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Obstentrics_Williams. Few randomized trials evaluate preconceptional counseling eicacy, in part because withholding such counseling would be unethical. Also, pregnancy outcomes are dependent on the interaction of various maternal, fetal, and environmental factors. hus, ascribing a salutary outcome to a specific intervention is diicult (Moos, 2004; Temel, 2014). However, prospective observational and case-control studies have demonstrated the successes of preconceptional counseling (American College of Obstetrics and Gynecologists, 2016b). \100s and coworkers (1996) assessed the efectiveness of a preconceptional counseling program administered during routine health care provision to reduce unintended pregnancies. he 456 counseled women had a 50-percent greater likelihood of subsequent pregnancies that they considered "intended" compared with 309 uncounseled


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Obstentrics_Williams. TABLE 8-1. Prevalence of Prepregnancy Maternal Behaviors, Experiences, Health Conditions, and Previous Poor Birth Outcomesa aln the United States in 2004. bAmong women who were not trying to become pregnant. Data from D'Angelo D, Williams L, Morrow 8, et al: Precon ception and interconception health status of women who recently gave birth to a live-born infant-Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. MMWR 56(1l0):1,l2007. women. Moreover, compared with another group of women who had no health care before pregnancy, the counseled group had a 65-percent higher rate of intended pregnancy. Interesting ethical aspects of paternal lifestyle modification were reviewed by van der Zee and associates (2013).


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Obstentrics_Williams. Gynecologists, internists, family practitioners, and pediatricians have the best opportunity to provide preventive counseling during periodic health maintenance examinations. The occasion of a negative pregnancy test is also an excellent time for education. Jack and colleagues (1995) administered a comprehensive preconceptional risk survey to 136 such women, and almost 95 percent reported at least one problem that could afect a uture pregnancy. These included medical or reproductive problems-52 percent; family history of genetic disease-50 percent; increased risk of human immunodeiciency virus infection-30 percent; increased risk of hepatitis B and illegal substance abuse-25 percent; alcohol use-17 percent; and nutritional risks-54 percent. Counselors should be knowledgeable regarding relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists (Simpson, 2014). If the


Obstentrics_Williams

Obstentrics_Williams. relevant medical diseases, prior surgery, reproductive disorders, or genetic conditions and must be able to interpret data and recommendations provided by other specialists (Simpson, 2014). If the practitioner is uncomfortable providing guidance, the woman or couple should be referred to an appropriate counselor.


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Obstentrics_Williams. Women presenting specifically for preconceptional evaluation should be advised that information collection may be time consuming, depending on the number and complexity of factors that require assessment. he intake evaluation includes a thorough review of the medical, obstetrical, social, and family histories. Useul information is more likely to be obtained by asking specific questions regarding each of these histories and each family member than by asking general, open-ended questions. Some important information can be obtained by questionnaires that address these topics. Answers are reviewed with the couple to ensure appropriate follow-up, including obtaining relevant medical records.


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Obstentrics_Williams. With specific medical conditions, general points include how pregnancy will afect maternl health and how a high-risk condition might afect the fetus. terward, advice for improving outcome is provided. Some chronic conditions that may ffect pregnancy outcomes include treated or active cancer, prior peripartum cardiomyopathy, and systemic lupus erythematosus (mant, 2015; Buyon, 2015; McNamara, 2015). Importantly, psychological health should be considered (Lassi, 2014). Detailed preconceptional information regarding a few exemplary conditions is found in the next sections and in the other topic-speciic chapters of this text.


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Obstentrics_Williams. Because maternal and fetal pathology associated with hyperglycemia is well known, diabetes is the protoype of a condition for which preconceptional counseling is beneficial. Diabetesassociated risks to both mother and fetus are discussed in detail in Chapter 57 (p. 1099). Many of these complications can be avoided if glucose control is optimized before conception. Another important aspect of counseling pertains to the frequent use of teratogenic angiotensin-converting enzyme inhibitors in this population (Podymow, 2015).


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Obstentrics_Williams. The American College of Obstetricians and Gynecologists (2016a) has concluded that preconceptional counseling for women with pregestational diabetes is both beneicial and costefective and should be encouraged. The American Diabetes Association has promulgated consensus recommendations for preconceptional care for diabetic women (Kitzmiller, 2008). hese guidelines advise obtaining a thorough inventory of disease duration and related complications and completing a clinical and laboratory examination for end-organ damage. Perhaps most essential, they encourage a preconceptional goal of the lowest hemoglobin Ale level possible without undue hypoglycemic risk to the mother. In addition to assessing diabetic control during the preceding 6 weeks, hemoglobin Ale measurement can also be used to estimate risks for major anomalies as shown in Figure lthough these data are from women with severe overt diabetes, the incidence of fetal anomalies in women who have gestational diabetes with fasting


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Obstentrics_Williams. risks for major anomalies as shown in Figure lthough these data are from women with severe overt diabetes, the incidence of fetal anomalies in women who have gestational diabetes with fasting hyperglycemia is increased fourfold compared with that in normal women (Sheield, 2002).


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Obstentrics_Williams. Such counseling in diabetic women has been shown to be efective. Leguizam6n and associates (2007) identiied 12 studies that included more than 3200 pregnancies in women with insulin-dependent diabetes. Of the 1618 women without precon o..Ac) 'uE .. 4.6-7.6 7.7-8.6 8.7-9.9 10-10.5 >10.6


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Obstentrics_Williams. FIGURE 8-1 Relationship between first-trimester glycosylated hemoglobin values and risk for major congenital malformations in 320 women with insulin-dependent diabetes. (Data from Kitzmiller JL, Gavin LA, Gin GO, et al: Preconception care of diabetics. JAMA 265:731, 1991.) ceptional counseling, 8.3 percent had a fetus with a major congenital anomaly, and this compared with a rate of 2.7 percent in the 1599 women who did have counseling. Tripathi and coworkers (2010) compared outcomes in 588 women with pregestational diabetes in whom approximately half had preconceptional counseling. hose women who received counseling had improved glycemic control before pregnancy and in the first trimester. his group also had higher folate intake rates preconceptionally, and they experienced lower rates of adverse outcomes-deined as a perinatal death or major congenital anomaly. hese cited beneits are accompanied by reduced helth-care costs in diabetic women. From their review, Reece and Homko (2007)


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Obstentrics_Williams. adverse outcomes-deined as a perinatal death or major congenital anomaly. hese cited beneits are accompanied by reduced helth-care costs in diabetic women. From their review, Reece and Homko (2007) found that each $1 expended for a preconceptional care program saved between $1.86 and $5.19 in averted medical costs. Despite such beneits, the proportion of diabetic women receiving preconceptional care is suboptimal. In their study of approximately 300 diabetic women in a managed-care plan, Kim and colleagues (2005) found that only approximately one half had preconceptional counseling. Counseling rates are undoubtedly much lower among uninsured and indigent women.


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Obstentrics_Williams. Compared with unafected women, those with a seizure disorder carry an undisputed augmented risk of having neonates with structural anomalies (Chap. 12, p. 240). Some early reports indicated that epilepsy conferred an elevated a priori risk for congenital malformations that was independent of anticonvulsant treatment efects. Although more recent publications have largely failed to conirm this increased risk in untreated women, it is diicult to refute entirely because women who are controlled without medication generally have less severe disease (Cassina, 2013; Vajda, 2015). Fried and associates (2004) conducted a metaanalysis of studies comparing epileptic women, both treated and untreated, with controls. In this study, greater malformation rates could only be demonstrated in the ofspring of women who had been exposed to anticonvulsant therapy. Veiby and coworkers (2009) used the Medical Birth Registry of Norway and identiied an increased malformation risk only in women who were


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Obstentrics_Williams. of women who had been exposed to anticonvulsant therapy. Veiby and coworkers (2009) used the Medical Birth Registry of Norway and identiied an increased malformation risk only in women who were exposed to valproic acid (5.6 percent) or poly therapy (6.1 percent). Untreated women had anomaly rates that were similar to those of nonepileptic controls. Risks for miscarriage and stillbirths in exposed epileptic women do not appear elevated (Aghajanian, 2015; Bech, 2014).


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Obstentrics_Williams. Ideally, seizure control is optimized preconceptionlly. For example, Vajda and colleagues (2008) nalyzed data from the Australian Register of Antiepileptic Drugs in Pregnancy. hey found the seizure risk during pregnancy was 50-to 70-percent lower in women without a seizure in the year preceding pregnancy compared with a group experiencing seizures in this preceding year. No urther advantages accrued if the seizure-free period exceeded a year.


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Obstentrics_Williams. Treatment goals attempt to achieve seizure control with monotherapy and with medications considered less teratogenic (Aguglia, 2009; Tomson, 2009). As discussed in detail in Chapter 60 (p. 1159) and shown in Table 8-2, some one-drug regimens are more teratogenic than others. Valproic acid, in particular, is avoided if possible, as this medication has consistently been associated with a greater risk for major congenital malformations than other antiepileptic drugs Qentink, 2010; Vajda, 2015). Trimethadione is contraindicated (Aghajanian, 2015). he American Academy of Neurology recommends consideration of antiseizure medication discontinuation before pregnancy in suitable candidates Qeha, 2005). hese include women who satisy the following criteria: (1) have been seizure-free for 2 to 5 years, (2) display a single seizure type, (3) have a normal neurological examination and normal intelligence, and (4) showeelectroencephalogram results that have normalized with treatment.


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Obstentrics_Williams. Epileptic women should be advised to daily take a 4-mg folic acid supplement. Even so, it is not entirely clear that folate supplementation reduces the fetal malformation risk in pregnant women taking anticonvulsant therapy. In one case-control study, Kjer and associates (2008) reported that the congenital abnormality risk was reduced by maternal folate supplementation in fetuses exposed to carbamazepine, phenobarbitl, phenytoin, and primidone. Conversely, from the United Kingdom Epilepsy and TABLE 8-2. First-Trimester .ntiepileptic Monotherapy and the Associated Major Malformation Risk Unexposed controls (442) 1.1 Reference Lamotrigine (1 562) 2.0 1.8 (0.7-4.6) Carbamazepine (1 033) 3.0 2.7 (1 .0-7.0) Phenytoin (4 16) 2.9 2.6 (0.9-7.4) Levetiracetam (450) 2.4 2.2 (0.8-6.4) Topiramate (359) 4.2 3.8 (1 .4-10.6) Valproate (323) 9.3 9.0 (3.4-23.3) Phenobarbital (1 99) 5.5 5.1 (1 .8-1 4.9) Oxcarbazepine (1 82) 2.2 2.0 (0.5-7.4) Gabapentin (1 45) 0.6 (0.07-5.2)


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Obstentrics_Williams. Topiramate (359) 4.2 3.8 (1 .4-10.6) Valproate (323) 9.3 9.0 (3.4-23.3) Phenobarbital (1 99) 5.5 5.1 (1 .8-1 4.9) Oxcarbazepine (1 82) 2.2 2.0 (0.5-7.4) Gabapentin (1 45) 0.6 (0.07-5.2) Clonazepam (64) 3.1 2.8 (0.5-14.8) aRisk compared with that of the unexposed reference population of nonepileptic women. n =number of exposed infants. Data from Hernandez-Oraz 5, Smith CR, Shen A., et al: Comparative safety of antiepileptic drugs during pregnancy. Neurology 78:1692, 2012. Pregnancy Register, Morrow and coworkers (2009) compared fetal outcomes of women who received preconceptional folic acid with those who did not receive it until later in pregnancy or not at all. In this study, a paradoxical increse in the number of major congenital malformations was observed in the group who received preconceptional folate. hese investigators concluded that folate metabolism may be only a part of the mechanism by which malformations are induced in women taking these medications.


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Obstentrics_Williams. Preconceptional counseling includes assessment of immunity against common pathogens. Also, depending on health status, travel plans, and time of year, other immunizations may be indicated as discussed in Chapter 9 (Table 9-7, p. 172). Vac cines that contain toxoids such as tetanus are suitable before or during gestation. Also, those containing killed bacteria or viruses-such as inluenza, pneumococcus, hepatitis B, menin gococcus, and rabies vaccines-are not associated with adverse fetal outcomes and are not contraindicated preconceptionally or during pregnancy. Conversely, live-virus vaccines are not recommended during pregnancy. Examples are vaccines against varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow fever. Moreover, 1 month or longer should ideally pass between vaccination and conception attempts. That said, inadvertent administration of measles, mumps, rubella (MMR) considered indications for pregnancy termination. Most reports indicate that the fetal


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Obstentrics_Williams. vaccination and conception attempts. That said, inadvertent administration of measles, mumps, rubella (MMR) considered indications for pregnancy termination. Most reports indicate that the fetal risk is only theoretical. Immunization to smallpox, anthrax, and other bioterrorism diseases should be discussed if clinically appropriate (Chap. 64, p. 1228).


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Obstentrics_Williams. With some infections, vaccines are unavailable. One recent example is the Zika virus (Brasil, 2016). For this virus, the CDC has issued travel advisories for pregnant women (Petersen, 2016; Schuler-Faccini, 2016). he CDC (20e16) estimates that 3 percent of neonates born each year in the United States will have at least one birth defect. Importantly, such defects are the leading cause of infant mortality and account for 20 percent of deaths. The benefits of preconceptional counseling usually are measured by comparing the incidence of new cases before and after initiation of a counseling program. Congenital conditions that clearly beneit from patient education include neural-tube defects, phenylketonuria, thalassemias, and other genetic diseases more common in individuals of Eastern European Jewish descent.


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Obstentrics_Williams. Pedigree construction using the symbols shown in Figure 8-2 is the most thorough method for obtaining a family history as a part of genetic screening. he health and reproductive status of each "blood relative" should be individually reviewed for medical illnesses, mental retardation, birth defects, infertility, and pregnancy loss. Certain racial, ethnic, or religious backgrounds may indicate elevated risk for specific recessive disorders. Although most women can provide some information regarding their history, their understanding may be limited. For example, several studies have shown that pregnant women often fail to report a birth defect in the family or they report it incorrectly. hus, any disclosed defect or genetic disease should be conirmed by reviewing pertinent medical records or by contacting afected relatives for additional information.


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Obstentrics_Williams. he incidence of neural-tube defects (NTDs) is 0.9 per 1000 live births, and they are second only to cardiac anomalies as the most frequent structural fetal malformation (Chap. 13, p. 270). Some NTDs, as well as congenital heart defects, are associated with speciic mutations. One example is the 677C -+=T substitution in the gene that encodes methylene tetrahydrofolate reductase. For this and similar gene defects, the trial conducted by the Medical Research Council Vitamin Study Research Group (1991) showed that preconceptional folic acid therapy significantly reduced the risk for a recurrent NTD by 72 percent. More importantly, because more than 90 percent of neonates with NTDs are born to women at low risk, Czeizel and Dudas (1e992) showed that supplementation reduced the a priori risk of a irst NTD occurrence. It is currently recommended, therefore, that all women who may become pregnant take daily 400 to 800 j1g of folic acid orally before conception and through the irst trimester


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Obstentrics_Williams. a irst NTD occurrence. It is currently recommended, therefore, that all women who may become pregnant take daily 400 to 800 j1g of folic acid orally before conception and through the irst trimester (U.S Preventive Services Task Force, 2009). Folate fortiication of cereal grains has been mandatory in the United States since 1998, and this practice has also resulted in decreased neural-tube defect rates (Williams, 2015). Despite the demonstrated benefits of folate supplementation, only half of women have taken folic acid supplementation periconceptionally (de Jong-van den Berg, 2005; Goldberg, 2006). The strongest predictor of use appears to be consultation with a health-care provider before conception.


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Obstentrics_Williams. More than 600 mutations have been identified in the phenylalanine hydroxylase gene. The inherited defect in phenylalanine metabolism exempliies diseases in which the fetus may not be at risk to inherit the disorder but may be damaged by maternal disease. Specifically, mothers with phenylketonuria (PKU) who eat an unrestricted diet have abnormally high blood phenylalanine levels. his amino acid readily crosses the placenta and can damage developing fetal organs, especially neural and cardiac tissues (Table 8-3). TABLE 8-3. Frequency of Complications in the Offspring of Women with Untreated Phenylketonuria Data from American Academy of Pediatrics: Matenal phenylketonuria, Pediatrics 2008 \ug;122(2):445-449. No offspring II Proband is II -2 Adopted out of a family FIGURE 8-2 Symbols used for pedigree construction. (Modified with permission from Thompson MW, Mcinnes RR, Huntington FW (eds): Number of children of sex indicated Carrier of X-linked recessive trait


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Obstentrics_Williams. Number of children of sex indicated Carrier of X-linked recessive trait Twins of unknown zygosity Genetics in Medicine, 5th ed. Philadelphia, Saunders, 1991o.) With appropriate preconceptional counseling and adherence to a phenylalanine-restricted diet before pregnancy, the incidence of fetal malformations is dramatically reduced (Camp, 2014; Vockley, 2014). Therefore, the phenylalanine concentration is ideally normalized 3 months before conception and then maintained throughout pregnancy (American College of Obstetricians and Gynecologists, 2017b). The target phenylalanine blood concentration is 120 to 360 �mol/L (Camp, 2014).


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Obstentrics_Williams. hese disorders of globin-chain synthesis are the most common single-gene disorders worldwide (Forget, 2013; Vichinsky, 2013). As many as 200 million people carry a gene for one of these hemoglobinopathies, and hundreds of mutations are known to cause thalassemia syndromes (Chap. 56, p. 1084). In endemic areas such as Mediterranean and Southeast Asian countries, counseling and other prevention strategies have reduced the incidence of new cases by up to 80 percent (Cao, 2013). The American College of Obstetricians and Gynecologists (2015a) recommends that individuals of high-risk ancestry be ofered carrier screening to allow them informed decision making regarding reproduction and prenatal diagnosis. One method of early prenatal diagnosis is preimplantation genetic diagnosis (PGD), which is coupled with assisted reproductive technologies. Described in Chapter 14 (p. 295), PGD is available for patients at risk for certain thalassemia syndromes (Kuliev, 2011).


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Obstentrics_Williams. • Individuals of Eastern European Jewish Descent Most individuals of Jewish ancestry in North America are descended from Ashkenazi Jewish communities and are at increased risk for having ofspring with one of several autosomal recessive disorders. These include Tay-Sachs disease, Gaucher disease, cystic ibrosis, Canavan disease, familial dysautonomia, mucolipidosis IV, Niemann-Pick disease type A, Fanconi anemia group C, and Bloom syndrome. The American College ofObstetricians and Gynecologists (20 16c, 2017a) recommends preconceptional counseling and screening for these in this population. Carrier frequency and features of these conditions are discussed in Chapter 14 (p. 290).


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Obstentrics_Williams. During preconceptional screening, information is sought regarding infertility; abnormal pregnancy outcomes that may include miscarriage, ectopic pregnancy, and recurrent pregnancy loss; and obstetrical complications such as cesarean delivery, preeclampsia, placental abruption, and preterm delivery (Stubblefield, 2008). As discussed in Chapter 35 (p. 646), details involving a prior stillbirth are especially important. For example, Korteweg and associates (2008) identiied chromosomal abnormalities in 13 percent ofstillborns who underwent karyotyping. Reddy and colleagues (2012) confirmed that chromosomal microarray analysis (CMA) yielded better detection of genetic abnormalities than did standard karyotyping, primarily because nonviable tissue can be used for the analysis. CMA is described and illustrated in Chapter 13 (p. 271). Identiication of a genetic abnormality in a stillborn can help determine the recurrence risk and aid in the preconceptional or prenatal management in subsequent


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Obstentrics_Williams. illustrated in Chapter 13 (p. 271). Identiication of a genetic abnormality in a stillborn can help determine the recurrence risk and aid in the preconceptional or prenatal management in subsequent pregnancies.


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Obstentrics_Williams. Women at both ends of the reproductive-age spectrum have unique outcomes to be considered. First, according to the CDC, in 2010,i3.4 percent ofbirths in the United Stateswerein women between the ages of 15 and 19 years (Martin, 2012). These adolescents are at increased risk for anemia, preterm delivery, and preeclampsia compared with women aged 20 to 35 years (Usta, 2008). he incidence of sexually transmitted diseases-common in adolescents-is even higher during pregnancy (Niccolai, 2003). Unfortunately, because most of their pregnancies are unplanned, adolescents rarely seek preconceptional counseling.


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Obstentrics_Williams. Conceptions after age 35 currently comprise approximately 15 percent ofpregnancies in the United Stares (Martin, 2012). By contrast, these older women are more likely to request preconceptional counseling, either because of postponed pregnancy with a desire to optimize outcomes or because of plans to undergo infertility treatment. Some studies-including data from Parland Hospital presented in Figure 8-3 indicate that ater age 35, the risks for obstetrical complications and for perinatal morbidity and mortality rise (Cunningham, 1995; Waldenstrom, 2015). he older woman who has a chronic illness or who is in poor physical condition usually has readily apparent risks. For rhe physicallyfit woman without medical problems, however, the risks are much lower than previously reported.


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Obstentrics_Williams. Overall, the maternal mortality rate is higher in women aged 35 and older. Compared wirh women in rheir 20s, women aged 35 to 39 are 2.5 times more likely and women aged 40 or older are 5.3 times more likely to sufer pregnancy-related mortality (Geller, 2006). Creanga and coworkers (2015) analyzed pregnancy-related deaths in the United States for 2006 through 2010. Although women older than 35 years contributed less than 15 percent of all live births, they constituted 27 percent ofmaternal deaths. For the fetus, maternal age-related risks primarily stem from: (1) indicated preterm delivery for maternal complications such as hypertension and diabetes, (2) spontaneous preterm birth, (3) fetal growth disorders related to chronic maternal disease or multifetal gestation, (4) fetal aneuploidy, and (5) pregnancies resulting from assisted reproductive technology.


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Obstentrics_Williams. Recall that older women have subfertility problems. And although the incidence of dizygotic twinning increases with maternal age, the more important cause of multifetal gestation in older women follows the use ofassisted reproductive technology (ART) and ovulation induction. Indeed, according to the CDC, 30 to 40 percent ofall multifetal gestations in the United States in 2012 were conceived with the use ofART (Sunderan, 2015). Morbidity and mortality with multifetal pregnancies stem from preterm delivery. Other obstetrical morbidities, such as placenta previa, abruption, and preeclampsia, are also risks associated with these conceptions (Lukes, 2017; Qin, 2016). Finally, experience has accrued that links ART to higher major congenital malformation rates. Davies and colleagues (2012) reported that of 308,974 births in South Australia, 8.3 percent ofneonates conceived byART had major birth defects.


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Obstentrics_Williams. In this analysis, after adjustment for maternal age and other risk factors, intracytoplasmic injection continued to be associated with a signiicantly elevated risk for malformations, but in vitro fertilization did not. Parental history and experiences-paternal and maternal-can exert efects through epigenomic information not contained in the DNA sequence. Examples include variations in sperm and oocyte cytosine methylation and other mechanisms (Cedars, 2015; Lane, 2014). Perhaps one example is the possible link between increasing paternal age and complex neuropsychiatric conditions (Malaspina, 2015). Finally, the incidence of genetic diseases in ofspring caused by new autosomal-dominant mutations in older men is increased. Still, the incidence is low (Chap. 13, p. 265). Accordingly, targeted sonographic examination performed solely for advanced maternal or paternal age is controversial.


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Obstentrics_Williams. Fetal risks associated with alcohol, marijuana, cocaine, amphetamines, and heroin are discussed in Chapter 12 (p. 239). he first step in preventing drug-related fetal risk is an honest assessment of use by the patient (American College of Obstetricians and Gynecologists, 2017 c) . Toward this end, questioning should be nonjudgmental. Screening for at-risk drinking can be accomplished using several validated tools. One is the wellstudied T ACE questions (American College of Obstetricians and Gynecologists, 2013). This is a series of four questions concerning .olerance to alcohol, being 4nnoyed by comments about their drinking, attempts to fut down, and a history of drinking early in the morning-the fye opener.


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Obstentrics_Williams. In a Canadian study of more than 1000 postpartum patients, Tough and coworkers (2006) found that a high percentage of women reported alcohol use concurrent with conception attempts. Specifically, nearly half of those planning for pregnancy reported a mean of 2.2 drinks daily during early gestation and before they recognized their pregnancy. Of note, Bailey and associates (2008) found that rates of binge drinking and marijuana use by men were unafected by their partner's pregnancy. The frequency and pattern of such behaviors clearly underscore the opportunity for preconceptional counseling.


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Obstentrics_Williams. Currently 20 million women in the United States smoke cigarettes (Centers for Disease Control and Prevention, 2014). Smoking in pregnancy has been consistently associated with numerous adverse perinatal outcomes, listed in Chapter 12 (p. 249). These risks are largely mitigated by cessation before pregnancy, highlighting the importance of screening for tobacco use in the preconceptional period and during prenatal care as outlined in Chapter 9 (p. 161). Contact with environmental substances is inescapable. Thus, it is fortunate that only a few agents have been shown to cause adverse pregnancy outcomes (Windham, 2008). Exposures to infectious diseases have myriad deleterious efects, and these are detailed in Chapters 64 and 65. Likewise, contact with some chemicals may impart signiicant maternal and fetal risks. As discussed in Chapters 9 and 12 (pp. 170 and 244), excess exposure to methyl mercury or lead is associated with neurodevelopmental disorders.


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Obstentrics_Williams. In the past, some concerns were raised over common everyday exposure to electromagnetic iels such as those emanated by high-voltage power lines, electric blankets, microwave ovens, and cellular phones. Fortunately, no human or animal evidence links these and adverse fetal outcomes (Robert, 1999). he efects of electrical shock are discussed in Chapter 47 (p. 930).


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Obstentrics_Williams. Pica is the craving for and consuming of ice, laundry starch, clay, dirt, or other nonfood items. It should be discouraged due to its inherent replacement of healthul food with nutritionally empty products (Chap. 9, p. 174). In some cases, it may represent an unusual physiological response to iron deficiency. Many vegetarian diets are protein deficient but can be corrected by increasing egg and cheese consumption. Anorexia and bulimia increase maternal risks of nutritional deiciencies, electrolte disturbances, cardiac arrhythmias, and gastrointestinal pathology (Becker, 1999). s discussed in Chapter 61 (p. 1180), pregnancy-related complications with these disorders include greater risks of low birthweight, smaller head circumference, microcephaly, and small-for-gestational-age newborns (Kouba, 2005).


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Obstentrics_Williams. In contrast to these perinatal morbidities, obesiy is linked with several maternal complications. As discussed in Chapter 48 (p. 939), these include preeclampsia, gestational diabetes, labor abnormalities, cesarean delivery, and operative complications (American College of Obstetricians and Gynecologists, 2015b). Obesity also appears to be associated with a range of structural fetal anomalies (Stothard, 2009).


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Obstentrics_Williams. Conditioned pregnant women usually can continue to exercise throughout gestation (American College of Obstetricians and Gynecologists, 2017d). As discussed in Chapter 9 (p. 170), no data suggest that exercise is harmful during pregnancy. One caveat is that as pregnancy progresses, balance problems and joint relaxation may predispose to orthopedic injury. A woman is advised not to exercise to exhaustion, and she should augment heat dissipation and fluid replacement. Further avoidances include prolonged supine position, activities requiring good balance, and extreme weather conditions.


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Obstentrics_Williams. Pregnancy can exacerbate interpersonal problems and is a time of elevated risk from an abusive partner. According to the American College of Obstetricians and Gynecologists (2012), approximately 324,000 pregnant women are abused each year. As discussed in Chapter 47 (p. 925), intimate partner violence has been associated with greater risk for several pregnancy-related complications, including hypertension, vaginal bleeding, hyperemesis, preterm delivery, and low-birthweight neonates (Silverman, 2006). Because domestic violence can escalate during pregnancy, even to the point of homicide, the preconceptional period provides an ideal time for screening and if indicated, intervention (Cheng, 2010). s detailed in Chapter 9 (p. 162), the American College of Obstetricians and Gynecologists (2012) provides recommendations and resources for screening both pregnant and nonpregnant women for domestic violence.


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Obstentrics_Williams. Certain laboratory tests may help assess the risk for and prevent some pregnancy complications. hese include basic tests that are usually performed during prenatal care and are enumerated in Chapter 9. More speciic tests may assist evaluation of women with certain chronic medical diseases. Examples of some chronic diseases that ideally would be assessed before conception are highlighted in Table 8-4. With several of these, optimizing maternal condition before conception will improve pregnancy outcomes. Cox and coworkers (1e992) reviewed pregnancy outcomes in 1075 high-risk women who received such evaluation. hey reported that the 240 women with hypertension, asthma, or renal, thyroid, or cardiac disease had better outcomes compared with the outcomes from their prior pregnancies. TABLE 8-4. Selected Preconceptional


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Obstentrics_Williams. TABLE 8-4. Selected Preconceptional Methyl mercury: Avoid shark, swordfish, king mackerel, and tile fish. Ingest no more than 12 ounces or 2 servings of canned tuna and no more than 6 ounces of albacore per week. Lead: Blood lead testing if a risk factor is identified; treat if indicated according to recommendations. Calculate BMI yearly from Figure 48-1, p. 937 BMI .25 kglm2: Counsel on diet. Test for diabetes and metabolic syndrome if indicated. Consider weight 105s prior to conception. BMI � 78.5 kglm2: Assess for eating disorder. Counsel on cardiac risks during pregnancy; discuss situations in which pregnancy is contraindicated. cardiac function. Discuss medication teratogenicity (warfarin, ACE inh'bitor, ARB) and, if possible, switch to less dangerous agent when conception planned. Ofer genetic counseling to those with congenital cardiac anomalies (Table 49-4, p. 953).


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Obstentrics_Williams. Counsel on specific risks during pregnancy. Assess those with long-standing HTN for ventricular hypertrophy, retinopathy, and rena! disease. Optimize blood pressure co trol. If medications indicated, select or switch to an agent appropriate for pregnancy. Counsel on asthma risks during pregnancy. Optimize pulmonary function preconceptionally. Treat women with pharmacologica l step therapy for chronic asthma. Question for personal or family history of thrombotic events or recurrent poor pregnancy outcomes. If a thrombopbilia is found or known, counsel and offer appropriate anticoagulation regimen. Counsel on specific risks during pregnancy. Optimize blood pressure control before conception. Counsel women taking ACE inhibitors and ARBs abolJt teratogenicity and the need to switch agents before pregnancy.


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Obstentrics_Williams. Inlammatory bowel disease: Counsel afected women on subfertility risks and risks of adverse pregnancy outcomes. Discuss teratogenicity of methotrexate and the other imnunomodulators. Offer effective contraception during their use and switch agents, if possible, before conception. Hepatitis B: Vaccinate all high-risk women before conception (Table 9-7, p. 1l72). Counsel chronic carriers on transmission prevention to partners and fetus. Treat if indicated. Hepatitis C: Screen high-risk women. Counsel affected ,fomen on risks of disease and transmission. If treatment indicated, discuss ramifications and appropriateness of pregnancy. Iron-deficiency anemia: Iron supplementation. Sickle-cell disease: Screen all black women. Counsel those with trait or disease. Test partner if desired. Thalassemias: Screen women of Southeast Asian or Mediterranean ancestry. Renal d:sease Chap. 9, p. 170 Chap. 12, p. 244 Chap.l48,lp.l936 Chap. 61A, p. 1180 Chap. 49, p. 951 Chap. 12, pp. 241,


Obstentrics_Williams

Obstentrics_Williams. Renal d:sease Chap. 9, p. 170 Chap. 12, p. 244 Chap.l48,lp.l936 Chap. 61A, p. 1180 Chap. 49, p. 951 Chap. 12, pp. 241, Chap. 50, p. 976 Chap. 51, p. 988 Chap.l52,lp.ll006 Chap. 53, p. 1025 Chap. 12, p. 241 Chap. 54, p. 1050 Chap. 12, pp. 242, Chap. 55, p. 1064 Chap.l56,lp.ll075 TABLE 8-4. Continued Diabetes Chap. 57, p. 1104 Optimize glycemic control to minimize teratogenicity of hyperglycemia. Evaluate for end-organ damage such as retinopathy, nephropathy, hypertension, and others. Discontinue ACE inhibitors. Thyroid disease Chap. 58, p. 1118 Screen those with thyroid disease symptoms. Ensure diet. Treat overt hyper-or hypothyroidism. Counsel on risks to pregnancy outcome. Connective Chap. 59, p. 11l38 RA: Counsel on flare risk after pregnancy. Discuss methotrexate and leflunomide tissue disease Chap. 12, p. 241 teratogenicity, as well as possible effects of other immunomodulators. Switch these agents before conception. Stop NSAIDs by 27 weeks' gestation.


Obstentrics_Williams

Obstentrics_Williams. Switch these agents before conception. Stop NSAIDs by 27 weeks' gestation. SLE: Counsel on risks during pregnancy. Optimize disease before conception. Discuss mycophenolate mofetil and cyclophosphamide teratogenicity as well as possible effects of newer immunomodulators. Switch these agents before conception. Psych iatric Cha p. 61, p. 11 75 Depression: Screen for symptoms of depression. Counsel on risks of treatment and disorders of untreated illness and the high risk of exacerbation during pregnancy and the puerperium. Neurological Chap. 60, p. 11l59 Seizure disorder: Optimize seizure control using monotherapy if possible. disorders Dermatological Chap. 12, p. 245 Discuss isotretinoin and etretinate teratogenicity and effective contraception disease during their use; switch agents before conception.


Obstentrics_Williams

Obstentrics_Williams. Cancer Chap. 63, p. 11l92 Counsel on fertility preservation options before cancer therapy and on decreased fertility following certain agents. Discuss appropriateness of pregnancy balanced with need for ongoing cancer therapy and prognosis of the disease state. Infectious Chap. 64, p. 1209 Influenza: Vaccinate all women who will be pregnant during flu season. Vaccinate diseases high-risk women prior to flu season. Malaria: Counsel to avoid travel to endemic areas during conception. If unable, offer effective contraception during travel or provide chemoprophylaxis for those planning pregnancy. Zika virus: See travel restrictions by CDC. Rubella: Screen for rubella immunity. If nonimmune, vaccinate and counsel on the need for effective contraception during the subsequent month. Tdap: tetanus, diphtheria, pertussis: Update vaccination in all reproductive-aged women.


Obstentrics_Williams

Obstentrics_Williams. Tdap: tetanus, diphtheria, pertussis: Update vaccination in all reproductive-aged women. Varicella: Question regarding immunity. If nonimmune, STDs Chap.l65,lp.l1235 Gonorrhea, syphilis, chlamydial infection: Screen high-risk women and treat as indicated. HIV: Screen at-risk women. Counsel afected women on risks during pregnancy and on perinatal transmission. Discuss initiation of treatment before pregnancy to decrease transmission risk. Offer effective contraception to those not desiring conception. HPV' Provide Pap smear screening per guidelines (Chap. 63, p. 1193). Vaccinate candidate patients. HSV: Provide serological screening to asymptomatic women with affected partners. Counsel affected women on risks of perinatal transmission and on preventative measures during the third trimester and labor.


Obstentrics_Williams

Obstentrics_Williams. ACE = angiotensin-converting enzyme; ACOG = American College of Obstetricians and Gynecologists; ARB = angiotensinreceptor blocker; BMI = body mass index; CDC = Centers for Disease Control and Prevention; HIV = human immunodeficiency virus; HPV = human papillomavirus; HSV = herpes simplex virus; HTN = hypertension; NSAID = nonsteroidal antiinflammatory drug; RA = rheumatoid arthritis; SLE = systemic lupus erythematosus; STD = sexually transmitted disease. Data from Jack BW, Atrash H, Coonrod DV, et al: The clinical content of preconception care: an and preparation of this supplement, Am J Obstet Gynecol. 2008 Dec;199(6 Suppl 2):5266-S279. Aghajanian P, Gupta M: Helping your epileptic patient. Contemp OB/GYN 60:10,s2015 Aguglia U, Barboni G, Battino 0, et al: Italian consensus conference on epilepsy and pregnancy, labor and puerperium. Epilepsia 50:7, 2009


Obstentrics_Williams

Obstentrics_Williams. Aguglia U, Barboni G, Battino 0, et al: Italian consensus conference on epilepsy and pregnancy, labor and puerperium. Epilepsia 50:7, 2009 Amant F, Vandenbroucke T, Verheecke M, et a1: Pediatric outcome after maternal cancer diagnosed during pregnancy. N Engl J Med 3(19): 1824, 2015 American Academy of Pediatrics: Maternal phenylketonuria. Pediatrics 122: 445, 2008 American College of Obstetricians and Gynecologists: Intimate partner violence. Committee Opinion No. 518, 2012 American College of Obstetricians and Gynecologists: At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Committee Opinion No. 496, August 2011, Reairmed 2013 American College of Obstetricians and Gynecologists: Hemoglobinopathies in pregnancy. Practice Bulletin No. 78, January 2007, Reairmed 2015a American College of Obstetricians and Gynecologists: Obesiry in pregnancy. Committee Opinion No. 549, January 2013, Reairmed 2015b


Obstentrics_Williams

Obstentrics_Williams. Committee Opinion No. 549, January 2013, Reairmed 2015b American College of Obstetricians and Gynecologists: Pregestational diabetes mellitus. Practice Bulletin No. 60, March 2005, Reairmed 2016a American College ofsObstetricians and Gynecologists: Reproductive life plan nll1g to reduce unIntended pregnancy. Committee Opinion No. 654, February 2016b American College of Obstetricians and Gynecologists: Screening for fetal aneuploidy. Practice Bulletin No. 163, March 2016c America� Coll�g� of Obstetricians and Gynecologists: Carrier screening for genetIc condltlons. Committee Opinion No. 691, March 2017a Ame:ican College of Obstetricians and Gynecologists: Management of women WIth phenylketonuria. Committee Opinion No. 636, June 2015, Reaffirmed 2017b American College of Obstetricians and Gynecologists: Marijuana use during pregnancy and lactation. Committee Opinion No. 722, July 2015, Reaffirmed 2017c


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Marijuana use during pregnancy and lactation. Committee Opinion No. 722, July 2015, Reaffirmed 2017c American Col�ege of Obstetricians and Gynecologists: Physical activiry and exerCIse dunng pregnancy and postpartum period. Committee Opinion No. 650, December 2015, Reairmed 2017 d American College of Obstetricians and Gynecologists: The importance of preconception care in the continuum of women's health care. Committee Opinion No. 313, September 2005, Reairmed 2017e Bailey]A, Hill KG, Hawkins ]0, et al: Men's and women's patterns of substance use around pregnancy. Birth 35:1, 2008 Be:h BH, Kjaersgaard MI, Pedersen HS, et al: Use of antiepileptic drugs durIl1g pregnancy and risk of spontaneous abortion and stillbirth: population based cohort study. BM] 349:g5159, 2014 Becker AE, Grinspoon SK, Klibanski A, et al: Eating disorders. N Engl ] Med 340: 14, 1999


Obstentrics_Williams

Obstentrics_Williams. Becker AE, Grinspoon SK, Klibanski A, et al: Eating disorders. N Engl ] Med 340: 14, 1999 Brasil P, Pereira JP, Gabaglia CR, et al: Zika virus infection in pregnant women in Rio de Janeiro-preliminary report. N Engl J Vied 375(24): 2321,s2016 Buyon ]P, Kim MY, Guerra Mvl, et al: Predictors of pregnancy outcomes in patients with lupus: a cohort study. Ann Intern Med 163(3): 153, 2015 Camp M, Paris A, Acosta PB, et al: Phenylketonuria scientific review conference: state of the science and future research needs. Mol Genet Metab 112(2):87,s2014 Cao A, Kan W: he prevention of thalassemia. Cold Spring Harb Perspect Med 3(2):aOll775, 2013 Cassina M, Dilaghi A, Di Gianantonio E, et al: Pregnancy outcome in women exposed to antiepileptic drugs: teratogenic role of maternal epilepsy and its pharmacologic treatment. Reprod ToxicoI39:50, 2013 Cedars MI: Introduction: childhood implications of parental aging. Fertil Steril 103(6):1379,s2015


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Obstentrics_Williams. Cedars MI: Introduction: childhood implications of parental aging. Fertil Steril 103(6):1379,s2015 Center� for Disease Control and Prevention: Women and smoking. 2014. AvaIlable at: http://www.cdc.gov/ tobaccol data_statisticsl sgrl50th-anniversary/pdfs/fs_women_smokin�508.pdf. Accessed April 5, 2016 Centers for Disease Control and Prevention: Preconception health and health care. 2015. Available at: http://www.cdc.gov/preconception/index.html. Accessed April 5,s2016 Centers for Disease Control and Prevention: Birth defects. 2016. Available at: http://www.cdc.gov/ncbddd/birthdefects/data.html. Accessed April 5, 2016 Cheng 0, Horon IL: Intimate-partner homicide among pregnant and postpar tum women. Obstet GynecoIsI15(6):1l81, 2010 Cox M, Whittle M], Byrne A, et al: Prep regnancy counseling: experience from 10 5 cases. B]OG 99:873, 1992 Creanga A, Berg CJ, Syverson C, et al: Pregnancy-related mortaliry in the United States, 2006-2010. Obstet Gynecol 125:5,s2015


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Obstentrics_Williams. Cunningham FG, Leveno KJ: Childbearing among older women-the message is cautiously optimistic. N Engl J Med 333:953, 1995 Czeize1 AE, Dudas I: �rev�ntion of the irst occurrence of neural-tube defects by penconceptIonal vltamll1 supplementation. N Engl J Med 327:1832, 1992 D'Angelo 0, Williams L, Morrow B, et al: Preconception and interconception health st�tus of women who recently gave birth to a live-born infant-Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004. IMWR 56(10): 1,s2007 Davies M], Moore VM, Willson KJ, et al: Reproductive technologies and the risk of birth defects. N Engl ] Med 366(19): 1803, 2012 de Jong-van den Berg LT, Hernandez-Diaz S, Weder MM, et al: Trends and predictors of folic acid awareness and periconceptional use in pregnant women. Am] Obstet Gynecolsl92:121, 2005 Forget BG, Bunn HF: Classiication of the disorders of hemoglobin. Cold Spring Harb Perspect Med 3(2):aOI1684, 2013


Obstentrics_Williams

Obstentrics_Williams. Forget BG, Bunn HF: Classiication of the disorders of hemoglobin. Cold Spring Harb Perspect Med 3(2):aOI1684, 2013 Fried S, Kozer E, Nulman I, et al: Malformation rates in children of women with untreated epilepsy: a meta-analysis. Drug Saf 27(3): 197, 2004 Geller SE, C?X SM, Callaghan WM, et al: Morbidiry and mortaliry in pregnancy: layll1g the groundwork for safe motherhood. Womens Health Issues 16: 176, 2006 Gold?erg BB, Alvarado 5, Chavez C, et al: Prevalence of periconceptional folic aCId use a�d perceived barriers to the postgestation continuance of supple mental folIc aCId: survey results from a Teratogen Information Service. Birth Defects Res Part A Clin Mol Teratol 76:193, 2006 Guttmacher Institute: State facts about unintended pregnancies. 2015. Available at: https:llwww.guttmacher.org/fact-sheet/ state-facts-abou t-unin tendedpregnancy. Accessed April 5, 2016


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Obstentrics_Williams. Guttmacher Institute: State facts about unintended pregnancies. 2015. Available at: https:llwww.guttmacher.org/fact-sheet/ state-facts-abou t-unin tendedpregnancy. Accessed April 5, 2016 Hernandez-Dlaz 5, Smith CR, Shen A, et al: Comparative safery of antiepileptic drugs during pregnancy. Neurology 78: 1692,s2012 Jack BW, Arrash H, Coonrod DV, et al: he clinical content of preconception care: an overview and preparation of this supplement. Ams] Obstet Gynecol 199(6 Suppl 2):5266, 2008 Jack BW, Campanile C, McQuade W, et al: he negative pregnancy test. An opportuniry for preconception care. Arch Fam Med 4:340, 1995 ]eha LE, Morris HH: Optimizing outcomes in pregnant women with epilepsy. Cleve Clin J Med 72:928, 2005 Jentink], Loane MA, Dolk H, et al: Valproic acid mono therapy in pregnancy and major congenital malformations. N Engl] Med 362(23):2185, 2010


Obstentrics_Williams

Obstentrics_Williams. Cleve Clin J Med 72:928, 2005 Jentink], Loane MA, Dolk H, et al: Valproic acid mono therapy in pregnancy and major congenital malformations. N Engl] Med 362(23):2185, 2010 Johnson KsPosner SF, Biermann J, et al: Recommendations to improve pre conception health and health care-United States. A report of the CDCI ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 55(6):1,2006 Kim C, Ferrara A, McEwen LN, et al: Preconception care in managed care: the translating research into action for diabetes study. Am J Obstet Gynecol 192:227,s2005 Kitzmiller JL, Block JM, Brown FH, et al: Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care 31(5):1060,s2008 Kitzmiller JL, Gavin A, Gin GO, et al: Preconception care of diabetics. JAMA 265:731, 1991


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Obstentrics_Williams. Kitzmiller JL, Gavin A, Gin GO, et al: Preconception care of diabetics. JAMA 265:731, 1991 Kjer 0, Horvath-Puh6 E, Christensens], et a1: Antiepileptic drug use, folic acid supplementation, and congenital abnormalities: a population-based case-control study. 115(1):98,s2008 Korteweg FJ, Bouman K, Erwich n, et al: Cytogenetic analysis after evaluation of 750 fetal deaths: proposal for diagnostic workup. Obstet Gynecol III (4):865, 2008 Kouba 5, Hallstrom T, Lindholm C, et al: Pregnancy and neonatal outcomes in women with eating disorders. Obstet Gynecol 105:255,s2005 Kuliev A, Pakhalchuk T, Verlinsky 0, et al: Preimplantation genetic for hemoglobinopathies. Hemoglobin 35(5-6):547, 201s1 Lane M, Robker RL, Robertson SA: Parenting from before conception. Science 345(6198):756,s2014 Lassi ZS, Imam AM, Dean SV, et al: Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 26:11, 2014


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Obstentrics_Williams. Lassi ZS, Imam AM, Dean SV, et al: Preconception care: screening and management of chronic disease and promoting psychological health. Reprod Health 26:11, 2014 Leguizam6n G, Igarzabal ML, Reece EA: Periconceptional care of women with diabetes mellitus. Obstet Gynecol C1in North Am 34:225, 200 Luke B: Pregnancy and birth outcomes in couples with infertility and with and without assisted reproductive technology: with an emphasis on US population-based studies. Am J Obstet Gynecol 217:270, 2017 Maillot F, �ook P, Lilburn M, et al: A practical approach to maternal phenylketonufla management. J Inherit Metab Dis 30: 198, 2007 Malaspina 0, Gilman C, Kranz TM: Paternal age and mental health of ofspring. Ferti! Steril 103(6):1392,s2015 Martin ]A, Hamilton BE, Ventura 5], et al: Births: inal data for 2010. Nat! Vital Stat Rep 61(1):1, 2012


Obstentrics_Williams

Obstentrics_Williams. Martin ]A, Hamilton BE, Ventura 5], et al: Births: inal data for 2010. Nat! Vital Stat Rep 61(1):1, 2012 McNamara OM, Elkayam U, Alharethi R, et al: Clinical outcomes for peripartum cardiomyopathy in North America: results of the IPAC study (investigations of pregnancy-associated cardiomyopathy). J Am ColI CardioIe66(8): 905,e2015 Medical Research Council Vitamin Study Research Group: Prevention of neural tube defects: results of the Medical Research Council vitamin study. Lancet 338:131, 1991 Moos MK: Preconceptional health promotion: progress in changing a prevention paradigm. J Perinat Neonatal Nurs 18:2,e2004 Moos MK, Bangdiwala SI, Meibohm R, et al: he impact of a preconceptional health promotion program on intendedness of pregnancy. Am J PerinatoIe13:103, 1996


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Obstentrics_Williams. Moos MK, Bangdiwala SI, Meibohm R, et al: he impact of a preconceptional health promotion program on intendedness of pregnancy. Am J PerinatoIe13:103, 1996 Morrow JI, Hunt SJ, Russell AJ, et al: Folic acid use and major congenital malformations in ofspring of women with epilepsy: a prospective study from the UK Epilepsy and Pregnancy Register. J Neurol Neurosurg Psychiatry 80(5):506, 2009 Niccolai LM, Ethier A, Kershaw TS, et al: Pregnant adolescents at risk: sexual behaviors and sexually transmitted disease prevalence. Am J Obstet Gynecol 188:63,e2003 Petersen EE, Staples JE, Meaney-Delman 0, et al: Interim guidelines for pregnant women during a Zika virus outbreak-United States, 2016. MMWR 65(2):30,e2016 Podymow T, Joseph G: Preconception and pregnancy management of women with diabetic nephropathy on angiotensin converting enzyme inhibitors. Clin NephroIe83(2):73, 2015


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Obstentrics_Williams. Podymow T, Joseph G: Preconception and pregnancy management of women with diabetic nephropathy on angiotensin converting enzyme inhibitors. Clin NephroIe83(2):73, 2015 Qin J, Liu X, Sheng X, et al: Assisted reproductive technology and the risk of pregnancy-related complications and adverse pregnancy outcomes in Singleton pregnancies: a meta-analysis of cohort studies. Fertil Steril 105(1):73, 2016 Reddy UM, Page GP, Saade GR, et al: Karyotype versus microarray testing for genetic abnormalities ater stillbirth. N Engl J Med 367(23):2185,2012 Reece EA, Homko CJ: Prepregnancy care and the prevention of fetal malformations in the pregnancy complicated by diabetes. Clin Obstet Gynecol 50:990, 2007 Robert E: Intrauterine efects of electromagnetiC ields (low frequency, midfrequency F, and microwave): review of epidemiologic studies. Teratology 59:292, 1999


Obstentrics_Williams

Obstentrics_Williams. Robert E: Intrauterine efects of electromagnetiC ields (low frequency, midfrequency F, and microwave): review of epidemiologic studies. Teratology 59:292, 1999 Schuler-Faccini L, Ribeiro EM, Feitosa 1M, et al: Possible association between Zika virus infection and microcephaly-Brazil, 2015. MMWR 65(3):59, 20e16 Sheield JS, Butler-Koster EL, Casey BM, et al: Maternal diabetes mellitus and infant malformations. Obstet Gynecolel00:925, 2002 Silverman JG, Decker MR, Reed E, et al: Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. States: associations with maternal and neonatal health. Am J Obstet Gynecol 195:140,e2006 Simpson LL: Preconception considerations. Semin Perinatol 38(5):236, 2014


Obstentrics_Williams

Obstentrics_Williams. Simpson LL: Preconception considerations. Semin Perinatol 38(5):236, 2014 Society for Maternal-Fetal Medicine (SMFM), Sciscione A, Berghella V, et al: Society for Maternal-Fetal Medicine (SMFM) special report: the maternal-fetal medicine subspecialists' role within a health care system. Am J Obstet Gynecole211 (6):607,e2014 Stothard KJ, Tennant PW, Bell R, et al: Maternal oveweight and obesity and the risk of congenital anomalies: a systematic review and meta-analysis. JAMA 301:636,e2009 Stubbleield PG, Coonrod DV, Reddy UM, et al: he clinical content of preconception care: reproductive history. Am J Obstet Gynecol 199(6 Suppl 2):S373, 2008 Sunderan S, Kissin OM, Crawford SB, et al: Assisted reproduction technology suveillance-United States, 20e12. MMWR 64:e1,e20e15


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Obstentrics_Williams. Sunderan S, Kissin OM, Crawford SB, et al: Assisted reproduction technology suveillance-United States, 20e12. MMWR 64:e1,e20e15 Temel S, Van Voorst SF, Jack BW, et al: Evidence-based preconceptionalelifestyle interventions. Epidemiol Rev 36:19,e2014 hompson MW, McInnes R, Huntington FW (eds): Genetics in Medicine, 5th ed. Philadelphia, Saunders, 1991 Tomson T, Battino 0: Pregnancy and epilepsy: what should we tell our patients? J Neurol 256(6):856, 2009 Tough S, ToHemire K, Clarke M, et al: Do women change their drinking behaviors while trying to conceive? n opportunity for preconception counseling. Clin Med Res 4:97, 2006 Tripathi A, Rankin J, Aarvold J, et al: Preconception counseling in women with diabetes: a population-based study in the North of England. Diabetes Care 33(3):586,e2010


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Obstentrics_Williams. Tripathi A, Rankin J, Aarvold J, et al: Preconception counseling in women with diabetes: a population-based study in the North of England. Diabetes Care 33(3):586,e2010 U.S. Preventive Services Task Force: Final update summary: folic acid to prevent neural tube defects. 2009. Available at: http://ww.uspreventiveservicestaskfo rce. 0rg/Pagel Documen t/U pdateS ummary F inall folic-acidto-prevent-neural-tube-defects-preventive-medication. Accessed April 5, 2016 Usta 1M, Zoorob 0, Abu-Musa A, et al: Obstetric outcome of teenage pregnancies compared with adult pregnancies. Acta Obstet Gynecol 87: 178, 2008 Vajda FJ, Hitchcock A, Graham J, et al: Seizure control in antiepileptic drug treated pregnancy. Epilepsia 49: 172, 2008 Vajda FJ, O'Brien TJ, Graham J, et al: he outcomes of pregnancy in women with untreated epilepsy. Seizure 24: 7, 2015


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Obstentrics_Williams. Van der Zee B, de Wert G, Steegers A, et al: Ethical aspects of paternal preconception lifestyle modiication. Am J Obstet Gynecol 209(1): 11, 2013 Veiby G, Daltveit AK, Engelsen BA, et al: Pregnancy, delivery, and outcome for the child in maternal epilepsy. Epilepsia 50(9):2130, 2009 Vichinsky EP: Clinical manifestations of a-thalassemia. Cold Spring Harb Perspect Med 3(5):aOI1742, 2013 Vockley J, Andersson HC, Antshel KM, et al: Phenylalanine hydroxylase deiciency: diagnosis and management guideline. American College of Medical Genetics and Genomics Therapeutics Committee 16:356,2014 Waldenstrom U, Cnattingius S, Norman M, et al: Advanced maternal age and stillbirth risk in nulliparous and parous women. Obstet Gynecol 126(2): 355, 2015 Williams J, Mai CT, Mulinare J, et al: Updated estimates of neural tube defects prevention by mandatory folic acid fortiication-United States, 1995-2011. MMWR 64(1):1, 2015


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Obstentrics_Williams. Williams J, Mai CT, Mulinare J, et al: Updated estimates of neural tube defects prevention by mandatory folic acid fortiication-United States, 1995-2011. MMWR 64(1):1, 2015 Windham G, Fenster L: Environmental contaminants and pregnancy outcomes. Fertil Steril 89:e Ill, 2008 DIAGNOSIS OF PREGNANCY. . . . . . . . . . . . . . . . . . . . .. 158 INITIAL PRENATAL EVALUATION .e. .e..... .e.. .e.. ...e. 159 SUBSEQUENT PRENATAL VISITS .... .e. .e......... .e. 164 ..NUTRITIONAL COUNSELING. . . . . . . . . . . . . . . . . . . . .. 165 COMMON CONCERNS . . . . . . . . . . . . . . . . . . . . . . . . . .. 170 The borderline between health and disease is less distincty marked during gestation, and therore, it accordingy becomes necessary to keep pregnant patients under strict supervision, and to be constanty on the alert or the appearance of untoward symptoms.


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) s emphasized above by Williams, prenatal care is important. According to the merican Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) a comprehensive antepartum program is deined as: "a coordinated approach to medical care, continuous risk assessment, and psychological support that optimally begins before conception and extends throughout the postpartum period and interconceptional period." Almost a century after its introduction, prenatal care has become one of the most frequently used health services in the United States. In 2001, there were approximately 50 million prenatal visits. The median was 12.3 visits per pregnancy, and many women had 17 or more visits. Still, as seen from


Obstentrics_Williams

Obstentrics_Williams. Figure 9-1, 6 to 7 percent of women in this country have late or no prenatal care. In 2014, the percentages of non-Hispanic white, Hispanic, and African-American women who received inadequate or no prenatal care were 4.3, 7.5, and 9.7, respec tively (Child Trends, 2015). he Centers for Disease Control and Prevention (CDC) (2000) analyzed birth certificate data and found that half of women with delayed or no prenatal care wanted to begin care earlier. Barriers to care varied by social and ethnic group, age, and payment method. he most common reason cited was late recognition of pregnancy by the patient. The second most commonly cited obstacle was lack of money or insurance. he third was inability to obtain an appointment.


Obstentrics_Williams

Obstentrics_Williams. Care designed during the early 1900s focused on lowering the extremely high maternal mortality rate. Prenatal care undoubtedly contributed to the dramatic decline in this mortality rate from 690 deaths per 100,000 births in 1920 to 50 per 100,000 •• Births in all states Births in states using the 1989 birth certificate/revision • Births in states using the 2003 birth certificate/revision FIGURE 9-1 Percentage of births to mothers who received late or no prenatal care-United States, 1990-2014. (Data from Trends, 2015.) by 1955 (Loudon, 1992). And, the low current maternal mortality rate of 10 to 15 per 100,000 is likely associated with the high utilization of this care (Xu, 2010). Indeed, data from 1998 to 2005 from the Pregnancy \10rtality Surveillance System identified a ivefold increased risk for maternal death in women who received no prenatal care (Berg, 2010).


Obstentrics_Williams

Obstentrics_Williams. Other reports also attest to prenatal care eicacy. In a study of almost 29 million births, the risk for preterm birth, stillbirth, early and late neonatal death, and infant death rose linearly with decreasing prenatal care (Partridge, 2012). Similarly, Leveno and associates (2009) found that a significant decline in preterm births at Parkland Hospital correlated closely with increased use of prenatal care by medically indigent women. Moreover, National Center for Health Statistics data showed that women with prenatal care had an overall stillbirth rate of 2.7 per 1000 compared with 14.1 per 1000 for women without this care (Vintzileos, 2002).


Obstentrics_Williams

Obstentrics_Williams. Evaluating the format of care, Ickovics and coworkers (2016) compared individual prenatal care and group prenatal care. he latter provided traditional pregnancy surveillance in a group setting with special focus on support, education, and active healthcare participation. Women enrolled in group prenatal care had significantly better pregnancy outcomes. Carter and colleagues (2016) cited similar results. Childbirth education classes are also reported to result in better pregnancy outcomes (Afshar, 2017). Adolescent pregnancies carry special risk, and guidelines have been developed that focus on this subgroup (Fleming, 2015). Few data are available to recommend the practice of ofering tangible incentives to improve prenatal care attendance (Till, 2015).


Obstentrics_Williams

Obstentrics_Williams. Pregnancy is usually identified when a woman presents with symptoms and possibly a positive home urine pregnancy test result. Typically, these women receive conirmatory testing of urine or blood for human chorionic gonadotropin (hCG). Further, presumptive signs or diagnostic indings of pregnancy may be found during examination. Sonography is often used, particularly if miscarriage or ectopic pregnancy is a concern. 100,000 50,000 E 10,000


Obstentrics_Williams

Obstentrics_Williams. 100,000 50,000 E 10,000 Amenorrhea in a healthy reproductive-aged woman who previously has experienced spontaneous, cyclical, predictable menses is highly suggestive of pregnancy. Menstrual cycles vary appreciably in length among women and even in the same woman (Chap. 5, p. 81). hus, amenorrhea is not a reliable pregnancy indicator until 10 days or more after expected menses have passed. Occasionally, uterine bleeding that mimics menstruation is noted after conception. During the irst month of pregnancy, these episodes are likely the consequence of blastocyst implantation. Still, irst-trimester bleeding should generally prompt evaluation for an abnormal pregnancy.


Obstentrics_Williams

Obstentrics_Williams. Of other symptoms, maternal perception of fetal movement depends on factors such as parity and habitus. In general, after a irst successful pregnancy, a woman may irst perceive fetal movements between 16 and 18 weeks' gestation. A primigravida may not appreciate fetal movements until approximately 2 weeks later. At about 20 weeks, depending on maternal habitus, an examiner can begin to detect fetal movements. Of pregnancy signs, changes in the lower reproductive tract, uterus, and breasts develop early. These are described in detail in Chapter 4 (p. 49). Detection of hCG in maternal blood and urine is the basis for endocrine assays of pregnancy. Syncytiotrophoblast produces hCG in amounts that increase exponentially during the irst trimester following implantation. A main function of hCG is to prevent involution of the corpus luteum, which is the principal site of progesterone formation during the irst 6 weeks of pregnancy.


Obstentrics_Williams

Obstentrics_Williams. With a sensitive test, the hormone can be detected in maternal serum or urine by 8 to 9 days after ovulation. he doubling time of serum hCG concentration is 1.4 to 2.0 days. As shown in Figure 9-2, serum levels range widely and increase from the day of implantation. They reach peak levels at 60 to 70 days. Thereafter, the concentration declines slowly until a plateau is reached at approximately 16 weeks' gestation. Measurement of hCG his hormone is a glycoprotein with high carbohydrate content. he general structure of hCG is a heterodimer composed of two dissimilar subunits, designated a and �, which are non covalently linked. The a-subunit is identical to those of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH), but the �-subunit is structurally distinct among these. hus, antibodies were developed with high speciicity for the hCG �-subunit.


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Obstentrics_Williams. FIGURE 9-2 Mean concentration (95% CI) of human chorionic gonadotropin (hCG) in serum of This speciicity allows its detecwomen throughout normal pregnancy. tion, and numerous commercial immunoassays are available for measuring serum and urine hCG levels. Although each immunoassay detects a slightly diferent mixture of hCG variants, its free subunits, or its metabolites, all are appropriate for pregnancy testing (Braunstein, 2014). Depending on the assay used, the sensitivity for the laboratory detection limit of hCG in serum is 1.0 mIU/mL or even lower (Wilcox, 2001). False-positive hCG test results are rare (Braunstein, 2002). erroneously with the test antibody directed to hCG in a given assay. The most common factors are heterophilic antibodies.


Obstentrics_Williams

Obstentrics_Williams. False-positive hCG test results are rare (Braunstein, 2002). erroneously with the test antibody directed to hCG in a given assay. The most common factors are heterophilic antibodies. hese are produced by an individual and bind to the animal derived test antibodies used in a given immunoassay. Thus, women who have worked closely with animals are more likely to develop these antibodies, and alternative laboratory tech niques are available (American College of Obstetricians and Gynecologists, 2017a). Elevated hCG levels may also reflect molar pregnancy and its associated cancers (Chap. 20, p. 391). Other rare causes of positive assays without pregnancy are: (1) exogenous hCG injection used for weight loss, (2) renal fail ure with impaired hCG clearance, (3) physiological pituitary hCG, and (4) hCG-producing tumors that most commonly originate from gastrointestinal sites, ovary, bladder, or lung (Montagnana, 2011).


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Obstentrics_Williams. Over-the-counter pregnancy test kits have been available since the early 1970s, and millions are sold annually in the United States. More than 60 such tests are available in this country (Grenache, 2015). Unfortunately, many of these are not as accurate as advertised Gohnson, 2015). For example, Cole and associates (201i1) found that a detection limit of 12.5 mIU/mL would be required to diagnose 95 percent of pregnancies at the time of missed menses, but they reported that only one brand had this degree of sensitivity. Two other brands gave false-positive or invalid results. In fact, with an hCG concentration of 100 mIU/mL, clearly positive results were displayed by only 44 percent of brands. Accordingly, only about 15 percent of pregnancies could be diagnosed at the time of the missed menses. Some manufacturers of even newer home urine assays claim >99-percent accuracy of tests done on the day of-and some up to 4 days before-the expected day of menses. Again, careful analysis


Obstentrics_Williams

Obstentrics_Williams. menses. Some manufacturers of even newer home urine assays claim >99-percent accuracy of tests done on the day of-and some up to 4 days before-the expected day of menses. Again, careful analysis suggests that these assays are often not as sensitive as advertised Gohnson, 2015).


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Obstentrics_Williams. • Sonographic Recognition of Pregnancy Transvaginal sonography has revolutionized early pregnancy imaging and is commonly used to accurately establish gestational age and conirm pregnancy location. A gestational sac-a small anechoic luid collection within the endometrial cavityis the irst sonographic evidence of pregnancy. It may be seen with transvaginal sonography by 4 to 5 weeks' gestation. A luid collection, however, can also be seen within the endometrial cavity with an ectopic pregnancy and is termed a pseudogestational sac or pseudosac (Fig. 19-4, p. 375). Thus, further evaluation may be warranted if this is the only sonographic inding, particularly in a woman with pain or bleeding. A normal


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Obstentrics_Williams. FIGURE 9-3 Transvaginal sonogram of a first-trimester intrauterine pregnancy. The double decidual sign is noted surrounding the gestational sac and is defined by the decidua parietalis (white asterisk) and the decidua capsularis (yellow asterisk). The arrow notes the yolk sac, and the crown-rump length of the embryo is marked with measuring calipers. (Used with permission from Dr. Elysia Moschos.) gestational sac implants eccentrically in the endometrium, whereas a pseudosac is seen in the midline of the endometrial cavity. Other potential indicators of early intrauterine pregnancy are an anechoic center surrounded by a single echogenic rim-the intradecidual sign-or two concentric echogenic rings surrounding the gestational sac-the double decidual sin shown in Figure 9-3. If sonography yields equivocal indings, the term pregnancy of unknown location (PUL) is applied. In these cases, serial serum hCG levels and transvaginal sonograms can help diferentiate a normal intrauterine


Obstentrics_Williams

Obstentrics_Williams. yields equivocal indings, the term pregnancy of unknown location (PUL) is applied. In these cases, serial serum hCG levels and transvaginal sonograms can help diferentiate a normal intrauterine pregnancy from an extrauterine pregnancy or an early miscarriage (Chap. 19, p. 373).


Obstentrics_Williams

Obstentrics_Williams. If the yolk sac-a brightly echogenic ring with an anechoic center-is seen within the gestational sac, an intrauterine location for the pregnancy is confirmed. The yolk sac can normally be seen by the middle of the ifth week. As shown in Figure 9-3, after 6 weeks, an embryo is seen as a linear structure immediately adjacent to the yolk sac. Cardiac motion is typically noted at this point. Up to 12 weeks' gestation, the crown-rump length is predictive of gestational age within 4 days (Chap. 10, p. 183). Prenatal care is ideally initiated early. Major goals are to: (1) deine the health status of the mother and fetus, (2) estimate the gestational age, and (3) initiate a plan for continued obstetrical care. Typical components of the initial visit are summarized in Table Subsequent care may range from relatively infrequent routine visits to prompt hospitalization because of serious maternal or fetal disease.


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Obstentrics_Williams. Subsequent care may range from relatively infrequent routine visits to prompt hospitalization because of serious maternal or fetal disease. Use of a standardized record within a perinatal health-care system greatly aids antepartum and intrapartum management. TABLE 9-1 . Typical Components of Routine Prenatal Care Chap. 9, p. 161 Chap. 9, p. 163 Chap. 40, p. 71l1 Chap. 9, p. 165 Chap. 9, p. 163 Chap. 9, p. 164 Chap. 9, p. 165 Chap. 56, p. 1075 Chap. 15, p. 301 Chap. 15, p. 301 Chap. 63, p. 1193 Chap. 57, p. 1108 Chap. 14, p. 278 Chap. 14, p. 283 Chap. 14, p. 289 Chap. 4, p. 66 Chap. 53, p. 1026 Chap. 64, p. 1215 Chap. 65, p. 1l237 Chap. 65, p. 1239 Chap. 65, p. 1240 Chap. 55, p. 1064 Chap. 65, p. 1247 Chap. 64, p. 1220 Chap. 51, p. 996 aFirst-trimester aneuploidy screening may be ofered between 11 and 14 weeks. A Performed at 28 weeks, if indicated. 8 Test should be ofered. C High-risk women should be retested at the beginning of the third trimester.


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Obstentrics_Williams. 8 Test should be ofered. C High-risk women should be retested at the beginning of the third trimester. o High-risk women should be screened at the first prenatal visit and again in the third trimester. culture should be between 35 and 37 weeks. HIV human immunodeficiency virus. Standardizing documentation allows communication and care continuity between providers and enables objective measures of care quality to be evaluated over time and across diferent clinical settings (Gregory, 2006). A prototype is provided by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) in their Guidelines or Perinatal Care, 8th edition. Several deinitions are pertinent to establishment of an accurate prenatal record. 1. Nulligravida-a woman who currently is not pregnant and has never been pregnant. 2.


Obstentrics_Williams

Obstentrics_Williams. Several deinitions are pertinent to establishment of an accurate prenatal record. 1. Nulligravida-a woman who currently is not pregnant and has never been pregnant. 2. Gravida-a woman who currently is pregnant or has been in the past, irrespective of the pregnancy outcome. With the establishment of the first pregnancy, she becomes a primigravida, and with successive pregnancies, a multigravida. 3. Nullpara-a woman who has never completed a pregnancy beyond 20 weeks' gestation. She may not have been pregnant or may have had a spontaneous or elective abortion(s) or an ectopic pregnancy. 4.


Obstentrics_Williams

Obstentrics_Williams. 3. Nullpara-a woman who has never completed a pregnancy beyond 20 weeks' gestation. She may not have been pregnant or may have had a spontaneous or elective abortion(s) or an ectopic pregnancy. 4. Primipara-a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated length of gestation of 20 or more weeks. In the past, a 500-g birthweight threshold was used to define parity. his threshold is now controversial because many states still use this weight to diferentiate a stillborn fetus from an abortus (Chap. 1, p. 3). However, the survival of neonates with birthweights < 500 g is no longer uncommon.


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Obstentrics_Williams. 5. Multpara-a woman who has completed two or more pregnancies to 20 weeks' gestation or more. Parity is determined by the number of pregnancies reaching 20 weeks. It is not increased to a higher number if multiples are delivered in a given pregnancy. Moreover, stillbirth does not lower this number. In some locales, the obstetrical history is summarized by a series of digits connected by dashes. hese refer to the number of term infants, preterm infants, abortuses younger than 20 weeks, and children currently alive. For example, a woman who is para 2-1-0-3 has had two term deliveries, one preterm delivery, no abortuses, and has three living children. Because these are nonconventional, it is helpful to speciy the outcome of any pregnancy that did not end normally.


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Obstentrics_Williams. The normal duration of pregnancy calculated from the irst day of the last normal menstrual period is very close to 280 days or 40 weeks. In a study of 427,581 singleton pregnancies from the Swedish Birth Registry, Bergsj0 and coworkers (1990) found that the mean pregnancy duration was 281 days with a standard deviation of 13 days. However, menstrual cycle length varies among women and renders many of these calculations inaccurate. This, combined with the frequent use of irst-trimester sonography, has changed the method of determining an accurate gestational age (Duryea, 2015).


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Obstentrics_Williams. he American College of Obstetricians and Gynecologists (2017e), the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine have concluded that irst-trimester ultrasound is the most accurate method to establish or reairm gestational age. For pregnancies conceived by assisted reproductive technology, embryo age or transfer date is used to assign gestational age. If available, the gestational ages calculated from the last menstrual period and from irst-trimester ultrasound are compared, and this estimated date of delivery is recorded. his is discussed in further detail in Chapter 7 (p. 124) and in Table 10-1 (p. 183).


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Obstentrics_Williams. A quick estimate of a pregnancy due date based on menstrual data can be made as follows: add 7 days to the irst day of the last period and subtract 3 months. For example, if the irst day of the last menses was October 5, the due date is 10-05 minus 3 (months) plus 7 (days) = 7-12, or July 12 of the following year. his calculation is the Naegele rule (American College of Obstetricians and Gynecologists, 2017 e).


Obstentrics_Williams

Obstentrics_Williams. It has become customary to divide pregnancy into three equal epochs or trimesters of approximately 3 calendar months. Historically, the irst trimester extends through completion of 14 weeks, the second through 28 weeks, and the third includes the 29th through 42nd weeks of pregnancy. Thus, there are three periods of 14 weeks each. Certain major obstetrical problems tend to cluster in each of these time periods. For example, most spontaneous abortions take place during the irst trimester, whereas most women with hypertensive disorders due to preg nancy are diagnosed during the third trimester.


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Obstentrics_Williams. In modern obstetrics, the clinical use of trimesters to describe a speciic pregnancy is imprecise. For example, it is inappropriate in cases of uterine hemorrhage to categorize the problem temporally as "third-trimester bleeding." Appropriate management for the mother and her fetus will vary remark ably depending on whether bleeding begins early or late in the third trimester (Chap. 41, p. 757). Because precise knowledge of fetal age is imperative for ideal obstetrical management, the clinically appropriate unit is weeks of gestation complete. And more recently, clinicians designate gestational age using com pleted weeks and days, for example, 334/7 weeks or 33 + 4, for 33 completed weeks and 4 days.


Obstentrics_Williams

Obstentrics_Williams. As elsewhere in medicine, history taking begins with queries concerning medical or surgical disorders. Also, detailed information regarding previous pregnancies is essential as many obstetrical complications tend to recur in subsequent pregnancies. The menstrual and contraceptive histories are also important. Gestational or menstrual age is the number of weeks since the onset of the last menstrual period in women with menstrual cycles lasting 28 to 30 days. For those with irregular menses, sonography in early pregnancy will clariy gestational age. Last, some methods of birth control favor ectopic implantation following method failure (Chap. 38, pp. 683 and 689).


Obstentrics_Williams

Obstentrics_Williams. Psychosocial Screening. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) define psychosocial issues as nonbiomedical factors that afect mental and physical well-being. Women should be screened regardless of social status, education level, race, or ethnicity. Such screening should seek barriers to care, communication obstacles, nutritional status, unstable housing, desire for pregnancy, safety concerns that include intimate-partner violence, depression, stress, and use of substances such as tobacco, alcohol, and illicit drugs. his screening is performed on a regular basis, at least once per trimester, to identiy important issues and reduce adverse pregnancy outcomes. Coker and colleagues (2012) compared pregnancy outcomes in women before and after implementation of a universal psychosocial screening program and found that screened women were less likely to have preterm or low-birthweight newborns, as well as other adverse outcomes.


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Obstentrics_Williams. and after implementation of a universal psychosocial screening program and found that screened women were less likely to have preterm or low-birthweight newborns, as well as other adverse outcomes. Speciic screens for depression are presented in Chapter 61 (p. 1174).


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Obstentrics_Williams. Cigarette Smoking. Data on this practice have been included on the birth certiicate since 1989. The number of pregnant women who smoke continues to decline. From 2000 to 2010, the prevalences were 12 to 13 percent (Tong, 2013). Based on the Pregnancy Risk Assessment Monitoring System, these women were more likely younger, had less education, and were either Alaska Natives or American Indians (Centers for Disease Control and Prevention, 20 13a). Numerous adverse outcomes have been linked to smoking during pregnancy (U.S. Department of Health and Human Services, 2000). Potential teratogenic efects are reviewed in TABLE 9-2. Five A's of Smoking Cessation ASK about smoking at the first and subsequent prenatal visits.


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Obstentrics_Williams. TABLE 9-2. Five A's of Smoking Cessation ASK about smoking at the first and subsequent prenatal visits. ADVISE with clear, strong statements that explain the risks of continued smoking to the woman, fetus, and newborn. ASSESS the patient's willingness to attempt cessation. ASSIST with pregnancy-specific, self-help smoking cessation materials. Ofer a direct referral to the smoker's quit line (1-800-QUIT NOW) to provide ongoing counseling and support. ARRANGE to track smoking progress at subsequent visits. Adapted from Fiore, 2008.


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Obstentrics_Williams. Adapted from Fiore, 2008. Chapter 12 (p. 249). Notable among these are greater rates of miscarriage, stillbirth, low birthweight, and preterm delivery (Man, 2006; Tong, 2013). here is also a twofold risk of placenta previa, placental abruption, and premature membrane rupture compared with nonsmokers. hus, the U.S. Preventive Services Task Force recommends that clinicians ofer counseling and efective intervention options to pregnant smokers at the irst and subsequent prenatal visits (Siu, 2015). Although beneits are greatest if smoking ceases early in pregnancy or preferably preconceptionally, quitting at any stage of pregnancy can improve perinatal outcomes (Fiore, 2008).


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Obstentrics_Williams. Person-to-person psychosocial interventions are signiicantly more successful in achieving smoking abstinence in pregnancy than is simply advising the woman to quit (Fiore, 2008). One example is a brief counseling session covering the "5As" of smoking cessation (Table 9-2). This approach can be accomplished in 15 minutes or less and is efective when initiated by health-care providers (American College of Obstetricians and Gynecologists, 20 17i).


Obstentrics_Williams

Obstentrics_Williams. Behavioral interventions and nicotine replacement products are successful in reducing smoking rates (Patnode, 2015). hat said, nicotine replacement has not been suiciently evaluated to determine its efectiveness and safety in pregnancy. Trials evaluating such therapy have yielded conflicting evidence (Coleman, 2015; Pollak, 2007; Spindel, 2016). Two recent randomized trials also produced nonconclusive results. In the Smoking and Nicotine in Pregnancy (SNAP) trial, Cooper and associates (2014) reported a temporary cessation of smoking that may have been associated with improved infant development. In the Study of Nicotine Patch in Pregnancy (SNIPP) trial, Berlin and coworkers (2014) found no diferences in smoking cessation rates or birthweights.


Obstentrics_Williams

Obstentrics_Williams. Because of limited available evidence to support pharmacotherapy for smoking cessation in pregnancy, the American College of Obstetricians and Gynecologists (2017i) has recommended that if nicotine replacement therapy is used, it should be done with close supervision and after careful consideration of the risks of smoking versus nicotine replacement.


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Obstentrics_Williams. Alcohol. Ethyl acohol or ethanol is a potent teratogen that causes a etal syndrome characterized by growth restriction, acial abnormalities, and central nervous system dyunction. s discussed in Chapter 12 (p. 239), women who are pregnant or considering pregnancy should abstain from using any alcoholic beverages. The CDC analyzed data from the Behavioral isk Factor Surveillance System from 2011 to 2013 and estimated that 10 percent of pregnant women used alcohol. It is estimated that 3.3 million women are at risk for such exposure (Green, 2016). he American College of Obstetricians and Gynecologists (2016b) in collaboration with the CDC has developed the Fetal Acohol Spectrum Disorders (FASD) Prevention Program, which provides resources for providers and is available at: http://www. acog.org/ alcohol.


Obstentrics_Williams

Obstentrics_Williams. Illicit Drugs. It is estimated that 10 percent of fetuses are exposed to one or more illicit drugs. Agents may include heroin and other opiates, cocaine, amphetamines, barbiturates, and marijuana (American Academy of Pediatrics, 2017; merican College of Obstetricians and Gynecologists, 20 15a, 2017 d). As discussed in Chapter 12 (p. 247), chronic use of most of these in large quantities is harmful to the fetus (Metz, 2015). Well-documented sequelae include fetal-growth restriction, low birthweight, and drug withdrawal soon ater birth. Adverse efects of marijuana are less convincing. Women who use such drugs frequently do not seek prenatal care, which in itself is associated with risks for preterm and low-birthweight newborns (EI-Mohandes, 2003; Eriksen, 2016).


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Obstentrics_Williams. For women who abuse heroin, methadone maintenance can be initiated within a registered methadone treatment program to reduce complications of illicit opioid use and narcotic withdrawal, to encourage prenatal care, and to avoid drug culture risks (American College of Obstetricians and Gynecologists, 2017£). Available programs can be found through the treatment locator of the Substance Abuse and Mental Health Services Administration at ww.samhsa.gov. Methadone dosages usually are initiated at 10 to 30 mg daily and titrated as needed. In some women, careful methadone taper may be an appropriate option (Stewart, 2013). Although less commonly used, buprenorphine alone or in combination with naloxone may also be ofered and managed by physicians with specific credentialing.


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Obstentrics_Williams. Intimate-Partner Violence. his term refers to a pattern of assault and coercive behavior that may include physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion (American College of Obstetricians and Gynecologists, 2012). Such violence has been recognized as a major public health problem. Unfortunately, most abused women continue to be victimized during pregnancy. With the possible exception of preeclampsia, domestic violence is more prevalent than any major medical condition detectable through routine prenatal screening (American Academy of Pediatrics and the Ameri can College of Obstetricians and Gynecologists, 2017). The prevalence during pregnancy is estimated to range between 4 and 8 percent. Intimate-partner violence is associated with an increased risk of several adverse perinatal outcomes including preterm delivery, fetal-growth restriction, and perinatal death (Chap. 47, p. 925).


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Obstentrics_Williams. The American College of Obstetricians and Gynecologists (2012) has provided methods for domestic violence screening and recommends their use at the irst prenatal visit, then again at least once per trimester, and again at the postpartum visit. Such screening should be done privately and away from family members and friends. Patient self-administered or computerized screenings appear to be as efective for disclosure as clinician-directed interviews (Ahmad, 2009; Chen, 2007). Physicians should be familiar with state laws that may require reporting of intimate-partner violence. Coordination with social services can be invaluable in these cases. The National Domestic Violence Hotline (l-800-799-SAFE [7233]) is a nonprofit telephone referral service that provides individualized information regarding city-speciic shelter locations, counseling resources, and legal advocacy.


Obstentrics_Williams

Obstentrics_Williams. A thorough, general physical examination should be completed at the initial prenatal encounter. Pelvic examination is performed as part of this evaluation. he cervix is visualized employing a speculum lubricated with warm water or waterbased lubricant gel. Bluish-red passive hyperemia of the cervix is characteristic, but not of itself diagnostic, of pregnancy. Dilated, occluded cervical glands bulging beneath the ectocervical mucosa-nabothian cysts-may be prominent. he cervix is not normally dilated except at the external os. To identiy cytological abnormalities, a Pap test is performed according to current guidelines noted in Chapter 63 (p. 1193). Specimens for identiication of Chlamydia trachomatis and Neisseria gonorrhoeae are also obtained when indicated.


Obstentrics_Williams

Obstentrics_Williams. Bimanual examination is completed by palpation, with special attention given to the consistency, length, and dilatation of the cervix; to uterine and adnexal size; to the bony pelvic architecture; and to any vaginal or perineal anomalies. Later in pregnancy, fetal presentation often can also be determined. Lesions of the cevix, vagina, or vulva are further evaluated as needed by colposcopy, biopsy, culture, or dark-field examination. The perianal region is visualized, and digital rectal examination performed as required for complaints of rectal pain, bleeding, or mass.


Obstentrics_Williams

Obstentrics_Williams. Precise knowledge of gestational age is one of the most important aspects of prenatal care because several pregnancy complications may develop for which optimal treatment will depend on fetal age. As discussed earlier and in Chapter 7 (p. 124), irst-trimester sonographic assessment is best correlated with menstrual history. That said, gestational age can also be estimated with considerable precision by carefully performed clinical uterine size examination that is coupled with knowledge of the last menses. Uterine size similar to a small orange roughly correlates with a 6-week gestation; a large orange, with an 8-week pregnancy; and a grapefruit, with one at 12 weeks (Margulies, 2001).


Obstentrics_Williams

Obstentrics_Williams. Recommended routine tests at the first prenatal encounter are listed in Table 9-1. Initial blood tests include a complete blood count, a determination of blood type with h status, and an antibody screen. The Institute of Medicine recommends universal human immunodeiciency virus (HIV) testing, with patient notiication and right of refusal, as a routine part of prenatal care. The CDC (Branson, 2006) as well as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20 16f, 2017) continue to support this practice. If a woman declines testing, this is recorded in the prenatal record. All pregnant women are also screened for hepatitis B virus infection, syphilis, and immunity to rubella at the initial visit. Based on their prospective investigation of 1000 women, Murray and coworkers (2002) concluded that in the absence of hypertension, routine urinalysis beyond the irst prenatal visit was not necessary. A urine culture is recommended by most because


Obstentrics_Williams

Obstentrics_Williams. women, Murray and coworkers (2002) concluded that in the absence of hypertension, routine urinalysis beyond the irst prenatal visit was not necessary. A urine culture is recommended by most because treating bacteruria signiicantly reduces the likelihood of developing symptomatic urinary tract infections in pregnancy (Chap. 53, p. 1026).


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Obstentrics_Williams. Chlamydia trachomatis is isolated from the cervix in 2 to 13 percent of pregnant women. he American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that all women be screened for chlamydia during the irst prenatal visit, with additional third-trimester testing for those at increased risk. Risk factors include unmarried status, recent change in sexual partner or multiple concurrent partners, age younger than 25 years, inner-city residence, history or presence of other sexually transmitted diseases, and little or no prenatal care. For those testing positive, treatment described in Chapter 65 (p. 1240) is followed by a second testing-a test of cure-3 to 4 weeks after treatment completion.


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Obstentrics_Williams. Neisseria gonorrhoeae typically causes lower genital tract infection in pregnancy. It also may cause septic arthritis (Bleich, 2012). Risk factors for gonorrhea are similar to those for chlamydial infection. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) recommend that pregnant women with risk factors or those living in an area of high N gonorrhoeae prevalence be screened at the initial prenatal visit and again in the third trimester. Treatment is given for gonorrhea and simultaneously for possible coexisting chlamydial infection (Chap. 65, p. 1240). Test of cure is also recommended following treatment. Many factors can adversely afect maternal and fetal well-being. Some are evident at conception, but many become apparent during the course of pregnancy. The designation of "high-risk pregnancy" is overly vague for an individual woman and probably is best avoided if a more specific diagnosis can be assigned.


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Obstentrics_Williams. TABLE 9-3. Conditions for Which Maternal-Fetal Medicine Consultation May Be Beneficial Cardiac disease-moderate to severe disorders Diabetes mellitus with evidence of end-organ damage or uncontroiled hyperglycemia Family or personal history of genetic abnormalities Renal insuficiency if associated with significant proteinuria (::500 mg/24 hour), serum creatininel::1.5 mg/dL, or hypertension Pulmonary disease if severe restrictive or obstructive, including severe asthma Human immunodeficiency virus infection Prior embolus or deep-vein thrombosis Severe systemic disease, including autoimmune conditions Bariatric surgery Epilepsy if poorly controlled or requires more than one anticonvulsant Cancer, especially if treatment is indicated in pregnancy CDE (Rh) or other blood group alloimmunization (excluding ABO, Lewis) Prior or current fetal structural or chromosomal abnormality Periconceptional exposure to known teratogens


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Obstentrics_Williams. CDE (Rh) or other blood group alloimmunization (excluding ABO, Lewis) Prior or current fetal structural or chromosomal abnormality Periconceptional exposure to known teratogens Infection with or exposure to organisms that cause congenital infection Higher-order multifetal gestation Severe disorders of amnionic fluid volume Some common risk factors for which consultation is recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) are shown in Table 9-3. Some conditions may require the involvement of a maternal-fetal medicine subspecialist, geneticist, pediatrician, anesthesiologist, or other medical specialist in the evaluation, counseling, and care of the woman and her fetus.


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Obstentrics_Williams. hese are traditionally scheduled at 4-week intervals until 28 weeks, then every 2 weeks until 36 weeks, and weekly thereafter. Women with complicated pregnancies-for example, with twins or diabetes-often require return visits at 1-to 2-week intervals (Luke, 2003; Power, 2013). In 1986, the Department of Health and Human Services convened an expert panel to review the content of prenatal care. his report was subsequently reevaluated and revised in 2005 (Gregory, 2006). he panel recommended, among other things, early and continuing risk assessment that is patient speciic. It also endorsed lexibility in clinical visit spacing; health promotion and education, including preconceptional care; medical and psychosocial interventions; standardized documentation; and expanded prenatal care objectives-to include family health up to 1 year after birth.


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Obstentrics_Williams. he World Health Organization conducted a multicenter randomized trial with almost 25,000 women comparing routine prenatal care with an experimental model designed to minimize visits (Villar, 2001). In the new model, women were seen once in the irst trimester and screened for certain risks. hose without anticipated complications-80 percent of those screened-were seen again at 26, 32, and 38 weeks. Compared with routine prenatal care, which required a median of eight visits, the new model required a median of only ive. No disadvantages were attributed to the regimen with fewer visits, and these indings were consistent with other randomized trials (Clement, 1999; McDuie, 1996).