Obstentrics_Williams

Obstentrics_Williams. At each return visit, the well-being of mother and fetus are assessed (see Table 9-1). Fetal heart rate, growth, and activity and amnionic fluid volume are evaluated. Maternal blood pressure and weight and their extent of change are examined. Symptoms such as headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal luid leakage, and dysuria are sought. Mter 20 weeks' gestation, uterine examination measures size from the symphysis to the fundus. In late pregnancy, vaginal examination often provides valuable information that includes conirmation of the presenting part and its station, clinical estimation of pelvic capacity and configuration, amnionic luid volume adequacy, and cervical consistency, efacement, and dilatation (Chap. 22, p. 435).


Obstentrics_Williams

Obstentrics_Williams. Between 20 and 34 weeks' gestation, the height of the uterine fundus measured in centimeters correlates closely with gestational age in weeks Gimenez, 1983). his measurement is used to monitor fetal growth and amnionic fluid volume. It is measured along the abdominal wall from the top of the symphysis pubis to the top of the fundus. Importantly, the bladder must be emptied before fundal measurement (Worthen, 1980). Obesity or the presence of uterine masses such as leiomyomas may also limit fundal height accuracy. Moreover, using fundal height alone, fetal-growth restriction may be undiagnosed in up to a third of cases (American College of Obstetricians and Gynecologists, 2015b; Haragan, 2015).


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Obstentrics_Williams. Instruments incorporating Doppler ultrasound are often used to easily detect fetal heart action, and in the absence of maternal obesity, heart sounds are almost always detectable by 10 weeks with such instruments (Chap. 10, p. 213). he fetal heart rate ranges from 11e0 to 160 beats per minute and is typically heard as a double sound. Using a standard nonampliied stethoscope, the fetal heart is audible by 20 weeks in 80 percent of women, and by 22 weeks, heart sounds are expected to be heard in all (Herbert, 1987). Because the fetus moves freely in amni onic fluid, the site on the maternal abdomen where fetal heart sounds can be heard best will vary. Additionally, with ultrasonic auscultation, one may hear the unic soule, which is a sharp, whistling sound that is syn chronous with the fetal pulse. It is caused by the rush of blood through the umbilical arteries and may not be heard consistently.


Obstentrics_Williams

Obstentrics_Williams. In contrast, the uterine soule is a soft, blowing sound that is synchronous with the maternal pulse. It is produced by the pas sage of blood through the dilated uterine vessels and is heard most distinctly near the lower portion of the uterus.


Obstentrics_Williams

Obstentrics_Williams. Sonography provides invaluable information regarding fetal anatomy, growth, and well-being, and most women in the United States have at least one prenatal sonographic examination during pregnancy (American College of Obstetricians and Gynecologists, 2016h). Continuing trends suggest that the number of these examinations performed per pregnancy is increasing. Siddique and associates (2009) reported that the average number rose from 1.5 in 1995 through 1997 to 2.7 almost 10 years later. his trend was noted in both high-and low-risk pregnancies. he actual clinical utility of this increased use in pregnancy has not been demonstrated, and it is unclear that the cost-benefit ratio is justified (Washington State Health Care Authority, 2010). The American College of Obstetricians and Gynecologists (20e16h) has concluded that sonography should be performed only when there is a valid medical indication and under the lowest possible ultrasound exposure setting. The College further states that a


Obstentrics_Williams

Obstentrics_Williams. (20e16h) has concluded that sonography should be performed only when there is a valid medical indication and under the lowest possible ultrasound exposure setting. The College further states that a physician is not obligated to perform sonography without a specific indication in a low-risk patient, but that if she requests sonographic screening, it is reasonable to honor her request.


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Obstentrics_Williams. If initial results were normal, most tests need not be repeated. Hematocrit or hemoglobin determination, along with serology for syphilis if it is prevalent in the population, is repeated at 28 to 32 weeks (Hollier, 2003; Kiss, 2004). For women at increased risk for HIV acquisition during pregnancy, repeat testing is recommended in the third trimester, preferably before 36 weeks (American College of Obstetricians and Gynecologists, 20 16). Similarly, women who engage in behaviors that place them at high risk for hepatitis B virus infection are retested at the time of hospitalization for delivery. Women who are D (h) negative and are unsensitized should have an antibody screening test repeated at 28 to 29 weeks, and anti-D immunoglobulin is given if they remain unsensitized (Chap. 15, p. 305).


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Obstentrics_Williams. he CDC (20e1e0b) recommends that vaginal and rectal group B streptococcal (GBS) cultures be obtained in all women between 35 and 37 weeks' gestation, and the American College of Obstetricians and Gynecologists (20e1e6g) has endorsed this recommendation. Intrapartum antimicrobial prophylaxis is provided to those whose culture results are positive. Women with GBS bacteriuria or a previous infant with invasive disease are given empirical intrapartum prophylaxis. Trials are in progress to test an investigational vaccine (Donders, 2016; Schrag, 2016). hese infections are described further in Chapter 64 (p. 1220).


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Obstentrics_Williams. All pregnant women are screened for gestational diabetes mellitus, whether by history, clinical factors, or routine laboratory testing. Although laboratory testing between 24 and 28 weeks' gestation is the most sensitive approach, there may be pregnant women at low risk who are less likely to beneit from testing (American College of Obstetricians and Gynecologists, 2017c). Gestational diabetes is discussed in Chapter 57 (p. 11 07).


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Obstentrics_Williams. Serum screening for neural-tube defects is ofered at 15 to 20 weeks. Fetal aneuploidy screening may be performed at 11 to 14 weeks' gestation and/or at 15 to 20 weeks, depending on the protocol selected (Rink, 2016). Additionally, screening for certain genetic abnormalities is ofered to women at increased risk based on family history, ethnic or racial background, or age (American College of Obstetricians and Gynecologists, 20 17h). These are discussed in greater detail in Chapter 14 (p. 277). Some examples include testing for Tay-Sachs disease for persons of Eastern European Jewish or French Canadian ancestry; �-thalassemia for those of Mediterranean, Southeast Asian, Indian, Pakistani, or Mrican ancestry; a-thalassemia for individuals of Southeast Asian or Mrican ancestry; sickle-cell anemia for people of African, Mediterranean, Middle Eastern, Caribbean, Latin American, or Indian descent; and trisomy 21 for those with advanced maternal age.


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Obstentrics_Williams. In 2009, the Institute of Medicine and National Research Council revised guidelines for weight gain in pregnancy and continued to stratiy suggested weight gain ranges based on prepregnancy body mass index (BMI) (Table 9-4). The new guidelines included a specific, relatively narrow range of recommended weight gains for obese women. Also, the same recommendations apply to adolescents, short women, and women of TABLE 9-4. Recommendations for Total and Rate of Weight Gain During Pregnancy Underweight 28-40 1 (1l-1l.3) «1l8.5) Normal weight 25-35 1 (0.8-1) (1l8.5-24.9) Overweight 15-25 0.6 (0.5-0.7) (25.0-29.9) Obese (::30.0) 11l-20 0.5 (0.4-0.6) aEmpirical recommendations for weight gain in twin pregnancies include: normal BMI, 37-54 Ib; overweight women, 31-50 Ib; and obese women, 25-42 lb. BMI = body mass index. Modified from the Institute of Medicine and National Research Council, 2009.


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Obstentrics_Williams. all racial and ethnic groups. The American College of Obstetricians and Gynecologists (2016i) has endorsed these measures.


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Obstentrics_Williams. When the Institute of Medicine guidelines were formulated, concern focused on low-birthweight newborns, however, current emphasis is directed to the obesity epidemic (Catalano, 2007). This explains renewed interest in lower weight gains during pregnancy. Obesity is associated with significantly greater risks for gestational hypertension, preeclampsia, gestational diabetes, macrosomia, cesarean delivery, and other complications (Chap. 48, p. 939). he risk appears "dose related" to prenatal weight gain. In a population-based cohort of more than 120,000 obese pregnant women, those who gained <15 lb had the lowest rates of preeclampsia, large-for-gestational age neonates, and cesarean delivery (Kiel, 2007). Among 100,000 women with normal prepregnancy BMI, De Vader and colleagues (2007) found that those who gained <25 Ib during pregnancy had a lower risk for preeclampsia, failed induction, cephalopelvic disproportion, cesarean delivery, and large-for-gestational age neonates. his cohort,


Obstentrics_Williams

Obstentrics_Williams. that those who gained <25 Ib during pregnancy had a lower risk for preeclampsia, failed induction, cephalopelvic disproportion, cesarean delivery, and large-for-gestational age neonates. his cohort, however, had an increased risk for smallfor-gestational age newborns. Lifestyle intervention during pregnancy can result in less weight gain (Sagedal, 2017).


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Obstentrics_Williams. There is irrefutable evidence that maternal weight gain during pregnancy inluences birthweight. Martin and coworkers (2009) studied this using birth certificate data for 2006. Approximately 60 percent of women gained 26 Ib or more during pregnancy, and maternal weight gain positively correlated with birthweight. Nloreover, women with the greatest risk14 percent-for delivering a newborn weighing <2500 g were those with weight gain < 16 lb. Nearly 20 percent of births to women with such low weight gains were preterm.


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Obstentrics_Williams. Meaningful studies of nutrition in human pregnancy are exceedingly diicult to design because experimental dietary deficiency is not ethical. In those instances in which severe nutritional deiciencies have been induced as a consequence of social, economic, or political disaster, coincidental events have oten created many variables, the efects of which are not amenable to quantiication. Some past experiences suggest, however, that in otherwise healthy women, a state of near starvation is required to establish clear diferences in pregnancy outcome.


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Obstentrics_Williams. During the severe European winter of 1944 to 1945, nutritional deprivation of known intensity prevailed in a wellcircumscribed area of The Netherlands occupied by the German military (Kyle, 2006). At the lowest point during this Dutch Hunger Winter, rations reached 450 kcal/d, with generalized rather than selective malnutrition. Smith (1947) analyzed the outcomes of pregnancies that were in progress during this 6-month famine. Median neonatal birthweights declined approximately 250 g and rose again ater food became available. This indicated that birthweight can be inluenced significantly by starvation during later pregnancy. he perinatal mortality rate, however, was not altered. Moreover, the incidence of fetal malformations or preeclampsia did not rise signiicantly. Parenthetically, weight loss in obese women during pregnancy is also associated with an increased risk for low-birthweight neonates (Cox Bauer, 2016).


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Obstentrics_Williams. Evidence of impaired brain development has been obtained in some animal fetuses whose mothers had been subjected to intense dietary deprivation. Subsequent intellectual development was studied by Stein and associates (1972) in young male adults whose mothers had been starved during pregnancy in the aforementioned Hunger Winter. The comprehensive study was made possible because all males at age 19 underwent compulsory examination for military service. It was concluded that severe dietary deprivation during pregnancy caused no detectable efects on subsequent mental performance. Several studies of the long-term consequences to this cohort of children born to nutritionally deprived women have been performed and have been reviewed by Kyle and Pichard (2006).


Obstentrics_Williams

Obstentrics_Williams. Several studies of the long-term consequences to this cohort of children born to nutritionally deprived women have been performed and have been reviewed by Kyle and Pichard (2006). Progeny deprived in mid to late pregnancy were lighter, shorter, and thinner at birth, and they had a higher incidences of sub sequent hypertension, reactive airway disease, dyslipidemia, diminished glucose tolerance, and coronary artery disease. Early pregnancy deprivation was associated with greater obesity rates in adult women but not men. Early starvation was also linked to higher rates of central nervous system anomalies, schizophre nia, and schizophrenia-spectrum personality disorders. hese observations and others have led to the concept of etal programming by which adult morbidity and mortality are related to fetal health. Known widely as the Barker hypothesis, as promulgated by Barker and colleagues (1989), this concept is discussed in Chapter 44 (p. 848).


Obstentrics_Williams

Obstentrics_Williams. Not all the weight gained during pregnancy is lost during and immediately after delivery. Schauberger and coworkers (1992) studied prenatal and postpartum weights in 795 women. Their average weight gain was 28.6 Ib or 12.9 kg. As shown in Figure 9-4, most maternal weight loss was at deliveryapproximately 12 lb or 5.4 kg-and in the ensuing 2 weeksapproximately 9 Ib or 4 kg. An additional 5.5 lb or 2.5 kg was lost between 2 weeks and 6 months postpartum. Thus, average retained pregnancy weight was 2.1 Ib or 1 kg. Excessive weight gain is manifest by accrual of fat and may be partially retained as long-term fat (Berggren, 2016; Widen, 2015). Overall, the more weight that was gained during pregnancy, the more that was lost postpartum. Interestingly, there is no relationship between pre pregnancy BMI or prenatal weight gain and weight retention.


Obstentrics_Williams

Obstentrics_Williams. Periodically, the Institute of Medicine (2006, 2011) publishes recommended dietary allowances, including those for pregnant aRecommendations measured as adequate intake. Calories are necessary for energy. Whenever caloric intake is inadequate, protein is metabolized rather than being spared for its vital role in fetal growth and development. Total physiologiWeeks of pregnancy cal requirements during pregnancy are not necessarily the sum or lactating women. The latest recommendations are summarized in Table 9-5. Certain prenatal vitamin-mineral supplements may lead to intakes well in excess of the recommended allowances. Moreover, the use of excessive supplements, which often are self-prescribed, has led to concern regarding nutrient toxicities during pregnancy. Those with potentialy toxic fects include iron, zinc, selenium, and vitamins A, B6, C, and D.


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Obstentrics_Williams. As shown in Figure 9-5, pregnancy requires an additional 80,000 kcal, mostly during the last 20 weeks. To meet this demand, a caloric increase of 100 to 300 kcal/d is recommended during pregnancy (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2017). This greater intake, however, should not be divided equally during the course of pregnancy. The Institute ofMedicine (2006) recommends adding 0, 340, and 452 kcal/d to the estimated nonpregnantenergy requirements in the irst, second, and third trimesters, respectively. he addition of 1000 kcal/d or more results in fat accrual Qebeile, 2015). From the Institute of Medicine, 2006, 2011. pregnancy may be compensated in whole or in part by reduced physical activity (Hytten, 1991). Protein requirements rise to meet the demands for growth and remodeling of the fetus, placenta, uterus, and breasts, and for 80,000 70,000 60,000 Maintenance ) 50,000 � 40,000 30,000 20,000 10,000


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Obstentrics_Williams. Protein requirements rise to meet the demands for growth and remodeling of the fetus, placenta, uterus, and breasts, and for 80,000 70,000 60,000 Maintenance ) 50,000 � 40,000 30,000 20,000 10,000 FIGURE 9-4 Cumulative weight loss from last antepartum visit to 6 months postpartum. *Significantly different from 2-week weight loss; **Significantly different from 6-week weight loss. (Redrawn from Schauberger CW, Rooney BL, Brimer LM: Factors that influence weight loss in the puerperium. Obstet Gynecol 79:424, 1992.)


Obstentrics_Williams

Obstentrics_Williams. FIGURE 9-5 Cumulative kilocalories required for pregnancy. (Redrawn of ordinary nonpregnant requirements plus those speciic to from Chamberlain G, Broughton-Pipkin F (eds): Clinical Physiology in pregnancy. For example, the additional energy required during Obstetrics, 3rd ed. Oxford, Blackwell Science, 1998.) increased maternal blood volume (Chap. 4, p. 55). During the second half of pregnancy, approximately 1000 g of protein are deposited, amounting to 5 to 6 g/d (Hytten, 1971). To accomplish this, protein intake that approximates 1 g/kg/ d is recommended (see Table 9-5). Data suggest this should be doubled in late gestation (Stephens, 2015). Most amino-acid levels in maternal plasma fall markedly, including ornithine, glycine, taurine, and proline (Hytten, 1991). Exceptions during pregnancy are glutamic acid and alanine, the concentrations of which rise.


Obstentrics_Williams

Obstentrics_Williams. Preferably, most protein is supplied from animal sources, such as meat, milk, eggs, cheese, poultry, and fish. hese furnish amino acids in optimal combinations. Milk and dairy products are considered nearly ideal sources of nutrients, especially protein and calcium, for pregnant or lactating women. Ingestion of specific ish and potential methylmercury toxicity are discussed on page 170. The intakes recommended by the Institute of Medicine (2006) for various minerals are listed in Table 9-5. With the exception of iron and iodine, practically all diets that supply suicient calories for appropriate weight gain will contain enough minerals to prevent deiciency.


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Obstentrics_Williams. Iron requirements are greatly increased during pregnancy, and reasons for this are discussed in Chapter 4 (p. 58). Of the approximately 300 mg of iron transferred to the fetus and placenta and the 500 mg incorporated into the expanding maternal hemoglobin mass, nearly all is used after midpregnancy. During that time, iron requirements imposed by pregnancy and maternal excretion total approximately 7 mg/ d (Pritchard, 1970). Few women have suicient iron stores or dietary intake to supply this amount. Thus, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20e17) endorse the recommendation by the National Academy of Sciences that at least 27 mg of elemental iron be supplemented daily to pregnant women. his amount is contained in most prenatal vitamins.


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Obstentrics_Williams. Scott and coworkers (1970) established that as little as 30 mg of elemental iron, supplied as ferrous gluconate, sulfate, or fumarate and taken daily throughout the latter half of pregnancy, provides suicient iron to meet pregnancy requirements and protect preexisting iron stores. his amount will also provide for iron requirements of lactation. he pregnant woman may benefit from 60 to 100 mg of elemental iron per day if she is large, has a multifetal gestation, begins supplementation late in pregnancy, takes iron irregularly, or has a somewhat depressed hemoglobin level. he woman who is overtly anemic from iron deficiency responds well to oral supplementation with iron salts. In response, serum ferritin levels rise more than the hemoglobin concentration (Daru, 2016).


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Obstentrics_Williams. Iodine is also needed, and the recommended iodine allowance is 220 Lg/d (see Table 9-5). The use of iodized salt and bread products is recommended during pregnancy to ofset the increased fetal requirements and maternal renal losses of iodine. Despite this, iodine intake has declined substantially in the past 15 years, and in some areas it is probably inadequate (Casey, 2017). Severe maternal iodine deficiency predisposes ofspring to endemic cretinism, which is characterized by multiple severe neurological defects. In parts of China and Africa where this condition is common, iodide supplementation very early in pregnancy prevents some cretinism cases (Cao, 1994). To obviate this, many prenatal supplements now contain various quantities of iodine.


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Obstentrics_Williams. Cacium is retained by the pregnant woman during gestation and approximates 30 g. Most of this is deposited in the fetus late in pregnancy (Pitkin, 1985). his amount of calcium represents only approximately 2.5 percent of total maternal calcium, most of which is in bone and can readily be mobilized for fetal growth. s another potential use, routine calcium supplementation to prevent preeclampsia has not proved efective (Chap. 40, p. 727). Zinc deficiency if severe may lead to poor appetite, suboptimal growth, and impaired wound healing. During pregnancy, the recommended daily intake approximates 12 mg. But, the safe level of zinc supplementation for pregnant women has not been clearly established. Vegetarians have lower zinc intakes (Foster, 2015). he bulk of studies support zinc supplementation only in zinc-deficient women in poor-resource countries (Nossier, 2015; Ota, 2015).


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Obstentrics_Williams. Manesium deficiency as a consequence of pregnancy has not been recognized. Undoubtedly, during prolonged illness with no magnesium intake, the plasma level might become critically low, as it would in the absence of pregnancy. We have observed magnesium deiciency during pregnancies in some with previous intestinal bypass surgery. As a preventive agent, Sibai and coworkers (1989) randomly assigned 400 normotensive primigravid women to 365-mg elemental magnesium supplementation or placebo tablets from 13 to 24 weeks' gestation. Supplementation did not improve any measures of pregnancy outcome.


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Obstentrics_Williams. Trace metals include copper, selenium, chromium, and manganese, which all have important roles in certain enzyme functions. In general, most are provided by an average diet. Selenium deficiency is manifested by a frequently fatal cardiomyopathy in young children and reproductive-aged women. Conversely, selenium toxicity resulting from oversupplementation also has been observed. Selenium supplementation is not needed in American women. Potassium concentrations in maternal plasma decline by approximately 0.5 mEq/L by midpregnancy (Brown, 1986). Potassium deficiency develops in the same circumstances as in nonpregnant individuals-a common example is hyperemesis gravidarum.


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Obstentrics_Williams. Fluoride metabolism is not altered appreciably during pregnancy (Maheshwari, 1983). Horowitz and Heifetz (1967) concluded that no additional ofspring beneits accrued from maternal ingestion of luoridated water if the newborn ingested such water from birth. Sa Roriz Fonteles and associates (2005) studied microdrill biopsies of deciduous teeth and concluded that antenatal luoride provided no additional fluoride uptake compared with postnatal fluoride alone. Finally, supplemental luoride ingested by lactating women does not raise the luoride concentration in breast milk (Ekstrand, 1981).


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Obstentrics_Williams. he increased requirements for most vitamins during pregnancy shown in Table 9-5 usually are supplied by any general diet that provides adequate calories and protein. he excep tion is folic acid during times of unusual requirements, such as pregnancy complicated by protracted vomiting, hemo lytic anemia, or multiple fetuses. hat said, in impoverished countries, routine multivitamin supplementation reduced the incidence of low-birthweight and growth-restricted fetuses, (Fawzi, 2007).


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Obstentrics_Williams. neural-tube defect risks (Chap. 13, p. 270). Namely, the CDC (2004) estimated that the number of afected pregnancies had decreased from 4000 pregnancies per year to approximately 3000 per year after mandatory fortiication of cereal products with folic acid in 1998. Perhaps more than half of all neural tube defects can be prevented with daily intake of 400 �g of folic acid throughout the periconceptional period. Evidence development (Ars, 2016). Putting 140 �g of folic acid into each 100 g of grain products may increase the folic acid intake of the average American woman of childbearing age by 1 00 �g/ d. Because nutritional sources alone are insuicient, however, folic acid supplementation is still recommended (American College of Obstetricians and Gynecologists, 20 16e). Likewise, the U.S. Preventive Services Task Force (2009) recommends that all women planning or capable of pregnancy take a daily supplement containing 400 to 800 �g of folic acid.


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Obstentrics_Williams. A woman with a prior child with a neural-tube defect can reduce the 2-to 5-percent recurrence risk by more than 70 percent with a daily 4-mg folic acid supplement taken during the month before conception and during the first trimester. As emphasized by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017), this dose should be consumed as a separate supplement and not as multivitamin tablets. This practice avoids excessive intake of fat-soluble vitamins.


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Obstentrics_Williams. Vitamin A, although essential, has been associated with congeni tal malformations when taken in high doses (> 10,000 IU / d) during pregnancy. These malformations are similar to those produced by the vitamin A derivative isotretinoin (Accutane), which is a potent teratogen (Chap. 12, p. 245). Beta-carotene, the precursor of vitamin A found in fruits and vegetables, has not been shown to produce vitamin A toxicity. Most prenatal vitamins contain vitamin A in doses considerably below the teratogenic threshold. Dietary intake of vitamin A in the United States appears to be adequate, and additional supplementation is not routinely recommended. In contrast, vitamin A deiciency is an endemic nutritional problem in the developing world (McCauley, 2015). Vitamin A deficiency, whether overt or subclinical, is associated with night blindness and with an increased risk of maternal anemia and spontaneous preterm birth (West, 2003).


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Obstentrics_Williams. Vitamin BJ2 plasma levels drop in normal pregnancy, mostly as a result of reduced plasma levels of their carrier proteinstranscobalamins. Vitamin BJ2 occurs naturally only in foods of animal origin, and strict vegetarians may give birth to neonates whose BI2 stores are low. Likewise, because breast milk of a vegetarian mother contains little vitamin B12, the deiciency may become profound in the breastfed infant (Higginbottom, 1978). Excessive ingestion of vitamin C also can lead to a functional deiciency of vitamin B12. Although its role is still controversial, vitamin BI2 deiciency preconceptionally, similar to folate, may elevate the risk of neural-tube defects (Molloy, 2009).


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Obstentrics_Williams. Vitamin B6, which is pyridoxine, does not require supple mentation in most gravidas (Salam, 2015). For women at high risk for inadequate nutrition, a daily 2-mg supplement is rec ommended. As discussed on page 174, vitamin B6, when com bined with the antihistamine doxylamine, is helpful in many cases of nausea and vomiting of pregnancy. Vitamin C allowances during pregnancy are 80 to 85 mg/ d Table 9-5). A reasonable diet should readily provide this amount, and supplementation is not necessary (Rumbold, 2015). Maternal plasma levels decline during pregnancy, whereas cord-blood levels are higher, a phenomenon observed with most water-soluble vitamins.


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Obstentrics_Williams. Vitamin D is a fat-soluble vitamin. After being metabolized to its active form, it boosts the eiciency of intestinal calcium absorption and promotes bone mineralization and growth. Unlike most vitamins that are obtained exclusively from dietary intake, vitamin D is also synthesized endogenously with exposure to sunlight. Vitamin D deiciency is common during pregnancy. his is especially true in high-risk groups such as women with limited sun exposure, vegetarians, and ethnic minoritiesparticularly those with darker skin (Bodnar, 2007). Maternal deiciency can cause disordered skeletal homeostasis, congenital rickets, and fractures in the newborn (American College of Obstetricians and Gynecologists, 2017k). Vitamin D supplementation to women with asthma may decrease the likelihood of childhood asthma in their fetuses (Litonjua, 2016). The Food and Nutrition Board of the Institute of Medicine (2011) established that an adequate intake of vitamin D during pregnancy and lactation was 15


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Obstentrics_Williams. asthma in their fetuses (Litonjua, 2016). The Food and Nutrition Board of the Institute of Medicine (2011) established that an adequate intake of vitamin D during pregnancy and lactation was 15 �g/d (600 IU/d). In women suspected of having vitamin D deficiency, serum levels of 25-hydroxyvitamin D can be obtained. Even then, the optimal levels in pregnancy have not been established (De-Regil, 2016).


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Obstentrics_Williams. Although researchers continue to study the ideal nutritional regimen for the pregnant woman and her fetus, basic tenets for the clinician include: 1. Advise the pregnant woman to eat food types she wants in reasonable amounts and salted to taste. 2. Ensure that food is amply available for socioeconomically deprived women. 3. Monitor weight gain, with a goal of approximately 25 to 35elb in women with a normal BMI. 4. Explore food intake by dietary recall periodically to discover the occasional nutritionally errant diet. 5. Give tablets of simple iron salts that provide at least 27 mg of elemental iron daily. Give folate supplementation before and in the early weeks of pregnancy. Provide iodine supplementation in areas of known dietary insuiciency. 6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks' gestation to detect signiicant anemia. TABLE 9-6. Some Contraindications to Exercise During Pregnancy


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Obstentrics_Williams. 6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks' gestation to detect signiicant anemia. TABLE 9-6. Some Contraindications to Exercise During Pregnancy Significant cardiovascular or pulmonary disease Significant risk for preterm labor: cerclage, multifetal gestation, significant bleeding, threatened preterm labor, prematurely ruptured membranes Obstetrical complications: preeclampsia, placenta previa, poorly controlled diabetes or epilepsy, morbid obesity, Summarized from American College of Obstetricians and Gynecologists, 2017g.


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Obstentrics_Williams. Summarized from American College of Obstetricians and Gynecologists, 2017g. More than half of the children in the United States are born to working mothers. Federal law prohibits employers from excluding women from job categories on the basis that they are or might become pregnant. he Family and Medical Leave Act of 1993 requires that covered employers must grant up to 12 work weeks of unpaid leave to an employee for the birth and care of a newborn child Qackson, 2015). In the absence of complications, most women can continue to work until the onset of labor (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2017).


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Obstentrics_Williams. Some types of work, however, may increase pregnancy complication risks. Mozurkewich and colleagues (2000) reviewed 29 studies that involved more than 160,000 pregnancies. With physically demanding work, women had 20-to 60-percent higher rates of preterm birth, fetal-growth restriction, or gestational hypertension. In a prospective study of more than 900 healthy nulliparas, women who worked had a ivefold risk of preeclampsia (Higgins, 2002). Newman and coworkers (2001) reported outcomes in more than 2900 women with singleton pregnancies. Occupational fatigue-estimated by the number of hours standing, intensity of physical and mental demands, and environmental stressors-was associated with an increased risk of preterm premature membrane rupture. For women reporting the highest degrees of fatigue, the risk was 7.4 percent.


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Obstentrics_Williams. Thus, any occupation that subjects the gravida to severe physical strain should be avoided. Ideally, no work or play is continued to the extent that undue fatigue develops. Adequate periods of rest should be provided. It seems prudent to advise women with prior pregnancy complications that commonly recur to minimize physical work. In general, pregnant women do not need to limit exercise, provided they do not become excessively fatigued or risk injury (Davenport, 2016). Clapp and associates (2000) reported that both placental size and birthweight were signiicantly greater in women who exercised. Duncombe and coworkers (2006) reported similar findings in 148 women. In contrast, vfagann and colleagues (2002) prospectively analyzed exercise behavior in 750 healthy women and found that working women who exercised had smaller infants and more dysfunctional labors.


Obstentrics_Williams

Obstentrics_Williams. The American College of Obstetricians and Gynecologists (2017 g) advises a thorough clinical evaluation before recommending an exercise program. In the absence of contraindications listed in Table 9-6, pregnant women are encouraged to engage in regular, moderate-intensity physical activity for at least 150 minutes each week. Each activity should be reviewed individually for its potential risk. Examples of safe activities are walking, running, swimming, stationary cycling, and low-impact aerobics. However, they should refrain from activities with a high risk of falling or abdominal trauma. Similarly, scuba diving is avoided because the fetus is at increased risk for decompression sickness.


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Obstentrics_Williams. In the setting of certain pregnancy complications, it is wise to abstain from exercise and even limit physical activity. For example, some women with pregnancy-associated hypertensive disorders, preterm labor, placenta previa, or severe cardiac or pulmonary disease may gain from being sedentary. Also, those with multiple or suspected growth-restricted fetuses may be served by greater rest.


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Obstentrics_Williams. Fish are an excellent source of protein, are low in saturated fats, and contain omega-3 fatty acids. The Avon Longitudinal Study of Parents and Children reported beneicial efects on pregnancy outcomes in women who consumed 340 g or more of seafood weekly (Hibbeln, 2007). Because nearly all fish and shellish contain trace amounts of mercury, pregnant and lactating women are advised to avoid specific types of ish with potentially high methylmercury levels. These include shark, swordfish, king mackerel, and tile fish. It is further recommended that pregnant women ingest 8 to 12 ounces of fish weely, but no more than 6 ounces of albacore or "white" tuna (U.S. Environmental Protection Agency, 2014). If the mercury content oflocally caught fish is unknown, then overall fish consumption should be limited to 6 ounces per week (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2017) .


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Obstentrics_Williams. Maternal lead exposure has been associated with several adverse maternal and fetal outcomes across a range of maternal blood lead levels (Taylor, 2015). These include gestational hypertension, miscarriage, low birthweight, and neurodevelopmental impairments in exposed pregnancies (American College of Obstetricians and Gynecologists, 2016c). The levels at which these risks rise remains unclear. However, recognizing that such exposure remains a significant health issue for reproductive-aged women, the CDC (201 Oa) has issued guidance for screening and managing exposed pregnant and lactating women. These guidelines, which have been endorsed by the American College of Obstetricians and Gynecologists (2016c), recommend blood lead testing only if a risk factor is identified. If the levels are > 5 /Lg1 dL, then counseling is completed, and the lead source is sought and removed. Subsequent blood levels are obtained. Blood lead levels >45 Lg/dL are consistent with lead poisoning, and women in


Obstentrics_Williams

Obstentrics_Williams. 5 /Lg1 dL, then counseling is completed, and the lead source is sought and removed. Subsequent blood levels are obtained. Blood lead levels >45 Lg/dL are consistent with lead poisoning, and women in this group may be candidates for chelation therapy. Afected pregnancies are best managed in consultation with lead poisoning treatment experts. National and state resources are available at the CDC website: ww.cdc.gov/ncehllead/.


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Obstentrics_Williams. Pregnant women are encouraged to wear properly positioned three-point restraints as protection against automobile crash injury (Chap. 47, p. 927). The lap portion of the restraining belt is placed under the abdomen and across her upper thighs. The belt should be comfortably snug. The shoulder belt also is irmly positioned between the breasts. Airbags should not be disabled for the pregnant woman.


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Obstentrics_Williams. In general, air travel in a properly pressurized aircraft has no harmful efect on pregnancy (Aerospace Medical Association, 2003). Thus, in the absence of obstetrical or medical complications, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20 16a, 2017) have concluded that pregnant women can safely ly up to 36 weeks' gestation. It is recommended that pregnant women observe the same precautions for air travel as the general population. Seatbelts are used while seated. Periodic lower extremity movement and at least hourly ambulation help lower the venous thromboembolism threat. Signiicant risks with travel, especially international travel, are infectious disease acquisition and development of complications remote from adequate healthcare resources (Ryan, 2002).


Obstentrics_Williams

Obstentrics_Williams. In healthy pregnant women, sexual intercourse usually is not harmul. Whenever miscarriage, placenta previa, or preterm labor threatens, however, coitus is avoided. Nearly 10,000 women enrolled in a prospective investigation by the Vaginal Infection and Prematurity Study Group were interviewed regarding sexual activity (Read, 1993). hey reported a decreased frequency of coitus with advancing gestation. By 36 weeks, 72 percent had intercourse less than once weekly. The decline is attributed to lower desire and fear of harming the pregnancy (Bartellas, 2000; Staruch, 2016).


Obstentrics_Williams

Obstentrics_Williams. Intercourse speciically late in pregnancy is not harmful. Grudzinskas and coworkers (1979) noted no association between gestational age at delivery and coital frequency during the last 4 weeks of pregnancy. Sayle and colleagues (2001) reported no increased-and actually a decreased-risk of delivery within 2 weeks of intercourse. Tan and associates (2007) studied women scheduled for non urgent labor induction and found that spontaneous labor ensued at equal rates in groups either participating in or abstaining from intercourse. Oral-vaginal intercourse is occasionally hazardous. Aronson and Nelson (1967) described a fatal air embolism late in pregnancy as a result of air blown into the vagina during cunnilingus. Other near-fatal cases have been described (Bernhardt, 1988).


Obstentrics_Williams

Obstentrics_Williams. Examination of the teeth is included in the prenatal examination, and good dental hygiene is encouraged. Indeed, periodontal disease has been linked to preterm labor. Unfortunately, although its treatment improves dental health, it does not prevent preterm birth (Michalowicz, 2006). Dental caries are not aggravated by pregnancy. Importantly, pregnancy is not a contraindication to dental treatment including dental radiographs (Giglio, 2009) .


Obstentrics_Williams

Obstentrics_Williams. Current recommendations for immunization during pregnancy are summarized in Table 9-7. Well-publicized concerns regarding a causal link between childhood exposure to the thimerosal preservative in some vaccines and neuropsychological disorders have led to some parents to vaccine prohibition. Although controversy continues, these associations have proven groundless (Sugarman, 2007; Thompson, 2007; Tozzi, 2009). Thus, many vaccines may be used in pregnancy. The American College of Obstetricians and Gynecologists (20 16b) stresses the importance of integrating an efective vaccine strategy into the care of both obstetrical and gynecological patients. The College further emphasizes that information on the safety of vaccines given during pregnancy is subject to change, and recommendations can be found on the CDC website at ww.cdc.gov/vaccines.


Obstentrics_Williams

Obstentrics_Williams. he frequency of pertussis infection has substantially risen in the United States. Young infants are at increased risk for death from pertussis and are entirely dependent on passive immunization from maternal antibodies until the infant vaccine series is initiated at age 2 months. For this reason, a three-agent tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (T dap) vaccine is recommended and is safe for pregnant women (Centers for Disease Control and Prevention, 2013b, 2016; Morgan, 2015). However, as demonstrated by Healy and coworkers (2013), maternal antipertussis antibodies are relatively shortlived, and T dap administration before pregnancy-or even in the first half of the current pregnancy-is not likely to provide a high level of newborn antibody protection. Thus, to maximize passive antibody transfer to the fetus, a dose of T dap is ideally given to gravidas between 27 and 36 weeks' gestation (American College of Obstetricians and Gynecologists, 2017j;


Obstentrics_Williams

Obstentrics_Williams. Thus, to maximize passive antibody transfer to the fetus, a dose of T dap is ideally given to gravidas between 27 and 36 weeks' gestation (American College of Obstetricians and Gynecologists, 2017j; Centers for Disease Control and Prevention, 2013b, 2016).


Obstentrics_Williams

Obstentrics_Williams. All women who will be pregnant during inluenza season should be ofered vaccination, regardless of gestational age. hose with underlying medical conditions that increase the risk for influenza complications are provided the vaccine before lu season starts. In addition to maternal protection against infection, prenatal maternal vaccination in one study reduced the infant influenza incidence in the irst 6 months of life by 63 percent (Zaman, 2008). Moreover, it reduced all febrile respiratory illnesses in these infants by a third. Women who are susceptible to rubella during pregnancy should receive measles, mumps, rubella (MMR) vaccination postpartum. Although this vaccine is not recommended during TABLE 9-7. Continued Rabies Postexposure prophylaxis Half dose at injury site, half dose in Used in conjunction with rabies deltoid killed-virus vaccine Tetanus Postexposure prophylaxis One dose 1M Used in conjunction with tetanus


Obstentrics_Williams

Obstentrics_Williams. Tetanus Postexposure prophylaxis One dose 1M Used in conjunction with tetanus Varicella Should be considered for One dose 1M within 96 hours of Indicated also for newborns or exposed pregnant women exposure women who developed varicella to protect against maternal, within 4 days before delivery or not congenital, infection 2 days following delivery Hepatitis A: Postexposure prophylaxis and 0.02 mUkg 1M in one dose Immune globulin should be given Hepatitis A those at high risk as soon as possible and within virus vaccine 2 weeks of exposure; infants should be used born to women who are with hepatitis A incubating the virus or are immune globulin acutely ill at delivery should receive one dose of0.5 mL as soon as possible after birth 'Two doses necessary for students entering institutions of higher education, newly hired medical personnel, and travel abroad. blnactlvated polio vaccine recommended for nonimmunized adults at increased risk.


Obstentrics_Williams

Obstentrics_Williams. 10 = intradermally; 1M = intramuscularly; MMR = measles, mumps, rubella; PO = orally; SC = subcutaneously. From the Centers for Disease Control and Prevention, 201 1; Kim, 201 6. pregnancy, congenital rubella syndrome has never resulted from its inadvertent use. Breastfeeding is compatible with MMR vaccination (Centers for Disease Control and Prevention, 201l). Whether adverse pregnancy outcomes are related to cafeine consumption is somewhat controversial. As summarized from Chapter 18 (p. 348), heavy intake of cofee each day-about five cups or 500 mg of cafeine-slightly raises the miscarriage risk. Studies of "moderate" intake-less than 200 mg dailydid not find a higher risk.


Obstentrics_Williams

Obstentrics_Williams. It is unclear if cafeine consumption is associated with preterm birth or impaired fetal growth. Clausson and coworkers (2002) found no association between moderate cafeine consumption of less than 500 mg/d and low birthweight, fetalgrowth restriction, or preterm delivery. Bech and associates (2007) randomly assigned more than 1200 pregnant women who drank at least three cups of cofee per day to cafeinated versus decafeinated cofee. They found no diference in birthweight or gestational age at delivery between groups. The CARE Study Group (2008), however, evaluated 2635 lowrisk pregnancies and reported a l.4-fold risk for fetal-growth restriction among those whose daily cafeine consumption was >200 mg/d compared with those who consumed <100 mg/d. he American College of Obstetricians and Gynecologists (20e1e6d) concludes that moderate consumption of caffeine-less than 200 mg/ d-does not appear to be associated with miscarriage or preterm birth, but that the relationship between cafeine


Obstentrics_Williams

Obstentrics_Williams. (20e1e6d) concludes that moderate consumption of caffeine-less than 200 mg/ d-does not appear to be associated with miscarriage or preterm birth, but that the relationship between cafeine consumption and fetal-growth restriction remains unsettled. The American Dietetic Association (2008) recommends that cafeine intake during pregnancy be limited to less than 300 mg/d, which approximates three 5-oz cups of percolated cofee.


Obstentrics_Williams

Obstentrics_Williams. Nausea and vomiting are common complaints during the first half of pregnancy. These vary in severity and usually commence between the first and second missed menstrual period and continue until 14 to 16 weeks' gestation. Although nausea and vomiting tend to be worse in the morning-thus erroneously termed morning sickness-both symptoms frequently continue throughout the day. Lacroix and coworkers (2000) found that nausea and vomiting were reported by three fourths of pregnant women and lasted an average of35 days. Halfhad reliefby 14 weeks, and 90 percent by 22 weeks. In 80 percent of these women, nausea lasted all day.


Obstentrics_Williams

Obstentrics_Williams. Treatment of pregnancy-associated nausea and vomiting seldom provides complete relief, but symptoms can be minimized. Eating small meals at frequent intervals is valuable. One systematic literature search reported that the herbal remedy ginger was likely efective (Borrelli, 2005). Mild symptoms usually respond to vitamin BG given along with doxylamine, but some women require phenothiazine or HI-receptor blocking antiemetics (American College of Obstetricians and Gynecologists, 2015c). In some with hyperemesis gravidarum, vomiting is so severe that dehydration, electrolyte and acid-base disturbances, and starvation ketosis become serious problems.


Obstentrics_Williams

Obstentrics_Williams. Heartburn is another common complaint of gravidas and is caused by gastric content reflux into the lower esophagus. The greater frequency of regurgitation during pregnancy most likely results from upward displacement and compression of the stomach by the uterus, combined with relaxation of the lower esophageal sphincter. Avoiding bending over or lying flat is preventive. In most pregnant women, symptoms are mild and relieved by a regimen of more frequent but smaller meals. Antacids may provide considerable relief (Phupong, 2015). Specifically, aluminum hydroxide, magnesium trisilicate, or magnesium hydroxide is given alone or in combination. Management of heartburn or nausea that does not respond to simple measures is discussed in Chapter 54 (p. 1045).


Obstentrics_Williams

Obstentrics_Williams. The craving of pregnant women for strange foods is termed pica. Worldwide, its prevalence is estimated to be 30 percent (Fawcett, 2016). At times, nonfoods such as ice-pagophagia, starch-amylophagia, or clay-geophagia may predominate. This desire is considered by some to be triggered by severe iron deficiency. Although such cravings usually abate after deficiency correction, not all pregnant women with pica are iron deficient. Indeed, if strange "foods" dominate the diet, iron deficiency will be aggravated or will develop eventually.


Obstentrics_Williams

Obstentrics_Williams. Patel and coworkers (2004) prospectively completed a dietary inventory on more than 3000 women during the second trimester. The prevalence of pica was 4 percent. The most common nonfood items ingested were starch in 64 percent, dirt in 14 percent, sourdough in 9 percent, and ice in 5 percent. he prevalence of anemia was 15 percent in women with pica compared with 6 percent in those without it. Interestingly, the rate of spontaneous preterm birth before 35 weeks was twice as high in women with pica. Women during pregnancy are occasionally distressed by profuse salivation-pyalism. Although usually unexplained, ptyalism sometimes appears to follow salivary gland stimulation by the ingestion of starch. At least 5 percent of pregnancies are estimated to be complicated by new-onset or new-type headache (Spierings, 2016). Common headaches are virtually universal. Acetaminophen is suitable for most of these, and an in-depth discussion is found in Chapter 60 (p. 1057).


Obstentrics_Williams

Obstentrics_Williams. Low back pain to some extent is reported by nearly 70 percent of gravidas (Liddle, 2015; Wang, 2004). Minor degrees follow excessive strain or significant bending, lifting, or walking. It can be reduced by squatting rather than bending when reaching down, by using a back-support pillow when sitting, and by avoiding high-heeled shoes. Back pain complaints increase with progressing gestation and are more prevalent in obese women and those with a history of low back pain. In some cases, troublesome pain may persist for years after the pregnancy (Noren, 2002).


Obstentrics_Williams

Obstentrics_Williams. Severe back pain should not be attributed simply to pregnancy until a thorough orthopedic examination has been conducted. Severe pain has other uncommon causes that include pregnancy-associated osteoporosis, disc disease, vertebral osteoarthritis, or septic arthritis (Smith, 2008). More commonly, muscular spasm and tenderness are classiied clinically as acute strain or ibrositis. Although evidence-based clinical research directing care in pregnancy is limited, low back pain usually responds well to analgesics, heat, and rest. Acetaminophen may be used chronically as needed. Nonsteroidal antiinlammatory drugs may also be beneicial but are used only in short courses to avoid fetal efects (Chap. 12, p. 241). Muscle relaxants that include cyclobenzaprine or baclofen may be added when needed. Once acute pain is improved, stabilizing and strengthening exercises provided by physical therapy help improve spine and hip stability, which is essential for the increased load of pregnancy. For


Obstentrics_Williams

Obstentrics_Williams. Once acute pain is improved, stabilizing and strengthening exercises provided by physical therapy help improve spine and hip stability, which is essential for the increased load of pregnancy. For some, a support belt that stabilizes the sacroiliac joint may be helpful (Gutke, 2015).


Obstentrics_Williams

Obstentrics_Williams. Venous leg varicosities have a congenital predisposition and accrue with advancing age. They can be aggravated by factors that raise lower extremity venous pressures, such as an enlarging uterus. Femoral venous pressures in the supine gravida rise from 8 mm Hg in early pregnancy to 24 mm Hg at term. Thus, leg varicosities typically worsen as pregnancy advances, especially with prolonged standing. Symptoms vary from cosmetic blemishes and mild discomfort at the end of the day to severe discomfort that requires prolonged rest with feet elevation. Treatment is generally limited to periodic rest with leg elevation, elastic stockings, or both. Surgical correction during pregnancy generally is not advised, although rarely the symptoms may be so severe that injection, ligation, or even stripping of the veins is necessary.


Obstentrics_Williams

Obstentrics_Williams. Vulvar varicosities frequently coexist with leg varicosities, but they may appear without other venous pathology. Uncommonly, they become massive and almost incapacitating. If these large varicosities rupture, blood loss can be severe. Treatment is with specially itted pantyhose that will also minimize lower extremity varicosities. With particularly bothersome vulvar varicosities, a foam rubber pad suspended across the vulva by a belt can be used to exert pressure on the dilated veins.


Obstentrics_Williams

Obstentrics_Williams. Hemorrhoids are rectal vein varicosities and may irst appear during pregnancy as pelvic venous pressures rise. Commonly, they are recurrences of previously encountered hemorrhoids. Up to 40 percent of pregnant women develop these (Poskus, 2014). Pain and swelling usually are relieved by topically applied anesthetics, warm soaks, and stool-softening agents. With thrombosis of an external hemorrhoid, pain can be considerable. This may be relieved by incision and removal of the clot following injection of a local anesthetic.


Obstentrics_Williams

Obstentrics_Williams. Beginning early in pregnancy, many women experience fatigue and need greater amounts of sleep. his likely is due to the soporiic efect of progesterone but may be compounded in the irst trimester by nausea and vomiting. In the latter stages, general discomforts, urinary frequency, and dyspnea can be additive. Sleep duration may be related to obesity and gestational weight gain (Facco, 2016; Lockhart, 2015). Moreover, sleep eiciency appears to progressively diminish as pregnancy advances. Wilson and associates (201i1) performed overnight polysomnography and observed that women in the third trimester had poorer sleep eiciency, more awakenings, and less of both stage 4 (deep) and rapid-eye movement sleep. Women in the irst trimester were also afected, but to a lesser extent. Daytime naps and mild sedatives at bedtime such as diphenhydramine (Benadryl) can be helpful.


Obstentrics_Williams

Obstentrics_Williams. Since the irst successful cord blood transplantation in 1988, more than 25,000 umbilical cord blood transplantations have been performed to treat hemopoietic cancers and various genetic conditions (Butler, 2011). There are two types of cord blood banks. Public banks promote allogeneic donation, for use by a related or unrelated recipient, similar to blood product donation (Armson, 2015). Private banks were initially developed to store stem cells for future autologous use and charged fees for initial processing and annual storage. The American College of Obstetricians and Gynecologists (20 15d) has concluded that if a woman requests information on umbilical cord banking, information regarding advantages and disadvantages of public versus private banking should be explained. Some states have passed laws that require physicians to inform patients about cord blood banking options. Importantly, few transplants have been performed by using cord blood stored in the absence of a known


Obstentrics_Williams

Obstentrics_Williams. have passed laws that require physicians to inform patients about cord blood banking options. Importantly, few transplants have been performed by using cord blood stored in the absence of a known indication in the recipient (Screnci, 2016). The likelihood that cord blood would be used for the child or family member of the donor couple is considered remote, and it is recommended that directed donation be considered when an immediate family member carries the diagnosis of a speciic condition known to be treatable by hemopoietic transplantation (Chap. 56, p. 1075).


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Obstentrics_Williams. Aerospace Medical Association, Medical Guidelines Task Force: Medical guidelines for airline travel, 2nd ed. Aviat Space Environ Med 74:5, 2003 Afshar Y, Wang ET, Mei J, et al: Childbirth education class and birth plans are associated with a vaginal delivery. Birth 44(1):29, 2017 Ahmad F, Hogg-Johnson S, Stewart 0,et al: Computer-assisted screening for intimate parmer violence and control. Ann Intern Med 151 (2):94, 2009 American Academy of Pediarrics, American College of Obstetricians and Gynecologists: Guidelines for perinatal care, 8th ed. Elk Grove Village, AAP, 2017 American College of Obstetricians and Gynecologists: Intimate partner violence. Committee Opinion No. 518, February 2012 American College of Obstetricians and Gynecologists: Alcohol abuse and other substance use disorders: ethical issues in obsterric and gynecologic practice. Committee Opinion No. 633, June 2015a American College of Obsterricians and Gynecologists: Fetal growth restriction.


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Obstentrics_Williams. American College of Obsterricians and Gynecologists: Fetal growth restriction. Practice Bulletin No. 134, May 2013, Reairmed 2015b American College of Obstetricians and Gynecologists: Nausea and vomiting of pregnancy. Practice Bulletin No. 153, September 2015c American College of Obstetricians and Gynecologists: Umbilical cord blood banking. Committee Opinion No. 648, December 201s5d American College of Obstetricians and Gynecologists: Air travel during pregnancy. Committee Opinion No. 443, October 2009, Reairmed 2016a American College of Obstetricians and Gynecologists: Integrating immuniza tion into practice. Committee Opinion No. 661, April 2016b American College of Obstetricians and Gynecologists: Lead screening during pregnancy and lactation. Committee Opinion No. 533, August 2012, Reafirmed 2016c American College of Obstetricians and Gynecologists: Moderate cafeine consumption during pregnancy. Committee Opinion No. 462, August 2010, Reairmed 2016d


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Moderate cafeine consumption during pregnancy. Committee Opinion No. 462, August 2010, Reairmed 2016d American College of Obstetricians and Gynecologists: Neural tube defects. Practice Bulletin No. 44, July 2003, Reairmed 2016e American College of Obstetricians and Gynecologists: Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Committee Opinion No. 635, June 2015, Reairmed 2016f American College of Obstetricians and Gynecologists: Prevention of early onset group B streptococcal disease in newborns. Committee Opinion No. 485, April 20e11e, Reairmed 20e16g American College of Obstetricians and Gynecologists: Ultrasound in pregnancy. Practice Bulletin No. 175, December 2016h


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Ultrasound in pregnancy. Practice Bulletin No. 175, December 2016h American College of Obstetricians and Gynecologists: Weight gain during pregnancy. Committee Opinion No. 548, January 2013, Reairmed 2016i American College of Obstetricians and Gynecologists: Avoiding inappropriate clinical decisions based on false-positive human chorionic gonadotropin test results. Committee Opinion No. 278, November 2002, Reairmed 20e17a American College of Obstetricians and Gynecologists: Fetal alcohol spectrum disorders (FASD) prevention program. 2017b. Available at: http://www. acog.org/alcohol. Accessed October 23,e2017 American College of Obstetricians and Gynecologists: Gestational diabetes mellitus. Practice Bulletin No. 180, July 2017c


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Gestational diabetes mellitus. Practice Bulletin No. 180, July 2017c American College of Obstetricians and Gynecologists: Marijuana use during pregnancy and lactation. Committee Opinion No. 722, October 20e17d American College of Obstetricians and Gynecologists: Method for estimating the due date. Committee Opinion No. 700, May 2017e American College of Obstetricians and Gynecologists: Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711, August 2017f American College of Obstetricians and Gynecologists: Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650, December 2015, Reairmed 2017g American College of Obstetricians and Gynecologists: Carrier screening for genetic conditions. Committee Opinion No. 691, March 2017h American College of Obstetricians and Gynecologists: Smoking cessation during pregnancy. Committee Opinion No. 721, October 2017i


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Smoking cessation during pregnancy. Committee Opinion No. 721, October 2017i American College of Obstetricians and Gynecologists: Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Committee Opinion No. 718, September 2017j American College of Obstetricians and Gynecologists: Vitamin 0: screening and supplementation during pregnancy. Committee Opinion No. 495, July 201e1, Reairmed 2017k American Dietetic Association: Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome. J Am Diet Assoc 108:553,e2008 Armson BA, Allan OS, Casper F, et al: Umbilical cord blood: counseling, collection, and banking. J Obstet Gynaecol Can 37:832, 2015 Aronson ME, Nelson PK: Fatal air embolism in pregnancy resulting from an unusual sex act. Obstet Gynecol 30: 127, 1967


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Obstentrics_Williams. Ars CL, Nijs 1M, Marroun HE, et al: Prenatal folate, homocysteine and vitamin B12 levels and child brain volumes, cognitive development and psychological functioning: the Generation R Study. Br J Nutr 22: 1, 20e16 Barker OJ, Osmond C, Law CM: he intrauterine and early postnatal origins of cardiovascular disease and chronic bronchitis. J Epidemiol Community Health 43:237, 1989 Bartellas E, Crane JM, Daley M, et al: Sexuality and sexual activity in pregnancy. BJOG 107:964,e2000 Bech BH, Obel C, Henriksen TB, et al: Efect of reducing cafeine intake on birth weight and length of gestation: randomized controlled trial. BMJ 335:409,e2007 Berg q, Callaghan M, Syverson C, et al: Pregnancy-related mortality in the United States, 1998 to 2005. Obstet GynecoIe1l6(6):1302, 2010 Berggren EK, Groh-Wargo S, Presley L, et al: Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain. Am J Obstet GynecoIe214(6):745.e1, 2016 Bergsj0 P, Denman OW III,


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Obstentrics_Williams. S, Presley L, et al: Maternal fat, but not lean, mass is increased among overweight/obese women with excess gestational weight gain. Am J Obstet GynecoIe214(6):745.e1, 2016 Bergsj0 P, Denman OW III, Hofman HJ, et al: Duration of human singleton pregnancy. A population-based study. Acta Obstet Gynecol Scand 69: 197, 1990 Berlin 1, Grange G, Jacob N, et al: Nicotine patches in pregnant smokers: randomized, placebo controlled, multicentre trial of eicacy. BMJ 348:g1622, 20e14 Bernhardt TL, Goldmann RW, Thombs PA, et al: Hyperbaric oxygen treatment of cerebral air embolism from orogenital sex during pregnancy. Crit Care Med 16:729, 1988 Bleich AT, Sheield JS, Wendel GO Jr, et al: Disseminated gonococcal infection in women. Obstet GynecoIe119(3):597, 2012 Bodnar LM, Simhan HN, Powers RW, et al: High prevalence of vitamin 0 insuiciency in black and white pregnant women residing in the northern United States and their neonates. J Nutr 137(2)e:447, 2007


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Obstentrics_Williams. Borrelli F, Capasso R, Aviello G, et al: Efectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol 105:849,e2005 Branson BM, Handsfield HH, Lampe A, et al: Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 55(RR-14):1, 2006 Braunstein GO: False-positive serum human chorionic gonadotropin results: causes, characteristics, and recognition. Am J Obstet Gynecol 187:217, 2002 Braunstein GO: he long gestation of the modern home pregnancy test. Clin Chen 60(1):18, 2014 Brown A, Sinosich MJ, Saunders OM, et al: Potassium regulation and progesterone-aldosterone interrelationships in human pregnancy: a prospective study. Am J Obstet Gynecol 155:349, 1986 Butler MG, Menitove JE: Umbilical cord blood banking: an update. J Assist Reprod Genet 28:669,e2011


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Obstentrics_Williams. Butler MG, Menitove JE: Umbilical cord blood banking: an update. J Assist Reprod Genet 28:669,e2011 Cao XY, Jiang XM, Dou ZH, et al: Timing of vulnerability of the brain to iodine deiciency in endemic cretinism. N Engl J Med 331: 1739, 1994 CARE Study Group: Maternal cafeine intake during pregnancy and risk of fetal growth restriction: a large prospective observational study. BMJ 337:a2332,e2008 Carter EB, Temming A, Akin J, et al: Group prenatal care compared with traditional prenatal care: a systematic review and meta-analysis. Obstet GynecoIe128(3):551,e2016 Casey BM, hon A, Peaceman M, et al: Treatment of subclinical hypothyroidism or hypothyroxinemia in pregnancy. N Engl J Med 376(9):815, 20e17 Catalano PM: Increasing maternal obesity and weight gain during pregnancy: the obstetric problems of plentitude. Obstet Gynecol 110:743,e2007 Centers for Disease Control and Prevention: Entry into prenatal care-United States, 1989-1997. MMWR 49:393,e2000


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Obstentrics_Williams. Centers for Disease Control and Prevention: Spina biida and anencephly before and ater folic acid mandate-United States, 1995-1996 and 19992000. MMWR 53(17):362, 2004 Centers for Disease Control and Prevention: Guidelines for the identiication and management of lead exposure in pregnant and lactating women. November 2010a. Available at: http://www.cdc.gov/nceh/lead/publications/ leadandpregnancy2010.pd. Accessed September 19, 2016 Centers for Disease Control and Prevention: Prevention of perinatal group B streptococcal disease: revised guidelines from CDC, 2010. MMWR 59(10): 1, 2010b Centers for Disease Control and Prevention: General recommendations on immunization-recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 60(2):1,e2011 Centers for Disease Control and Prevention: PMS and smoking. 2013a. Available at: http://www.cdc.gov/prams/TobaccoandPrams.htm. Accessed September 18,e2016


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Obstentrics_Williams. Centers for Disease Control and Prevention: PMS and smoking. 2013a. Available at: http://www.cdc.gov/prams/TobaccoandPrams.htm. Accessed September 18,e2016 Centers for Disease Control and Prevention: Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women-Advisory Committee on Immunization Practices (ACIP), 2012. MMWR 62(7):131, 2013b Centers for Disease Control and Prevention: Guidelines for vaccinating pregnant women. 2016. Available at: http://www.cdc.gov/vaccines/pubs/ downloads/b_pre-guide. pdf. Accessed September 18, 2016 Chamberlain G, Broughton-Pipkin F (eds): Clinical Physiology in Obstetrics, 3rd ed. Oxford, Blackwell Science, 1998 Chen PH, Rovi S, Washington J, et al: Randomized comparison of 3 methods to screen for domestic violence in family practice. Ann Fam Med 5(5):430, 2007


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Obstentrics_Williams. Chen PH, Rovi S, Washington J, et al: Randomized comparison of 3 methods to screen for domestic violence in family practice. Ann Fam Med 5(5):430, 2007 Child Trends: Databank: late or no prenatal care. 2015. Available at: http://www. childtrends.org/?indicators=late-or-no-prenatal-care. Accessed September 19, 20e16 Clapp JF III, Kim H, Burciu B, et al: Beginning regular exercise in early pregnancy: efect on fetoplacental growth. Am J Obstet Gynecol 183: 1484, 2000 Clausson B, Granath F, Ekbom A, et al: Efect of cafeine exposure during pregnancy on birth weight and gestational age. Am J Epidemiol 155:429, 2002 Clement S, Candy B, Sikorski J, et al: Does reducing the frequency of routine antenatal visits have long term efects? Follow up of participants in a randomised controlled trial. BJOG 106:367, 1999 Coker L, Garcia LS, Williams CM, et al: Universal psychosocial screening and adverse pregnancy outcomes in an academic obstetric clinic. Obstet GynecoIe1l9(6):1180,e2012


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Obstentrics_Williams. Coker L, Garcia LS, Williams CM, et al: Universal psychosocial screening and adverse pregnancy outcomes in an academic obstetric clinic. Obstet GynecoIe1l9(6):1180,e2012 Cole A: he utility of six over-the-counter (home) pregnancy tests. Clin Chen Lab Med 49(8): 1317,e2011 Coleman T, Chamberlain C, Davey MA, et al: Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 12:CD010078, 2015 Cooper S, Taggar J, Lewis S, et al: Efect of nicotine patches in pregnancy on infant and maternal outcomes at 2 years: follow-up from the randomized, double-blind, placebo-controlled SNAP trial. Lancet Respir Med 2(9):728, 20e14 Cox Bauer CM, Bernhard A, Greer OM, et al: Maternal and neonatal outcomes in obese women who lose weight during pregnancy. J Perinatol 36(4):278,e2016


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Obstentrics_Williams. EI-Mohandes A, Herman AA, Kl-Khorazaty MN, et al: Prenatal care reduces the impact of illicit drug use on perinatal outcomes. J Perinatol 23:354, 2003 Eriksen JLK, Pilliod A, Caughey AB: Impact oflate initiation of prenatal care on pregnancy outcomes among women who use drugs. Abstract No. 732. Am J Obstet Gynecol 214:S384, 2016 Facco F, Reid K, Grobman W, et al: Short and long sleep duration are associated with extremes of gestational weight gain. Abstract No. 33. Am J Obstet GynecoIe214:S24,e2016 Fawcett EJ, Fawcett JM, Mazmanian 0: A meta-analysis of the worldwide prevalence of pica during pregnancy and the postpartum period. Int J Gynaecol Obsrer 133(3):277,e2016 Fawzi W, Msamanga GI, Urassa W, et al: Vitamins and perinatal outcomes among HIV-negative women in Tanzania. N Engl J Med 356: 14, 2007


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Obstentrics_Williams. Fawzi W, Msamanga GI, Urassa W, et al: Vitamins and perinatal outcomes among HIV-negative women in Tanzania. N Engl J Med 356: 14, 2007 Fiore MC, Jaen CR, Baker TB, et al: Treating tobacco use and dependence: 2008 update. Clinical practice guideline. 2008. Available at: http://ww. ncbi.nlm.nih.gov/books/NBK63952/. Accessed September 19, 2016 Fleming N, O'Driscoll T, Becker G, et al: Adolescent pregnancy guidelines. J Obstet Gynaecol Can 37(8):740,e2015 Foster M, Herulah UNPrasad A, et al: Zinc status of vegetarians during pregnancy: a systematic review of observational studies and meta-analysis of zinc intake. Nutrients 7(6):4512, 2015 Giglio JA, Lanni SM, Laskin OM, et al: Oral health care for the pregnant patient. J Can Dent 5(1):43, 2009 Green PP, McKnight-Eily LR, Tan CH, et al: Vital signs: alcohol-exposed pregnancies-United States, 201e1-2013. MMWR 65(4):91,e2016 Gregory KD, Johnson CT, Johnson TR, et al: The content of prenatal care. Women's Health Issues 16:198,e2006


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Obstentrics_Williams. Gregory KD, Johnson CT, Johnson TR, et al: The content of prenatal care. Women's Health Issues 16:198,e2006 Grenache DG: Variable accuracy of home pregnancy tests: truth in advertising? Clin Chen Lab Med 53(3):339, 2015 Grudzinskas JG, Watson C, Chard T: Does sexual intercourse cause fetal distress? Lancet 2:692, 1979 Gutke A, Betten C, Degerskar K, et al: Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities. Acta Obstet Gynecol Scand 94(1e1): 1156, 2015 Haragan AF, Hulsey TC, Hawk AF, et al: Diagnostic accuracy of fundal height and handheld ultrasound-measured abdominal circumference to screen for fetal growth abnormalities. Am J Obstet Gynecol 212(6):820. e1,e2015 Healy CM, Rench A, Baker CJ: Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants. Clin Infect Dis 56(4):539, 2013


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Obstentrics_Williams. Herbert WNP, Bruninghaus HM, Barefoot AB, et al: Clinical aspects of fetal heart auscultation. Obstet GynecoIe69:574, 198 Hibbeln JR, Davis JM, Steer C, et al: Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (LSPAC study): an observation cohort study. Lancet 369:578, 2007 Higginbottom MC, Sweetman L, Nyhan L: A syndrome of methylmalonic aciduria, homocystinuria, megaloblastic anemia and neurologic abnormalities in a vitamin B 12-deicient breast-fed infant of a strict vegetarian. N Engl J Med 299:317, 1978 Higgins JR, Walshee]], Conroy M, et al: The relation between maternal work, ambulatory blood pressure, and pregnancy hypertension. J Epidemiol Community Health 56:389, 2002 Hollier LM, Hill J, Sheield JS, et al: State laws regarding prenatal syphilis screening in the United States. Am J Obstet Gynecol 189: 1178, 2003 Horowitz HS, Heifetz SB: Efects of prenatal exposure to fluoridation on dental caries. Public Health Rep 82:297, 1967


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Obstentrics_Williams. Hytten FE, Chamberlain G (eds): Clinical Physiology in Obstetrics, 2nd ed. Oxford, Blackwell, 1991 Hytten FE, Leitch I: The Physiology of Human Pregnancy, 2nd ed. Oxford, Blackwell, 1971 Ickovics JR, Earnshaw V, Lewis JB, et al: Cluster randomized controlled trial of group prenatal care: perinatal outcomes among adolescents in New York City health centers. Am J Public Health 106(2):359,e2016 Institute of Medicine: Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, The National Academies Press, 2006 Institute of Medicine: DRI Dietary Reference Intakes for Calcium and Vitamin D. Washington, The National Academies Press, 20e11 Institute of Medicine and National Research Council: Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, The National Academic Press, 2009 Jackson A, Gardner S, Torres LN, et al: My obstetrician got me fired: how work notes can harm pregnant patients and what to do about it. Obstet Gynecol 126(2):250, 2015


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Obstentrics_Williams. Jackson A, Gardner S, Torres LN, et al: My obstetrician got me fired: how work notes can harm pregnant patients and what to do about it. Obstet Gynecol 126(2):250, 2015 Jebeile H, Mijatovic J, Louie JC, et al: A systematic review and meta-analysis of energy intake and weight gain in pregnancy. Am J Obstet Gynecol 214(4): 465,e2015 Jimenez JM, Tyson JE, Reisch JS: Clinical measures of gestational age in normal pregnancies. Obstet Gynecol 61 :438, 1983 Johnson S, Cushion M, Bond S, et al: Comparison of analytical sensitivity and women's interpretation of home pregnancy tests. Clin Chen Lab Med 53(3):391,e2015 Kiel OW, Dodson EA, Artal R, et al: Gestational weight gain and pregnancy outcomes in obese women: how much is enough. Obstet Gynecol 110:752, 2007 Kim OK, Bridges CB, Harriman KH, et al: Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older-United States, 2016. MMWR 65(4):88,e2016


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Obstentrics_Williams. Kim OK, Bridges CB, Harriman KH, et al: Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older-United States, 2016. MMWR 65(4):88,e2016 Kiss H, Widham A, Geusau A, et al: Universal antenatal screening for syphilis: is it still justified economically? A 10-year retrospective analysis. Eur J Obstet Gynecol Reprod Bioi 112:24,e2004 Kyle UG, Pichard C: The Dutch Famine of 1944-1945: a pathophysiological model of long-term consequences of wasting disease. Curr Opin Clin Nutr Metab Care 9:388, 2006 Lacroix R, Eason E, Melzack R: Nausea and vomiting during pregnancy: a prospective study of its frequency, intensity, and patterns of change. Am J Obstet Gynecol 182:931, 2000 Leveno KJ, McIntire DO, Bloom SL, et al: Decreased preterm births in an inner-city public hospital. Obstet Gynecol 113(3):578, 2009


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Obstentrics_Williams. Leveno KJ, McIntire DO, Bloom SL, et al: Decreased preterm births in an inner-city public hospital. Obstet Gynecol 113(3):578, 2009 Liddle SO, Pennick V: Interventions for preventing and treating low-back and pelvic pain during pregnancy. Cochrane Database Syst Rev 9:CDOO 1139, 20e15 Litonjua AA, Carey VJ, Laranjo N, et al: Efect of prenatal supplementation with vitamin 0 on asthma or recurrent wheezing in ofspring by age 3 years: the VDAART randomized clinical trial. JAviA 315(4):362,e2016 Lockhart EM, Ben Abdallah M, Tuuli MG, et al: Obstructive sleep apnea in pregnancy: assessment of current screening tools. Obstet Gynecol 126(1): 93, 2015 Loudon I: Death in Childbirth. New York, Oxford University Press, 1992 Luke B, Brown MB, Misiunas R, et al: Specialized prenatal care and maternal and infant outcomes in twin pregnancy. Am J Obstet Gynecol 934, 2003


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Obstentrics_Williams. Luke B, Brown MB, Misiunas R, et al: Specialized prenatal care and maternal and infant outcomes in twin pregnancy. Am J Obstet Gynecol 934, 2003 Magann EF, Evans SF, Weitz B, et al: Antepartum, intrapartum, and neonatal significance of exercise on healthy low-risk pregnant working women. Obstet Gynecol 99:466, 2002 Maheshwari UR, King JC, Leybin L, et al: Fluoride balances during early and late pregnancy. J Occup Med 25:587, 1983 Man LX, Chang B: Maternal cigarette smoking during pregnancy increases the risk of having a child with a congenital digital anomaly. Plast Reconstr Surg :301,e2006 Margulies R, Miller L: Fruit size as a model for teaching irst trimester uterine sizing in bimanual examination. Obstet Gynecol 98(2):341, 2001 Martin ]A, Hamilton BE, Sutton PO, et al: Births: inal data for 2006. Natl Vital Stat Rep (7): 1, 2009


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Obstentrics_Williams. McCauley ME, van den Broek N, Dou L, et al: Vitamin A supplementation during pregnancy for maternal and newborn outcomes. Cochrane Database Syst Rev 1O:CD008666, 2015 McDuie RS ] r, Beck A, Bischof K, et al: Efect of frequency of prenatal care visits on perinatal outcome among low-risk women. A randomized controlled trial. ]AMA 275:847, 1996 Metz TO, Stickrath EH: Marijuana use in pregnancy and lactation: a review of the evidence. Am] Obstet Gynecol 213(6): 61,2015 Michalowicz BS, Hodges ]S, DiAngelis A], et al: Treatment of periodontal disease and the risk of preterm birth. N Engl] Med 355:1885, 2006 Molloy AM, Kirke PN, Troendle ]F, et al: Matenal vitamin BI2 status and risk of neural tube defects in a population with high neural tube defect prevalence and no folic acid fortiication. Pediatrics 123(3):917,s2009 Montagnana M, Trenti T, Aloe R, et al: Human chorionic gonadotropin in pregnancy diagnostics. Clin Chim Acta 412(17-18):1515,s2011


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Obstentrics_Williams. Montagnana M, Trenti T, Aloe R, et al: Human chorionic gonadotropin in pregnancy diagnostics. Clin Chim Acta 412(17-18):1515,s2011 Morgan ]L, Baggari SR, McIntire DO, et al: Pregnancy outcomes after antepartum tetanus, diphtheria, and acellular pertussis vaccine. Obstet Gynecol 125(6): 1433,s2015 Mozurkewich EL, Luke B, Avni M, et al: Working conditions and adverse pregnancy outcome: a meta-analysis. Obstet Gynecol 95:623, 2000 Murray N, Homer CS, Davis GK, et al: he clinical utility of routine urinalysis in pregnancy: a prospective study. Meds] Aust ,s2002 Newman RB, Goldenberg RL, Moawad AH, et al: Occupational fatigue and preterm premature rupture of membranes. Am ] Obstet Gynecol 184:438, 2001 Noren L, bstgaard S, Johansson G, et al: Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spines] 11 :267, 2002


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Obstentrics_Williams. Nossier SA, Naeim NE, EI-Sayed NA, et al: he efect of zinc supplementation on pregnancy outcomes: a double-blind, randomized cotrolled trial, Egypt. Br] Nutr 114(2):274,s2015


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Obstentrics_Williams. Ota E, Mori R, Middleton P, et al: Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database Syst Rev 2:CD000230, 2015 Patel MV, Nuthalapaty FS, Ramsey PS, et al: Pica: a neglected risk factor for preterm birth. Obstet Gynecol 103:68S, 2004 Patnode CD, Henderson ]T, hompson ]H, et al: Behavioral counseling and pharmacotherapy interventions for tobacco cessation in adults, including pregnant women: a review of reviews for the U.S. Preventive Services Task Force. Ann Intern Med 163(8):608,s2015 Partridge S, Balayla], Holcroft CA, et al: Inadequate prenatal care utilization and risks of infant mortality and poor birth outcome: a retrospective analysis of28,729,765 U.S. deliveries over 8 years. Am] Perinatol 29(10):787, 2012 Phupong V, Hanprasertpong T: Interventions for heartburn in pregnancy. Coch rane Database Syst Rev 9 :CDO 113 79, 2015 Pitkin M: Calcium metabolism in pregnancy and the perinatal period: a review. Am] Obstet Gynecol 151:99, 1985 Pollak KT,


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Obstentrics_Williams. for heartburn in pregnancy. Coch rane Database Syst Rev 9 :CDO 113 79, 2015 Pitkin M: Calcium metabolism in pregnancy and the perinatal period: a review. Am] Obstet Gynecol 151:99, 1985 Pollak KT, Oncken CA, Lipkus 1M, et al: Nicotine replacement and behavioral therapy for smoking cessation in pregnancy. Am ] Prev Med 33(4):297, 200 Poskus T, Buzinskiene 0, Drasutiene G, et al: Haemorrhoids and anal issures during pregnancy and after childbirth: a prospective cohort study. B]OG 121(13):1666,s2014 Power ML, Wilson EK, Hogan SO, et al: Patterns of preconception, prenatal and postnatal care for diabetic women by obstetrician-gynecologists. ] Reprod Med 58(1-2):7, 2013 Pritchard ]A, Scott DE: Iron demands during pregnancy. In Hallberg L, Harwerth HG, Vannotti A (eds): Iron Deficiency: Pathogenesis, Clinical Aspects, Therapy. New York, Academic Press, 1970 Read ]S, lebanof A: Sexual intercourse during pregnancy and preterm delivery: efects of vaginal microorganisms. Am ] Obstet Gynecol


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Obstentrics_Williams. Clinical Aspects, Therapy. New York, Academic Press, 1970 Read ]S, lebanof A: Sexual intercourse during pregnancy and preterm delivery: efects of vaginal microorganisms. Am ] Obstet Gynecol 168:514, 1993 Rink BD, Norton ME: Screening for fetal aneuploidy. Semin Perinatol 40(1): 35,s2016 Rumbold A, Ota E, Nagata C, et al: Vitamin C supplementation in pregnancy. Cochrane Database Syst Rev 9:CD0040 2,2015 Ryan ET, Wilson ME, Kain KC: Illness after international travel. N Engl ] Med 347:505, 2002 Sa Roriz Fonteles C, Zero DT, Moss ME, et al: Fluoride concentrations in enamel and dentin of primary teeth after pre-and postnatal luoride exposure. Caries Res 39:505, 2005 Sagedal LR, Overby NC, Bere E, et al: Lifestyle intervention to limit gestational weight gain: the Norwegian Fit for Delivery randomized controlled trial. B]OG 1240):97,s2017


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Obstentrics_Williams. Salam A, Zuberi NF, Bhutta ZA: Pyridoxine (vitamin BG) supplementation during pregnancy or labour for maternal and neonatal outcomes. Cochrane Database Syst Rev 6:CD0001 9,2015 Sayle AE, Savitz DA, Thorps]M ]r, et al: Sexual activity during late pregnancy and risk of preterm delivery. Obstet Gynecol 97:283, 2001 Schau berger CW, Rooney BL, Brimer LM: Factors that inluence weight loss in the puerperium. Obstet Gynecol 9:424, 1992 Schrag S]: Maternal immunization to prevent neonatal group B streptococcal disease. Obstet Gynecol 127(2):199,s2016 Scott DE, Pritchard ]A, Satin AS, et al: Iron deficiency during pregnancy. In Hallberg L, Harwerth HG, Vannotti A (eds): Iron Deiciency: Pathogenesis, Clinical Aspects, Therapy. New York, Academic Press, 19 Screnci M, Murgi E, Valle V, et al: Sibling cord blood donor program for hematopoietic cell transplantation: the 20-year experience in the Rome Cord Blood Bank. Blood Cells Mol Dis 57:71, 2016


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Obstentrics_Williams. Screnci M, Murgi E, Valle V, et al: Sibling cord blood donor program for hematopoietic cell transplantation: the 20-year experience in the Rome Cord Blood Bank. Blood Cells Mol Dis 57:71, 2016 Sibai BM, Villar MA, Bray E: Magnesium supplementation dring pregnancy: a double-blind randomized controlled clinical trial. Ams] Obstet Gynecol 161:115,s1989 Siddique ], Lauderdale OS, VanderWeele T], et al: Trends in prenatal ultrasound use in the United States. Med Care 47:1129,2009 Siu AL, U.S. Preventive Services Task Force: Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 163(8):622,s2015 Smith CA: Efects of maternal under nutrition upon the newborn infant in Holland 0944-1945). Am] Obstet GynecoI30:229, 1947 Smith MW, Marcus PS, Wurtz LD: Orthopedic issues in pregnancy. Obstet Gynecol Surv 63: 103, 2008


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Obstentrics_Williams. Stewart RD, Nelson DB, Adhikari EH, et al: he obstetrical and neonatal impact of maternal opioid detoxiication in pregnancy. Ams] Obstet Gynecol 209:267.e1, 2013 Sugarman SO: Cases in vaccine court-legal battles over vaccines and autism. N Engl] Med 257:1275, 200 Tan Pc, Yow CM, Omar SZ: Efect of coital activity on onset of labor in women scheduled for labor induction. Obstet Gynecol 110:820,s200 Taylor CM, Golding ], Emond AM: Adverse efects of maternal lead levels on birth outcomes in the ALSPAC study: a prospective birth cohort study. B]OG 122(3):322,s2015 hompson W, Price C, Goodson B, et al: Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl ] Med 257:1281, 2007 Till SR, Everetts 0, Haas OM: Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes. Cochrane Database Syst Rev 12:CD009916, 2015


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Obstentrics_Williams. Till SR, Everetts 0, Haas OM: Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes. Cochrane Database Syst Rev 12:CD009916, 2015 Tong T, Dietz PM, Morrow B, et al: Trends in smoking before, during, and after pregnancy-pregnancy risk assessment monitoring system, United States, 40 sites, 2000-2010. MMWR 62(6):1,s2013 Tozzi AE, Bisiacchi P, Tarantino V, et al: Neuropsychological performance 10 years after immunization in infancy with thimerosal-containing vaccines. Pediatrics 123(2):475, 2009 U.S. Department of Health and Human Services: Reducing tobacco use: a report of the Surgeon General. Atlanta, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Oice on Smoking and Health, 2000 U.S.


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Obstentrics_Williams. U.S. Environmental Protection Agency: Fish: what pregnant women and parents need to know. 2014. Available at: http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucm393070.htm. Accessed September 19, 2016 U.S. Preventive Services Task Force: Recommendation statement: clinical guidelines: folic acid for the prevention of neural tube defects. Ann Intern Med 150:626, 2009 Villar], Baaqeel H, Piaggio G, et al: WHO atenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet 357:1551, 2001 Vintzileos M, Ananth CV, Smulian JC, et al: Prenatal care and black-white fetal death disparity in the United States: heterogeneity by high-risk conditions. Obstet Gynecol 99:483, 2002 Wang SM, Dezinno P, Maranets I, et al: Low back pain during pregnancy: prevalence, risk facrors, and outcomes. Obstet Gynecol 104:65, 2004


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Obstentrics_Williams. Wang SM, Dezinno P, Maranets I, et al: Low back pain during pregnancy: prevalence, risk facrors, and outcomes. Obstet Gynecol 104:65, 2004 Washington State Health Care Authority: Ultrasonography (ultrasound) in pregnancy: a health technology assessmenr. 2010. Available at: http://www. hta.hca. wa.gov/ documen ts/i naLreporcul trasound. pdf. Accessed September 19,r2016 West KP: Vitamin A deiciency disorders in children and women. Food Nun Bull 24:578, 2003 Widen EM, Whyatt vl, Hoepner A, et al: Excessive gestational weight gain is associated with long-term body fat and weight retention at 7 y postpartum in African American and Dominican mothers with underweight, normal, and overweight prepregnancy BM!. Am J Clin NLltr 102(6):1460, 2015 Wilcox AJ, Baird DD, Dunson D, et al: Natural limits of pregnancy testing in relation to the expected menstrual period. JAMA 286: 1759, 2001


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Obstentrics_Williams. Wilson DL, Barnes M, Ellett L, et al: Decreased sleep eiciency, increased wake after sleep onset and increased cortical arousals in late pregnancy. Aust N Z J Obstet Gynaecol 51(1):38, 2011 Worthen N, Bustillo M: Efect of urinary bladder fullness on fundal height measurements. Am J Obstet Gynecol 138:759, 1980 XU J, Kochanek KD, Murphy SL: Deaths: inal data for 2007. Nat Stat Vit Rep 58(19):1, 2010 Zaman K, Roy E, Arifeen SE, et al: Efectiveness of maternal inluenza immunization in mothers and infants. N Engl J vIed 359(15): 1555, 2008 SONOGRAPHY IN OBSTETRICSe. . . . . . . . . . . . . . . . . . .. 182 TECHNOLOGY AND SAFETYe. . . . . . . . . . . . . . . . . . . . . . 182 GESTATIONAL AGE ASSESSMENT . . . . . . . . . . . . . . . .. 183 FIRST-TRIMESTER SONOGRAPHY ....e.....e...e...... 185 SECOND-AND THIRD-TRIMESTER SONOGRAPHY .... 186 CERVICAL LENGTH ASSESSMENT. . . . . . . . . . . . . . . .. 189 NORMAL AND ABNORMAL FETAL ANATOMY. ....... 191


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Obstentrics_Williams. SECOND-AND THIRD-TRIMESTER SONOGRAPHY .... 186 CERVICAL LENGTH ASSESSMENT. . . . . . . . . . . . . . . .. 189 NORMAL AND ABNORMAL FETAL ANATOMY. ....... 191 DOPPLER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 MAGNETIC RESONANCE IMAGING ....e...e.......... 215 After discovey of the Roentgen ray and the demonstration of the various uses to which it might be put, it was thought possible that it might also aord a valuable method ofinvestigating the shape and size of the pelvis. -]. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -]. Whitridge Williams (1903) X-ray techniques were just on the horizon when the first edition of this textbook was published. he first application focused on the maternal pelvis without attention to the fetus. hus, congenital abnormalities were routinely not discovered until birth. Subsequent radiographic eforts to evaluate the fetus were later replaced by ultrasonography and more recently by magnetic resonance (MR) imaging, techniques which have become increasingly sophisticated. he subspecialty of fetal medicine has developed only because of these advances, and today's practitioner can hardly imagine obstetrical care without them.


Obstentrics_Williams

Obstentrics_Williams. Prenatal sonography can be used to accurately assess gestational age, fetal number, viability, and placental location, and it can aid diagnosis of many fetal abnormalities. With improvements in resolution and image display, anomalies are increasingly detected in the irst trimester, and Doppler is used to manage pregnancies complicated by growth impairment or anemia. he American College of Obstetricians and Gynecologists (2016) recommends that prenatal sonography be performed in all pregnancies and considers it an important part of obstetrical care in the United States.


Obstentrics_Williams

Obstentrics_Williams. The real-time image on the ultrasound screen is produced by sound waves that are relected back from fluid and tissue interfaces of the fetus, amnionic fluid, and placenta. Sector array transducers contain groups of piezoelectric crystals working simultaneously in arrays. These crystals convert electrical energy into sound waves, which are emitted in synchronized pulses. Sound waves pass through tissue layers and are reflected back to the transducer when they encounter an interface between tissues of diferent densities. Dense tissue such as bone produces high-velocity reflected waves, which are displayed as bright echoes on the screen. Conversely, luid generates few relected waves and appears dark. Digital images generated at 50 to more than 100 frames per second undergo postprocessing that yields the appearance of real-time imaging.


Obstentrics_Williams

Obstentrics_Williams. Ultrasound refers to sound waves traveling at a frequency above 20,000 hertz (cycles per second). Higher-frequency transducers yield better image resolution, whereas lower frequencies penetrate tissue more efectively. Transducers use wide-bandwidth technology to perform within a range of frequencies. In early pregnancy, a 5-to 10-megahertz (MHz) transvaginal transducer usually provides excellent resolution, because the early fetus is close to the transducer. And, in the first and second trimesters, a 4-to 6-MHz transabdominal transducer is similarly close enough to the fetus to yield precise images. By the third trimester, however, a lower frequency 2-to 5-MHz transducer may be needed for tissue penetration-particularly in obese patients-and this can lead to compromised resolution.


Obstentrics_Williams

Obstentrics_Williams. cation, using the lowest possible exposure setting to gain neces sary information-the AAA principle-as low as reasonably 4chievable. Examinations are performed only by those trained pathology, using techniques to avoid ultrasound exposure beyond what is considered safe for the fetus (American College of Obstetricians and Gynecologists, 2016; American Institute of Ultrasound in Medicine, 2013b). No causal relationship has ognized adverse efect in human pregnancy. The International Society of Ultrasound in Obstetrics and Gynecology (2016) further concludes that there is no scientifically proven associa tion between ultrasound exposure in the first or second trimes ters and autism spectrum disorder or its severity.