Protocols for High-Risk Pregnancies

1 Cover

2 Title Page Protocols for High‐Risk Pregnancies An Evidence‐Based Approach SEVENTH EDITION EDITED BY John T. Queenan, MD Professor and Chair Emeritus Department of Obstetrics and Gynecology Georgetown University School of Medicine Washington, DC, USA Catherine Y. Spong, MD Professor and Vice Chair Department of Obstetrics and Gynecology Chief, Division of Maternal‐Fetal Medicine Gillette Professorship of Obstetrics and Gynecology University of Texas Southwestern Medical Center, Dallas, TX, USA Charles J. Lockwood, MD, MHCM Senior Vice President, USF Health Dean of the Morsani College of Medicine Professor of Obstetrics and Gynecology, and Public Health University of South Florida, Tampa, FL, USA

3 Copyright Page

4 Preface Reference

5 List of Contributors

6 PART 1: Concerns in Pregnancy PROTOCOL 1: Alcohol Use in Pregnancy and Lactation Overview Alcohol use during pregnancy Alcohol use during lactation Screening for alcohol use Intervention and referral to treatment Conclusion Suggested reading PROTOCOL 2: Smoking, Vaping, and Nicotine Exposure Clinical significance Pathophysiology Screening for tobacco, nicotine, and vaping exposure Interventions Pharmacotherapy Complications Follow‐up and prevention Suggested reading PROTOCOL 3: Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum Overview Opioid use and misuse Screening and diagnosis Management Labor and delivery Postpartum Conclusion Suggested reading PROTOCOL 4: Depression Clinical significance Pathophysiology Diagnosis Management Follow‐up Conclusion Suggested reading

7 PART 2: Antenatal Testing PROTOCOL 5: Prenatal Testing for Chromosomal Abnormalities Overview Pathophysiology Diagnosis and screening protocols Conclusion Suggested reading PROTOCOL 6: Fetal Echocardiography Overview Pathophysiology Structural heart disease Fetal arrhythmias Suggested reading PROTOCOL 7: Clinical Use of Doppler Overview Pathophysiology Diagnosis Management Summary Suggested reading PROTOCOL 8: Antepartum Testing Nonstress test Biophysical profile Modified biophysical profile Contraction stress test Umbilical Artery Doppler Velocimetry Indications for antepartum fetal surveillance Suggested reading PROTOCOL 9: Fetal Blood Sampling and Transfusion Clinical significance Cytogenetic diagnosis Fetal infection Fetal anemia Procedure‐related risks Long‐term effects Technique Future directions Suggested reading PROTOCOL 10: Preconception Genetic Screening Overview Cystic fibrosis Spinal muscular atrophy Hemoglobinopathies Fragile X syndrome Tay–Sachs disease and other disorders more prevalent in individuals of Ashkenazi Jewish descent Management and follow‐up Conclusion Suggested reading

8 PART 3: Maternal Disease PROTOCOL 11: Maternal Anemia Definition Consequences Diagnostic work‐up and treatment Macrocytic anemia Suggested reading PROTOCOL 12: Hemoglobinopathies in Pregnancy Clinical significance Diagnosis Role of transfusion therapy Pregnancy management of sickle cell disease Pregnancy management of thalassemias Suggested reading PROTOCOL 13: Fetal and Neonatal Alloimmune Thrombocytopenia Introduction Diagnosis Management Conclusion Suggested reading PROTOCOL 14: Rheumatological Disorders Introduction Systemic lupus erythematosus Rheumatoid arthritis Scleroderma Suggested reading PROTOCOL 15: Antiphospholipid Syndrome Overview Pathophysiology Diagnosis Effect on pregnancy Antepartum management Conclusion Suggested reading PROTOCOL 16: Inherited Thrombophilias Overview Mechanisms of hemostasis Mechanisms of thrombosis Genetic risk factors for thrombosis Adverse pregnancy outcome Evaluation and treatment Suggested reading PROTOCOL 17: Valvular Heart Disease in Pregnancy Introduction Diagnosis and work‐up Etiology of VHD Maternal risk stratification Stages of progression of valvular heart disease Cardiac medications in pregnancy Stenotic versus regurgitant valve lesions Mixed anomalies Artificial valves Cardiac surgery in pregnancy Preconception and early pregnancy counseling Antepartum management Anticoagulation Delivery planning Medications on L&D Delivery and the immediate postpartum period Prophylactic antibiotics Anesthesia Follow‐up Suggested reading PROTOCOL 18: Peripartum Cardiomyopathy Peripartum cardiomyopathy and the obstetric care provider Clinical presentation and diagnosis Etiopathogenesis of peripartum and other cardiomyopathies Stabilization and treatment Cardiomyopathy pearls for the obstetric care provider Suggested reading PROTOCOL 19: Thromboembolism Introduction Hemostasis changes during pregnancy Clinical risk factors for thromboembolism associated with pregnancy Inherited thrombophilias Acquired thrombophilia Diagnosis and management of venous thromboembolism associated with pregnancy Radiation considerations in pregnancy Treatment of venous thromboembolism Anticoagulation management considerations in the peripartum and postpartum periods Postpartum anticoagulation Anticoagulation prophylaxis considerations for women at risk for pregnancy‐related venous thromboembolism Summary Suggested reading PROTOCOL 20: Renal Disease Overview Pre‐pregnancy counseling Management Suggested reading PROTOCOL 21: Obesity Clinical significance Diagnosis Treatment Pregnancy and obesity Prenatal care Intrapartum care Postpartum care Conclusion Suggested reading PROTOCOL 22: Diabetes Mellitus Overview Pathophysiology Pregestational diabetes mellitus Gestational diabetes mellitus Suggested reading PROTOCOL 23: Thyroid Disorders Overview Diagnosis Hypothyroidism Hyperthyroidism Suggested reading PROTOCOL 24: Hepatitis in Pregnancy Hepatitis A in pregnant and breastfeeding women Hepatitis B in pregnant and breastfeeding women Hepatitis C in pregnant and breastfeeding women Hepatitis D in pregnant and breastfeeding women Hepatitis E in pregnant and breastfeeding women Suggested reading PROTOCOL 25: Asthma Overview Pathophysiology Diagnosis Management Conclusion Suggested reading PROTOCOL 26: Epilepsy Overview Pathophysiology and risks Antiepileptic drugs Pregnancy management Suggested reading PROTOCOL 27: Chronic Hypertension Definition and diagnosis Etiology and classification Maternal–perinatal risks Treatment Suggested management Evaluation and classification Low‐risk hypertension High‐risk hypertension Summary Suggested reading PROTOCOL 28: Cytomegalovirus, Genital Herpes, Rubella, and Toxoplasmosis Cytomegalovirus Genital herpes simplex virus Rubella Toxoplasmosis Suggested reading PROTOCOL 29: Syphilis Epidemiology Pathophysiology and clinical manifestations Congenital syphilis Diagnosis in pregnancy Management Suggested reading PROTOCOL 30: Vector‐Borne Diseases in Pregnancy: Zika, West Nile, and Chagas Disease Zika virus West Nile virus Chagas disease Suggested reading PROTOCOL 31: Influenza Overview Pathophysiology Diagnosis Treatment Complications Prevention Suggested reading PROTOCOL 32: Malaria Overview Life cycle of the parasite Clinical significance and pathophysiology Epidemiology Diagnosis Prevention Travel to endemic areas Conclusion Suggested reading PROTOCOL 33: Human Immunodeficiency Virus Infection Epidemiology Pathophysiology Screening in pregnancy Diagnosis Initial counseling Initial laboratory assessment Treatment Follow‐up Intrapartum management Postpartum management Conclusion Suggested reading PROTOCOL 34: Parvovirus B19 Overview Epidemiology Pathophysiology Clinical features Diagnosis Management Follow‐up Prevention Screening Summary Suggested reading PROTOCOL 35: Group B Streptococcus Clinical significance Pathophysiology Diagnosis Treatment Preterm labor Preterm prelabor rupture of the membranes Bacteriuria Cesarean delivery Penicillin allergy Unknown GBS status Prevention Conclusion Suggested reading PROTOCOL 36: Biliary, Liver, and Pancreatic Disease Chronic calculus cholecystitis/biliary dyskinesia Acute cholecystitis Choledocholithiasis Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy Acute pancreatitis during pregnancy Suggested reading