ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Pregnant women of all ages should be offered screening and invasive diagnostic testing for chromosomal abnormalities before 20 weeks' gestation. New developments in screening methods have increased the number of options for patients. Diagnostic options include chorionic villus sampling in the first trimester and amniocentesis in the second trimester. Screening options in the first trimester include nuchal translucency testing in combination with measurement of pregnancy-associated plasma protein A and human chorionic gonadotropin. Nuchal translucency testing alone is not as effective. Screening options in the second trimester include serum screening using triple or quadruple screening, and ultrasonography. Patients may also choose a combination of first- and second-trimester screening in an integrated, stepwise sequential, or contingent sequential fashion. These options include an analysis of pregnancy-associated plasma protein A, with or without nuchal translucency testing, in combination with quadruple screening. An integrated test with nuchal translucency testing is the most effective method for women who present in the first trimester. If nuchal translucency testing is unavailable, the maternal serum-integrated test is safest and most effective. For women who do not present until the second trimester, the quadruple screen is recommended. Comprehensive counseling should be available to all pregnant women. Specific screening tests will depend on availability of the procedure and patient preference.
Screening for Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery - Putting Prevention into Practice
First Trimester Bleeding - Article
ABSTRACT: Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.
Sharing Maternity Care - Feature
ABSTRACT: According to the American College of Obstetricians and Gynecologists, it has become standard in prenatal care to offer screening tests for neural tube defects and genetic abnormalities. There have been some changes in the recommended method of prenatal screening over the past few years, and research to improve detection rates with better combinations of maternal serum analytes is ongoing. The issues facing physicians are the sensitivity and specificity of multiple serum analyte combinations. The current maternal serum analytes in use in most areas are alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and unconjugated estriol. Measurement of AFP alone can detect the vast majority of neural tube defects and a small portion of trisomy 21-affected pregnancies in patients of all ages. Adding hCG and unconjugated estriol to this screen increases the rate of detection of trisomies 21 and 18. Counseling patients about the risks and benefits of such screening is important to provide a balanced discussion of screening issues.
ABSTRACT: Vaginal birth after cesarean section is common in this country. Physicians providing obstetric care should be aware of the potential complications. Uterine rupture occurs in approximately one of every 67 to 500 women (with one prior low-transverse incision) undergoing a trial of labor for vaginal birth after cesarean section. Rupture poses serious risks to mother and infant. There are no reliable predictors or unequivocal clinical manifestations of rupture, so physicians must maintain a high index of suspicion for possible rupture, especially in the presence of fetal bradycardia or other evidence of fetal distress. Management is surgery for prompt delivery of the infant and control of maternal hemorrhage. Newborns often require admission to an intensive care nursery. Prevention of poor outcomes depends on thorough anticipation and preparation. The physicians and the delivery institution should be prepared to provide emergency surgical and neonatal care in the event of uterine rupture.
ABSTRACT: In patients without established cardiac disease, the occurrence of premature ventricular complexes without sustained ventricular tachycardia is more an annoyance than a medical risk, and treatment is not required. In contrast, patients with established heart disease and premature ventricular complexes have a higher likelihood of developing ventricular tachycardia or fibrillation. These patients should be treated with a beta blocker or class I antiarrhythmic drug. Treatment of arrhythmias in pregnant women is rarely needed. When treatment is required, amiodarone should be avoided, and beta blockers should be used with caution, because these agents have been associated with fetal growth retardation. The most important rhythm abnormality in athletes is ventricular tachycardia associated with hypertrophic cardiomyopathy. If the presence of the disease is confirmed by echocardiography, beta-blocker therapy is necessary, and these patients should be limited to participation in nonstrenuous sports. Acute arrhythmias in children with Wolff-Parkinson-White syndrome can be treated with adenosine. Radiofrequency ablation of the accessory pathway can provide long-term control.
Nausea and Vomiting in Pregnancy - Article
ABSTRACT: Nausea and vomiting of pregnancy, commonly known as 'morning sickness,' affects approximately 80 percent of pregnant women. Although several theories have been proposed, the exact cause remains unclear. Recent research has implicated Helicobacter pylori as one possible cause. Nausea and vomiting of pregnancy is generally a mild, self-limited condition that may be controlled with conservative measures. A small percentage of pregnant women have a more profound course, with the most severe form being hyperemesis gravidarum. Unlike morning sickness, hyperemesis gravidarum may have negative implications for maternal and fetal health. Physicians should carefully evaluate patients with nonresolving or worsening symptoms to rule out the most common pregnancy-related and nonpregnancy-related causes of severe vomiting. Once pathologic causes have been ruled out, treatment is individualized. Initial treatment should be conservative and should involve dietary changes, emotional support, and perhaps alternative therapy such as ginger or acupressure. Women with more complicated nausea and vomiting of pregnancy also may need pharmacologic therapy. Several medications, including pyridoxine and doxylamine, have been shown to be safe and effective treatments. Pregnant women who have severe vomiting may require hospitalization, orally or intravenously administered corticosteroid therapy, and total parenteral nutrition.
Vacuum-Assisted Vaginal Delivery - Article
ABSTRACT: The second stage of labor is a dynamic event that may require assistance when maternal efforts fail to effect delivery or when there are nonreassuring fetal heart tones. Therefore, knowing how to perform an operative vaginal delivery with forceps or vacuum is vital for family physicians who provide maternity care. Vacuum is rapidly replacing forceps as the predominant instrument, but each has advantages and disadvantages, including increased risk of maternal trauma with forceps and increased risk of neonatal cephalohematoma with vacuum. Use of a second instrument if the first one fails is associated with worse outcomes. Routine episiotomy in operative vaginal delivery is no longer recommended. The "ABCDEFGHIJ" mnemonic can facilitate proper use and application of the vacuum device and minimize risks, and practicing the techniques on mannequins can provide an introduction to the skills of operative vaginal delivery.