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The Obstetric Hematology Manual
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Book description

Obstetric hematology is a fast-growing area of medicine covering the diagnosis and management of hematological problems of pregnancy. Comprehensive in approach, The Obstetric Hematology Manual addresses the many hematological conditions that can cause serious problems in pregnancy, delivery and the post-partum period for both mother and baby. Written by a team of international authorities, this text provides up-to-date, evidence-based guidelines on best care, as well as sound advice based on the experience and opinion of experts. Where appropriate, basic principles are discussed to clarify the rationale for management, and systems and procedures for disease prevention are highlighted. Many conditions and cases are discussed, including venous thromboembolism, pre-eclampsia, anemia, thrombocytopenia and inherited disorders. This book will appeal to both trainees and practitioners in obstetrics, obstetric medicine, obstetric anesthesia and hematology. It is also an accessible text for midwives, nurses, and laboratory staff.

Reviews

'… does an excellent job of reviewing the relevant data and then presenting it in a practical and aesthetically pleasing manner. … will certainly prove an invaluable addition to the libraries of clinicians who deal with these patients.'

Source: Doody's

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Contents


Page 1 of 2


  • Chapter 9 - Prosthetic heart valves
    pp 109-119
  • View abstract

    Summary

    There are both subtle and substantial changes in hematological parameters during pregnancy and the puerperium, orchestrated by changes in the hormonal milieu. Red cell count and hematocrit (Hct) values are likewise lower in pregnancy, but the other red cell indices change little, although red cells show more variation in size and shape than in the non-pregnant state. There has been much discussion about the normal ranges for the different types of white blood cells (WBC). Lymphocyte count decreases during pregnancy through first and second trimesters, increases during the third trimester, but remains low in the early puerperium as compared to normal non-pregnant values. Screening tests used to assess the coagulation pathways include the activated partial thromboplastin time (APTT), the prothrombin time (PT), and the thrombin time (TT). There are changes in the balance of the natural anticoagulants during pregnancy and the puerperium.
  • Chapter 10 - Management of anticoagulants at delivery
    pp 120-128
  • View abstract

    Summary

    Iron, folate, and vitamin B12 deficiency are the most common hematinic deficiencies. Maternal iron deficiency anemia affects both mother and fetus. Iron-dependent enzymes in every cell are affected and there are neuromuscular, gastrointestinal, and epithelial consequences that can influence fetal mortality, growth, and programing. Anemia screening is primarily done by measuring the hemoglobin. Further investigation is usually a ferritin level or a trial of iron. Periconceptual folic acid is advised to reduce the incidence of neural tube defects. Folate prophylaxis should be considered in at risk groups such as those on anticonvulsants and with chronic hereditary or acquired red cell disorders. Folate stores can be depleted within months and women need education on diet to ensure recommended folate consumption. B12 deficiency is rare in pregnancy and vitamin B12 levels should be interpreted with caution. B12 levels fall in pregnancy by up to 50% in the third trimester.
  • Chapter 11 - Antiphospholipid syndrome
    pp 131-140
  • View abstract

    Summary

    This chapter concentrates on inherited red cell disorders: sickle cell disease and thalassemia. Care of the patient with thalassemia involves collaboration of hematologists, endocrinologists, diabetologists, cardiologists, with occasional input from other specialities such as hepatology. The sickling disorders are a group of inherited chronic hemolytic anemias with clinical manifestations occurring as a result of the polymerization of hemoglobin S. The clinical manifestations in sickle cell disease are as a result of many interacting pathological processes including: polymerization of HbS, hemolysis and nitric oxide depletion, and vaso-occlusion. All patients with sickling disorders should be jointly managed by an obstetrician and a hematologist with interest and experience in these diseases. Since these pregnancies are high risk, patients will require frequent review by the multidisciplinary team. Deficiencies in red cell enzymes often lead to shortened red cell lifespan.
  • Chapter 12 - Thrombophilia and pregnancy loss
    pp 141-148
  • View abstract

    Summary

    This chapter discusses three auto-immune hematological conditions that may complicate pregnancy: immune/idiopathic thrombocytopenic purpura (ITP), autoimmune hemolytic anemia (AIHA), and autoimmune neutropenia (AIN). They are characterized by the development of an autoantibody specific for a surface antigen on the platelet, erythrocyte, or neutrophil. ITP usually occurs in isolation but may occur with other immune cytopenias or be secondary to a systemic autoimmune condition, e.g. SLE. The pathogenesis of AIN is similar to that of other maternal immune cytopenias. Patients with symptomatic neutropenia are likely to present outside of pregnancy and have an established diagnosis. The differential diagnosis includes: drugs, viral infections, immune mediated disorders, large granular lymphocyte (LGL) disease, benign ethnic neutropenia, and CIN. For patients presenting during pregnancy, the diagnosis of AIHA requires careful exclusion of other causes of anemia, biochemical evidence of hemolysis and serological evidence that the hemolysis is immune mediated.
  • Chapter 13b - Management of obstetric hemorrhage: anesthetic management
    pp 158-165
  • View abstract

    Summary

    This chapter describes the epidemiology, clinical diagnosis, and clinical significance of Fetal and neonatal alloimmune thrombocytopenia (FNAIT) in pregnancy. FNAIT is the commonest cause of severe neonatal thrombocytopenia, and is analogous to the fetal/neonatal anemia caused by hemolytic disease of the fetus and newborn (HDFN). FNAIT is usually suspected in neonates with bleeding or severe, unexplained, and/or isolated postnatal thrombocytopenia. The strategies for ante-natal treatment have included the use of serial platelet transfusions, which while effective are invasive and associated with significant morbidity and mortality. Significant recent progress has involved refinement of maternal treatment, stratifying it according to the likely severity of FNAIT based on the history in previous pregnancies. However, the ideal ante-natal treatment, which is effective without causing significant side-effects to the mother or fetus, has yet to be determined, and further clinical trials are needed.
  • Chapter 13c - Management of obstetric hemorrhage: hemostatic management
    pp 166-170
  • View abstract

    Summary

    This chapter focuses on red cell alloimmunization that is the immune-mediated destruction of erythrocytes initiated by maternal red cell antibodies which reach the fetal circulation by transportation across the placenta, onwards from approximately 12 weeks' gestation. Hemolytic disease of the newborn (HDN) describes the consequences of the antenatal pathogenic process which continues on into the newborn period. Prevention of Rhesus D (RhD) isoimmunization, and improvements in the ante-natal and neonatal care of isoimmunized women and their babies, has all but eradicated serious morbidity and mortality associated with this condition. Exogenous anti-D is produced by exposing RhD negative volunteers to the RhD antigen. The use of intravenous immunoglobulin is well established now in the treatment of neonatal alloimmune thrombocytopenia and HDN. Phenotypic tests of RhD status examine how blood from an individual behaves when it is added to serum containing anti-D antibodies.
  • 14 - Inherited disorders of primary hemostasis
    pp 176-185
  • View abstract

    Summary

    Acute postnatal venous thromboembolism (VTE) should be suspected during pregnancy in women with symptoms and signs consistent with possible VTE, particularly if there are other risk factors for VTE. During pregnancy, clinical assessment is even more unreliable since many of the symptoms and signs of VTE, such as leg swelling, chest pain and dyspnea, are commonly found in normal pregnancy. As a consequence, the accuracy of clinical diagnosis falls to about 8% for deep venous thrombosis (DVT) and to less than 5% for suspected pulmonary embolism (PE). Compression Duplex ultrasound of the entire proximal venous system is the optimal initial diagnostic test for DVT in pregnancy. For women on therapeutic anticoagulation, a planned delivery, either through induction of labour or elective caesarean section, allows accurate timing of events or minimizes the risk of the woman having to deliver on full anticoagulation.
  • Chapter 15 - Inherited coagulopathies
    pp 186-193
  • View abstract

    Summary

    Venous thromboembolism (VTE) is the leading direct cause of maternal mortality in the UK, but many cases are potentially preventable. Risk factors for VTE should be identified pre-pregnancy, or at least early in pregnancy, and reassessed throughout pregnancy and the puerperium, as level of risk may change. Pregnancy itself is a risk factor for VTE, and additional risk factors include previous VTE, thrombophilia, and obesity. Thromboprophylaxis should be introduced depending on the level of risk. Guidelines are given for both ante-natal and post-natal management and in particular for the highest risk period immediately postpartum. Thromboprophylaxis involves both nonpharmacological and pharmacological measures, and the various modalities and drugs that can be used are discussed in this chapter. Non-pharmacological measures include appropriate hydration, early mobilization after surgery or delivery, graduated compression stockings (TEDS), and pneumatic compression boots. Aspirin, heparin, and warfarin are the main pharmacological agents to be used in thromboprophylaxis.

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