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Intra-amniotic infection and inflammation is a frequent and important cause of spontaneous preterm labor and delivery. Indeed, it is the only pathologic process for which both a causal link with spontaneous preterm birth has been established and a molecular pathophysiology defined. Fetal infection/inflammation has been implicated in the genesis of fetal and neonatal injury leading to cerebral palsy (CP) and chronic lung disease. Pathologic intra-amniotic inflammation can occur in the absence of detectable microorganisms using cultivation and molecular microbiologic techniques. This condition is known as sterile intra-amniotic inflammation and has been observed in patients with preterm labor and intact membranes, preterm PROM, and a short cervix. A mild sterile inflammatory process also participates in spontaneous labor at term, but this is considered to be an example of physiologic inflammation similar to that implicated in other important events in reproductive physiology, such as ovulation and implantation. Sterile pathologic inflammation has been implicated in gout, in which the danger signals are urate crystals and atherosclerosis. Thus, pathologic sterile inflammation is an important mechanism of disease.
Modern antenatal care aims to optimize both maternal and fetal outcomes. The various methods of prenatal fetal surveillance are directed towards early detection and, sometimes, prevention of chronic fetal hypoxia. The fetal response to acute or chronic hypoxia varies and is modified by the preceding fetal condition. Prenatal fetal surveillance tools are useful in pregnancies that are at high risk of developing chronic fetal hypoxia, but less so for acute events (e.g., placental abruption). There is evidence that fetal surveillance in unselected low-risk population is not cost-effective and leads to unnecessary interventions. Therefore routine prenatal fetal surveillance techniques or tests are not universally adopted in this group.
Postpartum hemorrhage (PPH) is the leading direct cause of maternal death in both industrialized and nonindustrialized nations, second only to preexisting conditions and indirect causes of maternal death.
“Normal” has different meanings. In the context of physical or laboratory measurements, “normal” may mean “average,” “disease-free,” or “within a given statistical range.” However, it is important to know the characteristics of the population yielding “normal” values before deciding whether these values provide an appropriate reference range with which to compare an individual test result. Many laboratories now print reference ranges on their reports and highlight test values that fall outside these values as “abnormal.” When the test subject is a pregnant woman, a fetus, or a newborn, and the reference population is composed predominantly of middle-aged men, then comparisons are patently inappropriate. It is important to understand how the physiologic changes of pregnancy affect the results of various tests and measurements before deciding whether an out-of-range result is actually abnormal.
This online resource answers the key questions that any clinician encounters with a high-risk pregnancy: what are the risks for the woman and/or the baby with this condition? How do I manage a pregnancy complicated by this condition? How do I perform this procedure (e.g. amniocentesis, cesarean section)? All the chapters are newly written or updated to reflect current, evidence-based management and changes in practice. The 'Normal Values' section, a hugely popular reference source, is included. Over half of the chapters have new authors. New chapters have also been added to keep the content up to date with modern developments. This comprehensive online resource provides links to key websites (e.g. National Clinical Guidelines), video recordings - especially of procedures - and additional images and all content will be reviewed annually and updated as necessary.
Complications arise more frequently during the first trimester than at any other stage of pregnancy. Most present with bleeding, pain, or both. Vaginal bleeding occurs in about 20% of clinically diagnosed pregnancies. It causes considerable anxiety for the woman and her partner. In the vast majority of cases, no intervention alters the outcome. The main aim of clinical management is a prompt and accurate diagnosis, with reassurance if the pregnancy is appropriately developed and viable, or appropriate intervention if not. This chapter focuses on the principles of diagnosis and management and three principal diagnoses: miscarriage, ectopic pregnancy, and gestational trophoblastic disease. The other differential diagnoses are shown in Table 5.1.
Imagine asking yourself the question, “How would I describe a typical pregnant woman who uses drugs?” You might reply that she comes from a different social class, cannot think beyond the pregnancy, uses jargon, and doesn’t listen or care about the welfare of the child. However, my experience when asking drug-using women what they thought about the typical obstetrician is that they say the doctor was from a different social class, could not think beyond the pregnancy, used jargon, and didn’t listen or care about the welfare of the child.
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