Management of High-Risk Pregnancy
A Practical Approach
Management of High-Risk Pregnancy
A Practical Approach
SS Trivedi MS FICOG FIMSA
Director Professor and Head
Department of Obstetrics and Gynecology
Lady Hardinge Medical College and SSK Hospital
New Delhi, India
Manju Puri MD
Professor
Department of Obstetrics and Gynecology
Lady Hardinge Medical College and SSK Hospital
New Delhi, India
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Management of High-Risk Pregnancy—A Practical Approach
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
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First Edition: 2010
ISBN 978-93-80704-73-9
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Contributors
Abha Singh MD KK Gombar MD
Professor Ex-Professor and Head
Department of Obstetrics and Gynecology Department of Anesthesia
Lady Hardinge Medical College and Intensive Care
and SSK Hospital Government Medical College
New Delhi, India and Hospital
Chandigarh, India
Amita Suneja MD FICOG FIMCH MNAMS
Professor Kazila Bhutia MD
Department of Obstetrics and Gynecology Ex-Senior Resident
The University College of Medical Department of Obstetrics and Gynecology
Sciences (UCMS) and Guru Teg Bahadur Lady Hardinge Medical College
(GTB) Hospital and SSK Hospital
Delhi, India New Delhi, India
Aruna Nigam MS Kiran Aggarwal MD
Assistant Professor Professor
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Lady Hardinge Medical College Lady Hardinge Medical College
and SSK Hospital and SSK Hospital
New Delhi, India New Delhi, India
Chitra Raghunandan MD Lambhir Dhaliwal DGO MD
Director Professor Professor and Head
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Lady Hardinge Medical College Postgraduate Institute of Medical
and SSK Hospital Education and Research (PGIMER)
New Delhi, India Chandigarh, India
Deepika Deka MD FICOG Madhu Goel MD DNB MNAMS
Professor Senior Obstetrician and Gynecologist
Department of Obstetrics and Gynecology Rockland Hospital
All India Institute of Medical Sciences Qutub Institutional Area
(AIIMS) New Delhi, India
New Delhi, India
Mandakini Pradhan MD DNB
Evita Fernandez FRCOG Head of Department
Consultant Obstetrician Material and Reproductive Health
Fernandez Hospital for Women Sanjay Gandhi Post Graduate Institute
and the Newborn of Medical Sciences
Hyderabad, Andhra Pradesh, India Lucknow, Uttar Pradesh, India
Manisha MS Pikee Saxena MD PGCHM PGDCR
Assistant Professor Assistant Professor
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Lady Hardinge Medical College Lady Hardinge Medical College
and SSK Hospital and SSK Hospital
New Delhi, India New Delhi, India
Manju Puri MD Prabha Lal MD
Professor Assistant Professor
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Lady Hardinge Medical College Lady Hardinge Medical College
and SSK Hospital and SSK Hospital
New Delhi, India
New Delhi, India
Ratna Biswas MD
Management of High-Risk Pregnancy—A Practical Approach
Monika Madaan MD
Professor
Assistant Professor
Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
Lady Hardinge Medical College
Lady Hardinge Medical College
and SSK Hospital
and SSK Hospital
New Delhi, India
New Delhi, India
Reena Yadav MD DGO FICOG
Monika B Nagpal DCH MS
Professor
Senior Resident Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Lady Hardinge Medical College
Lady Hardinge Medical College and SSK Hospital
and SSK Hospital New Delhi, India
New Delhi, India
Ritu Rana MD DNB MRCOG
Nidhi Bhatia MD DNB Specialist Registrar
Assistant Professor Department of Obstetrics and Gynecology
Department of Anesthesiology Princess Alexandra Hospital
Government Medical College and Hospital Harlow, United Kingdom
Chandigarh, India
SS Trivedi MS FICOG FIMSA
Nidhi Malhotra MBBS Director Professor and Head
Postgraduate Student Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Lady Hardinge Medical College
Lady Hardinge Medical College and SSK Hospital
and SSK Hospital New Delhi, India
New Delhi, India
Sandhya Jain MD DNB MNAMS
Pakhee Aggarwal MD Assistant Professor
Senior Resident Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology The University College of Medical
All India Institute of Medical Sciences (UCMS) and Guru Teg Bahadur
Sciences (AIIMS) (GTB) Hospital
New Delhi, India New Delhi, India
vi
Sarita Malhotra MD Smiti Nanda MD
Senior Resident Senior Professor and Head
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Maulana Azad Medical College Pt Bhagwat Dayal Sharma Postgraduate
and Lok Nayak Jai Prakash Hospital Institute of Medical Sciences
New Delhi, India Rohtak, Haryana, India
Sudha Salhan MD
Satinder Gombar MD
Professor, Consultant and Head
Professor and Head
Department of Obstetrics and Gynecology
Department of Anesthesia
Vardhman Mahavir Medical College and
and Intensive Care
Safdarjung Hospital
Government Medical College
New Delhi, India
and Hospital
Chandigarh, India Suneeta Mittal
MD FRCOG (Anesthesia) FICOG FAMS FICMCH FIMSA
Seema Singhal MS Professor and Head
Assistant Professor Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Director Incharge WHO-CCR in Human
Lady Hardinge Medical College Reproduction
and SSK Hospital All India Institute of Medical Sciences
New Delhi, India (AIIMS)
New Delhi, India
Shalini Malhotra MD DNB MNAMS
Ex-Senior Resident Swaraj Batra MS FICOG
Department of Obstetrics and Gynecology Director Professor and Head
Department of Obstetrics and Gynecology
Lady Hardinge Medical College
Maulana Azad Medical College and
and SSK Hospital
Lok Nayak Jai Prakash Hospital
New Delhi, India
New Delhi, India
Sharda Patra MD DNB Usha Gupta MD MNAMS FICOG FIMSA
Assistant Professor Professor and Head of Unit
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
Contributors
Lady Hardinge Medical Lady Hardinge Medical College
and SSK Hospital and SSK Hospital
New Delhi, India New Delhi, India
vii
Preface
Management of high-risk pregnancy is a challenge for all practicing
obstetricians. True to its title, Management of High-Risk Pregnancy—A Practical
Approach, this book focuses mainly on the practical aspects of the management
of high-risk pregnancies. The various chapters have been contributed by
clinicians with vast academic and clinical experience. The text is presented in
an easy-to-read and user-friendly manner. The material is essentially evidence
based and derived from the personal experience of the contributors. A number
of flow charts have been included to serve as ready reckoners. This book
includes most of the high-risk pregnancy situations and will be valuable to
practicing clinicians, residents and faculty. A dedicated Chapter on critical
care in obstetrics—what an obstetrician should know, provides useful
information which needs to be known to clinicians taking care of critically-
ill obstetric patients. Topics like prenatal screening and diagnosis, diagnosis
and management of congenital malformations and antepartum fetal
surveillance have been included to guide the clinicians in screening and
monitoring of high-risk pregnancy situations. We have also included a Chapter
on drugs in pregnancy which discusses the safety profile of drugs used in
the management of at-risk pregnancies. This is not a complete textbook of
obstetrics, but will serve as a useful complement to the already existing
textbooks with special emphasis on the management of high-risk pregnancies.
We are thankful to our Director, GK Sharma who encouraged us to take
up the task of writing this book and gave his constant support. Our thanks
are due to all the contributors who spared their valuable time to write the
various chapters of this book. Efforts of Dr Shalini Singh deserve special
mention as she tirelessly assisted us in giving the final shape to the book.
Finally, this book would not have been possible without the expert and
organized support and cooperation of our publishers M/s Jaypee Brothers
Medical Publishers (P) Ltd.
We hope that all practicing obstetricians, residents and teachers will benefit
from this book and we would welcome any comments and suggestions from
them.
SS Trivedi
Manju Puri
Foreword
I would like to congratulate Dr SS Trivedi, Director, Professor and Head of
the Department of Obstetrics and Gynecology from Lady Hardinge Medical
College and Smt. SK Hospital, New Delhi for producing this magnificent
book on the Management of High-risk Pregnancy – A Practical Approach. The
topics have been highly selected and there are 29 chapters which cover the
entire spectrum of high-risk pregnancy. The chapters are well laid down
starting from prenatal diagnosis through to obstetric and medical disorders
in pregnancy and labor and ending with a chapter on Drugs in Obstetrics.
The individual chapters provide extensive knowledge needed in that particular
topic. The scan pictures, photographs of actual patients and that using models
to illustrate the mechanism of labor and the technical procedures of labor
and delivery are very clear and worth commending. The latest information
available in the literature from various clinical guidelines, cochrane data base
and meta-analysis has been incorporated into each chapter. The summary,
recommendations and key points which are given at the end of each chapter
are commendable and make reading and remembering the important facts
easy compared to standard textbooks. The references are up-to-date and the
latest references up to the time of publication are provided.
The authors are well known for their expertise in high-risk pregnancy
and have contributed to the literature in obstetric medicine. Navigating
through each chapter has been made easy as every chapter has the same
layout. The contents are of a high standard, which is applicable for those
who are training to be specialists in obstetrics and gynecology as well as
practicing clinicians. I would highly commend this book and this book should
be with in the libraries of the hospitals and medical schools and the clinicians
office.
Sir Sabaratnam Arulkumaran
Professor and Head of Obstetrics and Gynecology
St George’s University of London
Contents
1. Prenatal Diagnosis ........................................................................................ 1
Ratna Biswas, Mandakini Pradhan
2. Screening and Management of Congenital Anomalies ..................... 27
Manisha
3. Antepartum Fetal Surveillance ............................................................... 57
Seema Singhal
4. Preterm Labor .............................................................................................. 72
Monika B Nagpal
5. Premature Rupture of Membranes ......................................................... 98
Sharda Patra
6. Prolonged Pregnancy ............................................................................... 112
Amita Suneja, Sandhya Jain
7. Polyhydramnios Oligohydramnios ...................................................... 120
Prabha Lal
8. Antepartum Hemorrhage ........................................................................ 132
SS Trivedi, Madhu Goel, Monika B Nagpal
9. Multifetal Pregnancy ............................................................................... 152
Reena
10. Intrauterine Growth Restriction (IUGR) ............................................ 176
Abha Singh
11. Malpresentations ....................................................................................... 199
Usha Gupta
12. Pregnancy with Previous Cesarean Section ....................................... 230
Ritu Rana
13. Rh Negative Pregnancy .......................................................................... 255
Aruna Nigam
14. Anemia in Pregnancy .............................................................................. 273
Manju Puri, Nidhi Malhotra
15. Hypertensive Disorders of Pregnancy ................................................. 296
SS Trivedi, Monika B Nagpal
16. Diabetes Mellitus with Pregnancy ....................................................... 322
Manju Puri, Kazila Bhutia
17. Jaundice in Pregnancy ............................................................................. 348
Chitra Raghunandan
18. Heart Disease in Pregnancy ................................................................... 369
Monika B Nagpal, Shalini Malhotra
19. Thromboembolism in Pregnancy .......................................................... 389
Swaraj Batra, Sarita Malhotra
20. Thyroid Disorders with Pregnancy ...................................................... 405
Kiran Aggarwal
21. Renal Disease in Pregnancy ................................................................... 426
Pakhee Aggarwal, Suneeta Mittal
22. Tuberculosis in Pregnancy ...................................................................... 441
Lakhbir Dhaliwal
Management of High-Risk Pregnancy—A Practical Approach
23. Epilepsy with Pregnancy ........................................................................ 454
Monika Madaan
24. TORCH Infections in Pregnancy .......................................................... 460
Deepika Deka
25. HIV in Pregnancy ..................................................................................... 470
Sudha Salhan
26. Obesity and Pregnancy ........................................................................... 487
Evita Fernandez
27. Gynecological Diseases in Pregnancy ................................................. 499
Smiti Nanda
28. Critical Care Issues in High-Risk Obstetric Patient ........................ 515
Satinder Gombar, KK Gombar, Nidhi Bhatia
29. Drugs in Pregnancy ................................................................................. 544
Pikee Saxena
Index ....................................................................................................................... 567
xii
