. This is estimated
to b~ around 20-.3.0 % less tbart the non-pregnant.
levels.
The clinical implication ofthis.is that-in order
tp achieve the same adequate therapeutic levels
of antibiotics in the se~m, drugs will.have to be
Scanned 8y:
903
given at a relatively higher dose or at ~. :more
frequent interval, .or both. this applies . e~pecially
to ceph~losporins and other beta lactam
antibiotics, as well as aminaglycosides.' Short of
measurittg serum l~vels of s.ntibictics to assure
adequate dosages, it is recommended to use the
higher.dosage range. 1t is possible t.~at the correct
choice of antimicrobial is made, but the pregnant
patient does not improve because of the relatively
Jow dose being administered when this basic
concept is unrecognized ..
INFECTED ABORTIONS
Termination of a pregnancy before the
~may be spontaneous, meaning uruntended and
merely a. f..esu.l t of the natural cour-S.e .of the
pregnancy:Or it m~y be' imfuced, tneanb,:lg the~
was an intentional or willful intervention to.
terminate a viable :gestation.' InduCed, a;bgrf;i.o.n,
which is also termed criminal beCa::u~~~t;j.y,jol.~f.*,s.
establishea laws '(~s in the Philipp,~.,s1".~I\be
further ~lassj.fied depen~g on tl1e..-l!l,~J;\1P4. .~ey..,
Induced s.bo(tion by' instrumenta,.tion ~fe~;. to .
temiination Of p~gnancy und~r illicit an4 usually
septic circl,UlistanGes by inserting._iAA~~~~..~r..:' .
obJects. J nto the .uterine.cavity .tp.: n113.~Px.<~ilie:
amniotic sac, separate the placeAtacm!l~~yj~F.-\Wtet
the Uhwimted embryoffetu~. D1J.ring;~J:ti:e
. procedure, exogeJ16Us micrQprg~l$m~ ;()Jl" the ..
instruments-used,aswelt-as~miertrorganisttrs.
colonizing the vagina as nornrat nom a_~ diteetly
incculated in the endometrial cavity cauSing the
infection. Induced abOrtion by medication refers
to the administratibn of sul)stances either top~cally
into the vagina . Qr exoc.e rvix to GaUse uterine.
contractions, cervi~ softe~g artd dilafutiori,and, .
rupture of the ap:tni9tic s ac, separation of the .
placenta <md expulsion of ~he prpducts of.
conception. In this instance, as w.e ll as in
spontaneous a bor tion, infection sets in wb,en ..
mjcroo;-ganisms colorti.Zing the vagina a~ normal
flora are able to ascend throug..lt the open cervix
and mt1ltiply in th~; endome.t rial cavity that
contains blood and non-vial>le products of
conception. that are widely known to be excellent
nutrient media. Usually exogenous
mitroorganisms are not involved in this..,~~cond
type of infected .abortion. . .~- .
' ~ .
. . 'l'h1s classificatio n. of .abortion has cliniCal,.
so~ial and lega l implication:~~ .Infecti~n.~is not
limited to induced abortions. Induced abortions
~
 904. SECTION X: MEDICAL, SURGICAL AND REPROD.UCTiVE ILLNESSES AFFECTING PREGNAI~CY

may involve different microorganisms depending . resuscitative mea~ures 'instead of the last resort
on.the.spedfi~ method.used. pelay in. the when all else fail. ~ost deaths from infected
. evactJ.ation of non-vjable "p roducts of concep.tiori abortions are due to delays ..in performing the
in cas~s of either :~pontaneous abortion or abortion appropriate evacuation :procedures.
indu~e~ by me~i~tion aUdws for in!ecfiori to
develop. A broad spectrum antibiotic .regimen v;rill
usually surfice. ) 3.ecaU:se gram ~sitive anaerobes
DiagnoSis including Clostri!iium species may be inv.ol~ed.,
high dose penicillin G 5vd1um is appropriate. The
Tl)e patient with an in'Iect~d abortion wtll addition of an aminoglycoside, us1.thlly gent:3,:micin,
usually ~omplaip ofvaginai'bleeding f!,ft~a_perio:d for synergistic .action against gram n~gative
of amenprrh~a. 'assoc!a.ted with .hypogastric :pa.iJ?., qrganisros in severe infet.ti.ons .is J;"eci>mmended. .
passage ~of blood Clots or 'i+leaty :material When gra.PJ. r1egative anaerob~s are.S\l~_?e.ctCd
(embryonal/ feta:l. and pla~ental) and fever, The such as in the -presence of pelVic absces~ and foul
is
cervix i~ .o pen, .the 1-tteru.s :e.n lh{g to vari.Ot:,s necrotic tissues or discharge!;, .metronidazeie o.r:
d~es _ de~r~d..i.rig on thp .age of gest,a,tion, atid clir..dainycin is .added to the regimen. Patients lvith
there i's :pain on _p alpation o( tl:l~ ut.~rus .~d co~fir~:ed or s\lspected abortbn hy.
actnc./.\~'thhl vari~~ ffi.inleri.sitydej:>ehQ.i.11.g'on tl;l<: instrumentation. whose tetanus inuii.wuZ<i:tion
. severity of. the iec~on .. tn: inQ.~ced :a9::'tJ.6ns ~Y . . status i~ .either uiiknown or not current should
in~trun:i:ent.aqon, _'f9r~~gn .b.odies or . evidepce of ~ given antl'-tetair-.ls. $e~.ari:d toxoid .as well.
.t;-atn:rla .;roaj_l?e.:-tm~n4.:.k. th~ :g~l)ital tract. .:Fopi Patjents .at .high risk fox: h.arbori.ng sexually
oaor''inlplies')ruected.:,'riecr.otic ..tissues..,zaus.de transmitted pathogens .(multiple sexua".l ~ers,
. :gu.lu-~-g:ifria:.S:ffi~~~f~gidiij ill<1?ii~cira~- ,.n:ew.:partn~r wriliin. '3 ~anth~~. symp.~itiatic:
a.n~r .~.bOw.i::I:teiJ;aei=n~:.~P.li~~;i:~J6Y:~mro~ptiVic ' . p~er. 0r lif'et.i.i:O.e sxua".l.',part:bers. oore. than s) .
~trihliis:a;ro. :po.ssibk'uterliie ~g even. bow~T. .mibht oe~efit with,'th~ use :o"r :t:h?.ro-.g~ration
perlofation'foil6~: abo:iti9(by i'(l~~tati9n. cephalospg,rir1s and. n~orb.quinolones tri.cOver N .
syst~pi~~:.~e~t.atio~~rof:.sep~:S~.aihe ~~P,t: gonorrhod~.: and-c. trachoma~~ ;:P.a~~nt3~with:
in' sp;~.re ca~-a~.-, ~r-a:~liypci:x:~-t~; t::a:c~ypnea, .unwan.ted p~.~g~ahcies--undergoing irrduced
hJTe>.t.e*~i~#, .P.~lor; cpld cla~~y $kin .a~P. a~rtions ;:e~d ~omp~ei?-t n;t~~, aFt-~~!1,~!1 : as
disori~ntation are .obvi9l+s late n'l.an..ifesfa,tioiis .. of w .e lL as :sympathy ,.and 'l!'l).'der.S4-'nd.i.Ug,. no t
~~rt:Jnf.~q;;::< -.. ....-. ______ ___ .. ,_---- j'~ifg:ffi:eiit' ~na .co.nct;e'Inna:tion.'~To p~e\1tiir
.~, .. . ' re~tition of th:f~' co~p'ie:fprdbr&i:ii~-wo~er;~hoUld
~erii be erilpowere'd conc.erb.i~g their .r~produt:tive
he~th. The vei:y least~-:: t 0 inform. them :ab9ut,
.'i:lid~:Mrner~tone of t reatment .. of 'a n :in:fecteci and: provide acGess to reliable arid safe m.et:hQ.ds
.al)Qrti~~ :i~;~~-~c,tiatlon offue: in.fected.:p;Odiict~ of. of" c?i:i:traception.'
~o.t}cpp9:~i.-iro r.n:th~ uteri/Ie C3:~ty:.tti'e~:inf~ted.
pr.oa~c~l;: mc1uHe uk~m:czyqf f.etU.s, p~acenta: ~d.
i~ riiyiribnme~. -~~tic :~ui~ .i tany reiilalli~! ~s
~ell as dtodua.-: rhe admi.riistralib~ 6I.:ah.tibiot1e:s; Intra-amniotic inf~etion is in:fdtioh lriv:olvin.g
although necd-ss~, . is not .suffj.oient to tre~t the amniotic $ac and t~ con~epts whlcp ar~ the
.int:e,c te4 -abOi::Uons .. Aft~r inJ.~atilig .. in4;;:lvho~s fetus, .placenta, amniotic {J,uid ahd amriiotie
fl4id. teplacernent, sirti~it~neous ,corte.cti;on..0( membranes both amnl6n a.hd choti0n:. Thd'>lder.
aneinHt by bl'ood cofup-on:ent replaceni~nt,': term used: Jorthis' condition'is chorioariili..iob.ius;
~dmlni.stci:tion of oxjgef!., cqr'rf!c.tiO.n o f electrolyte which is less 'preferred becaus e.. it i~ more "~f a.
ari.d:any acid'~base i.rPb.al<i.m:es, andad~t;ration pa:tholqgic term rather than a clinical one.
oiiiltial dose of-antibiotics; th~ -p~ysicia:ir:should . .
expedite .the appropriate ~vacl,latlon procedut~, The most common predispos ing risk condition
usually-a completion curettag~.:Inst>ine:in'stances', to the d,evelopinent of intra-amniotic infeetion is:
an CXI>loratory lapatotorp.y p1ay be; necessary to rupture of the. amniotic membrane~ The dis~ption .
. a.ssess the ne.e d for h yst!!recfomy, pelvic cteah- o( this protective biUT.ier allows th~ ascent of
upor _rep~of uterine or bcrivei perlo'r.a tioils :~nd microorganisms coloniZing the vagina into 'the
evacuation oi abs ~e sses .. Thes .'e vacuation normally sterile amniotic'cavity leading to infection
procedures should be viewed as part o' ' ' - ~- ...c :n.ts. In rare. instances, hematogeno .
us
Scanned 8y: . 0
 CHAPTER 59: INFECTIONS
or lymphatic spread of microorganisms to the
amniotic .c avity is the mechanism l)y which W
develops.
DiagJl~sis
lntta-~otic infection is diagnosed clink:ally
by the presence of fever in a pregnant patient
without other id-entifiable cause-s. .O ther
concomitant $ympt<;>ms include ut~rine ir:ritability
leading to preterm. labor, mat~rnal and fetal
tachycardia, other indkators offetal distress, and
on th~~~m>w).d <)f ruptured amniotic sac, the
passa~~ of turbid, fon.l-smelling. ~otic fluid ..
Laboratory fmdin.gs that may be helpful in
suppOrting the clinical diagnosis -o iiAI include
leukocytosis par:ti.(;Ula:rly ne\ltrophilia, 'e levated
erythrocyte sed.i.rtlep~tion rate, elevated levels o f
C~teac.tive pr()tein, ~emop-stratio~ ~r
polyli1orphon.ucleats, or dem-pristra,~o:n of
I;Dicrootg~~s and t heir _
related prod~cts such
a.s.-~~~~_,on asp~ted amniOtic fluid..
~atment
.., ...
.o~~:.i,~7 ,c~iea1 diagnosis of w. is m a de,
antibl(>tic:therapy should 1;>e insti~- .T he logical
neJt(,~~~~:;:Js~tQ. eff~t t,.l)e deUve!y otthe. pregnant
patierttin-14ie \'Yith the ba~le concept o! ~ating
the focu~ of ir.fectiQn a$ a.n: important part of 'its
treattne~i. This 'p resents With a 'difficult clinical
dilenuna:-.w:he~-the-~pregooney-is -tE>o~retn.afure-;
The choiee of anooiotics depends to a large
extent oa tile anticlpated or actual tnod~ -of
delivery. For vagfna l delivery, where the
a1;1ticipated pathogens are E. coli, .group B
strepto...--oeci arid ertterocOc:ci-; t!1e .use of:high dose
Ampicillinwith c:r Without :an am:lnoglyco~de like
G~ntamicin .is u~ually .adeqU.at~. However, for
abdomina"l delivery, where the anticipated
pathogens include the . anaerobes e~pedally
the gram negatives, the addition of Me tronidazole
or C!indamy~-. , .~r som. -Q~~r ~r,tibiotics w~th
similar anti-anaerobic activity, js recommended.
Such strategy will minimize the risk of developing
puerperal sep~is artd p elvic abscess.
POGS Ta$k(orce on Clinlcal Practice Guidelines
RecommendaUons
. forProphylaitls
. ln ~sarean
Sections
It is recommended tha t all women undergoing
einergen cy or elt:ctive cesarean . s_ection. be
Scanned 8y:
905
given prophylactic intravenous antibiQtics
(Level lA) . The choice of antibiotic sh~uld
preferably be based on the hospital's antibiotic
resistance pattern (Level \To.).
Both ampicillin . and first generation
cephalo::;porins. have ~imilar effi(:acy in
reducing postoperative endometritis (IK..el IA).
The optimal timing administration of
antibiotics preoperatively or immediately after
the cord is clamped remains discretionary
{Level IB).
For elective cesarean seetions. one
recommenda.tion is -for the attending physician
,t o ~ive prophyhictic antibiotics in -~tti..ngs
where it mayb:: beneficial, su~ as those.with
high prevalence .of :nl):rsery sepsis .or ward
.congestion (~v~t VO}. ,
Single dose regimens .are likely to :~ le~s
expen~sive and .might en:mr~ upive~:ti@.lt;iit;i~h;
of prophylactic antibioti~s. for.. ",(!.~ :lg~.; -~ ::;~:.- .
recoil'1mendation regarding the optimal' tDnin~9f''
administration .(preoperative ve.-sus .f!her.:co:rd
damping) re.~'$ -dis.cretionWY.
.~ ~-<::~ ~~;_::~:'
Tlle c)aeSic:d:ef'lili?Ct1 ofpuetperal ~'is th~ ..
development- ofsjgrillieant-fever-during-~iifttlQ . .
dayspost:partu:In; exeept thefirst24 hoUrs:::eUrre:nt
concepts vf puerperal s.e psis h.av~ add'oo som~
refinements. Other causes of fever such~~oh .
outside the genit&l tract should be ruled out fever
in the. fU"st 24 hours should not be dismissed
becau~e newly document~ microorganism$ ate.
now ,knOWil .to cause puerperal $epsis in the first
day .po.s tp.artum. Breas.t engorg~ment and.
dehydration .should be. 'last in the list of~ted
cau ses of fever in the pUerperh1m to avoid delay in
the i nvestigation of sep sis .
The main focus of infection in.puerperalsepsis
is the endometrium. Other po.s sible Joci include .
the surgical sites . like the
.episiotomy w9urid;
abdominal incision and uterine iricision following
cesarean .delivery.
~'
Severe puerperal sepsis is rare fo}Jpwing
. vaginal delivery,' -especially if the episiQtcmy site.
is not infected. Although' the hnplanta:tion s ite is
a raw area in the endometrium; it is .a gQod nidus
C
 - -----. -----------

9.06 SECTION X: .MEDICAL, $URGlCAL AND :Rl::P~.9DUCT1VE ILLNESSES AFFECT1NG P.REGNANCY

for bacterial coloniZation, the

open cervix serves The .fir:st clinical pattem is when fever occur:s
as a natural d.rain..age o f the endomet:rial cavity in the first 24 hours postpartum, moderate to high_
during the first several.day.s_p oStpartl.un.. grade. The surgical wound is uare!!larkable. The
abdomen has mild to mpderate tenderness. The
Following cesarean section however, seve_re pelvic findings are limited. to minimal tendem~ss
puerperal sepsis could dev.el0 p, especially oh tl)e with no unusual. disch.~e. The usual pathogen
background of intva-a~ni(?fiC infection. The a
inyolyed is gram_ positive orga:rllsm. An e.x.a.nipie
relatively 'hypoxic uterine incision where sutures of this is. group B streplococcu~~
act as,foreign Pody can harbor highly j~><l..thogc:n:ic
m:icroor~sms Pat:tiC:q.larly ~a:6-ebes: The second dinica~ pattern iS when 'fever
octv.rs withi11 ~8 'ho~_r.s ~'ost:Partum, \lsually
Dlagnosls n1od~rate grad. Tl::l:c surgic;al :wound is.
:L; u:nre'!Jlar.kaplc. The.r~ - is inodetate . to severe
Pu.erperal ~ndometrltis typle:a:lly m.ailifests :as abdominal; aswell as pelVic tendern~ss, mth ~o
fey>tr, hypegastric .p;ii.n a,nd foul~sm~lling lochia. UI)U~ual-~Uscharg~. The :u~ual_ pathogen involved-
The utet.u's may. b'e s ub'invoiu.ter!, l>~ggj in a
is gra.l'\ln~gative o~ganism, usually-E. coii.
consistency ,and tender ofi' paJ.pati.pn. the ~
remains ~J>{!n ahd tend~r oi1-. -~o:v:~m'en't.' 'The 'The t.hir(i _clinital. pattern is when 'fe~:er 's ets in
parametria atay b.e . indurated -~a. teA.C:et on
72 hour~ . p:os~p~:m wn.ell, -~m'e pati~nts ru::e
pa.Jpatkm if the :infection'ha~ sp'reaa.beyOri:G tl:).e e..i.re;idy-~t. :liie. fever .is ~su~y low @:-'a.d~. The
uterus. .surg12alwvund 'is pain:fUl,_in'dwa_ted; red ' i ri .c olor
. -:and -:m~y ha;;~_\purtilent ru5ch~e and deh.i~.
... .;!.. Helpfill'-'init.'1e as'Sessment:o.(~i:)uernil.<~psis -- The abdomen.and 'pelVi~-areusliailY' 'ben.igrt:' The '
. _ _ !S the : ~i'vi,c:;ult:ras(?~lid\~)u~ualiy;~e:.t~al::.! .. usuhl..pa$ogen."is -a gra.rC.::positive cocci; usualJ.y-
:vrn!:fi.~lvlc-~:nderoes~;-lini:Jtli':fu.e~~ili~-:tp :.xhap: Staphylocoecus.-auteus. :
out b} pilpa'!;i6!l t4e -upper.geru;tiili'~tnicttU-es~-- the ~ . . . . . .. . .
.. 1J].trasQ~'t{ c'o~l~~P.rO.:vi<i;~ ~~:.,-:-;~fa:tiv'elY, 'ti:Ci;:Uiate
. . .Til~ J6.u rtll clini~ P.attem:is':whenfeven :Octu.rs
piCtui!! :of ~th'th~ e~d6~p:etr.!..$l~caVit:y:and-:tb.~' wi.tb.iri;7~ 'h9m pos~;uS".ihlly-om6dera~-.to .. -
peli?c>strucfur~~;~:Rethln:e!i-~p4i'i;;en'@~~8t?/;. : ~~: gra&;. bU:tt bisitim:'e;--the:1S'tigicill.fwo'und .is....
integrity,~ ~f '\((e'ri!ie "-irici'sio'n~ . r~p~r ;~_<t''th-e-. .intag. :'f:P..e. aqd9men is .-se,v~t~ly t~1';:. and the
. .pi~ce:rif'~tocy.iQ:as'~s~~-~ho~aelected.. . . :Vlc.i:iariiinati0n'...may_:f'inC...:'pdViC.~aoug't..y_ to
-bysono_grapf!y" cysiic ,t en.de.r --ma:sse!?. The:r:e Pll:I..Y a.ls<! --~ .fou)-
. sm~lling discparge from -th~ .v agina. The usual
.Since--feven is the cardina1-:~esta'tioQ. -'o l:a pathogen is -an anaero~, com..r:n:cmly J?a(;:tex:oi_d es
patient..-Mlli:pueijkr:~J:s~~>-.~d~it.~ii i~--~~ fragiiis. -
mc>si eop:Unqn :P.re~tfugc;O~p4Uil.t. .it w.9ulO. be
:help~l:to:h.a.~e .a gui~d~_~e.-9.q. ,fu~ :$p~e'ril'atic . The4 .s t .Clinic;al ~ttern 'is When fever :~CurS
ev:al'uati,on_ :of -:a .p~fi:ent Viiljh ."fev~r: j>'Q:stp_~pi, 96'nours ;#ter .delivery. 'Most patients ~e already.
'There [fe .fot:;r, es;sept~~-~he!J:!,~_-.tha~. mtist 1be hotne: w,l:leri ihcy deve~op. ni.o~iera:te .to -high -~de
evhl~e,teg:- ~.J' ih~ - :~i:Q.Jc_ia_:ri . .!fh~$. ,~r~ '.tb~n fever. '_I:hewj)undjs:bcn.ign, Qut t.Qeat:xlomen-a:nd:
~rrei~t~:in ori:ler'to :artive :e:t ~ mpst.'pro'Qa'ble pdv:i~ .are markedly te.hder. 'i':h'e.re is u sual_ly
pathogen iniolVed. lfuowin[uh~ ipathog~- e:na.'Q~e~ yellow-"gren vaginal discharge that is non-.Joul
one _to ~hoo~e- the most aP.prqpiia:t~ . ahti~'iQtic. sme.Wng~ T h,e .usual_P<!-thogen :is .a slow"growing
reghnep. -to..ac:lm.itUsi:er. H must be -kept in mjnd or-ganism such as Chlam)'i:Ua trachomc:ttis.
however that: most rem'a1e 'pelVic mfeC:tions are
poly!ri.i<:;robial, and- :th~.ls ~ous co.mb~ations of Treatm~nt
th~ _.evC>Iv:in,'g-.sympt0 matoli;>i:Y -ar.e ..pessi:ol~.