Essentials of

OBSTETRI CS

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Essenfials of Obstetrics

First Editioni 2OO5

Second Editioil 2011

Third Edition: 2017

tsBN 978-93-86056-66-5

Pinted at Sanat Printers

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Essentials of Obstetrics

t Gonorrhea 230t AnogenitalWarts 231t GenitalHerpes 231

' Swhilis 232. Bartholin's Cysts and Abscesses 233t Disorders of the Ceruix 233t Female Genital Mutilation 234t Fibroids 235. Retrouerted Grauid Uterus 235: (JrogynecologicalProbleminPregnancy 236t Peluic Organ Prolapse 236t Abnormal Ceruical Cytology in Pregnancy 237t Carcinoma Ceruix in Pregnancy 237t Adnexal Masses in Pregnancy 237

Chapter 27. Multiple Pregnancy and Polyhydramnios

Suchitra N Pandit, Viiay C Pawal Sonioy B Rao

t Multiple Pregnancy 241t NomenclatureofUltrasoundinTwinPregnancy 243t Maternal Complications 244t Fetal Complications 244t ChorionicVillus Sampling 247t Technt4ue ofAmniocentesisinTwin Pregnancy 247t PolYhYdramnios 250t Diagnosis 251

Chapter 28. Preterm Labor and Prelabor Rupture of Membranes

Tan Peng Chiong

. PretermLabor 255s PretermPrelaborRuptureofMembranes 263

Chapter 29. lntrauterine Growth Restriction

MuralidharV Pai

t Complications 271

Chapter30. ProlongedPregnancYPrashantJoshi

t Incidence 277t RiskFactors 278t Fetal and Maternal Complications 278: Principles of Management 279t MonitoringinLabor 279: Clinical Practice Guidelines 279

Chapter 31. Thalassemia and Rhesus Isoimmunization

Ja miyoh H osso n, Sofioh Su I aima n

t NormalHemoglobin 282t AlphaThalnssemia 282- BetaThalassemia 283t Rhesus Isoimmunization 284

240

254

269

277

281

apter

31Thalassemia and Rhesus

lsoimmu nizalion

.)amiyah Hassan, Sofiah Sulaiman

Hemoglobinopathy is one of the most common cause of anemia in certain parts of the world like Mediterranean Countries,Middle East, Africa and Southern Asia.The patients usually present with various degrees of anemia. There are two main groups-alpha and beta thalassemiadepending on whether the alpha or beta chain synthesis of adult hemoglobin is depressed, viz.:i. Alpha thalassemia where one to four of the alpha genes are deleted.ii. Beta thalassemia where one to two of the beta genes are deleted.

The common findings include smaller red cells (low MCV) and a reduced individual cell content of hemoglobin (low MCH).They usually have a normal mean cell hemoglobin cell concentration (normal MCHC) unlike iron-deficiency anemia.ln beta thalassemia trait, woman may develop anemia during the antenatal period. As in alpha thalassemia, the indices infull blood count reveal low MCV and MCH with a normal MCHC.The demands of pregnancy can lead to anemia and in women with thalassemia trait, oral iron and folate supplements can begiven throughout the antenatal period. Howevel parenteral iron is contraindicated.When both parents are affected, they should be counseled and offered prenatal diagnosis. The options available includechorionic villous or fetal blood sampling and amniocentesis.Rh isoimmunization: Rhesus-negative mothers who have become sensitized to the D antigen with a rhesus-positive fetus developanti-D antibodies. This can cross the placenta and attack the blood of a rhesus-positive fetus in subsequent pregnancies. Thiswill lead to destruction and removal of rhesus-positive fetal red blood cells in maternal and fetal circulations. This conditionis usually referred to as rhesus isoimmunization.These will lead to fetal anemia and increased erythroblasts in circulation, fetal hepatosplenomegaly and increased bilirubinin amniotic fluid. The fetus may have cardiomegaly with high output cardiac failure leading to fetal edema, ascites andhydrothorax (fetal hydrops).Hence, doing indirect Coomb's test is mandatory for all Rh-negative women if their partners are Rh-positive. Timely detectionofthe probem and intervention is needed.All Rh-negative mothers who deliver an Rh-positive baby should get anti-D injection within 36 hours of delivery.

UCTION some of these countries, premarital screening has beenincorporated into the medical services in order to reducethe medical cost of managing such problems.

The thalassemia syndromes are the most commongroup of hemoglobinopathies. These genetic disordersare inherited defects of hemoglobin as a result of globinsynthesis. The presentation can be varied and even

is one of the most common causes ofin certain parts of the world like Mediterranean

tries, Middle East, Africa and Southern Asia. Ines where there is a high rate of immigrants like theKingdom, this is a common health problem. In

undetected in mild forms and will be unmasked duringpregnancy. They usually present with various degrees ofanemia.

The syndromes are divided into two main groups, thealpha and the beta thalassemias depending on whetherthe alpha or beta chain synthesis of adult hemoglobin isdepressed, viz.:i. Alpha thalassemia where one to four of the alpha genes

are deleted.ii. Beta thalassemia where one to two of the beta genes

are deleted.

NORMAL HEMOGLOBIN

It is important to understand the normal structure ofhemoglobin (Fig. 31.1) so that one is able to identifu theproblems that can occur in a pregnancywhere the coupleis affected by this genetic disorder. The normal hemoglobinhas four globin chains each of which is associated with ahame complex. Each globin chain is controlled by a separategene. In humans, there are three normal hemoglobins,namely HbA, HbA2 and HbF and each of these consists oftwo pairs of globin chains. There are four globin chains;alpha (cr), beta (B), gamma (y) and delta (5). HbA constitutes95% of the total adult circulatinghemoglobin and it containsa pair each of o and B chains. cr chain is common to all threehemoglobins and it is controlled by four genes with twogenes inherited from each parent, whereas the beta chainis controlled by two genes and one gene is inherited fromeach parent.

ATPHA THALASSEMIA

The alpha genes play a very important role in the geneticmake-up of the normal circulating adult hemoglobin. Inthe normal individuals, they have four functional alphagenes; tvvo on each chromosome 16 and it is inherited as

pairs. Therefore, the absence of either one or all oftlgenes will result in varying degrees of anemia. Ithalassemia trait, there will be either three normigenes (a') or tvvo normal alpha genes (a'). In this 1

individuals, they are usually asymptomatic or maywith mild anemia. HbH disease or an intermediatealpha thalassemia has onlv one normal alnha genrinilividuals u sually preseniwitn moderate hn emra rrequire blood transfusions. Alpha thalassemia majofunctional alpha genes and this will result in no alpts1'nthesis. Therefore, the fetal hemoglobin (HbF a,

form together with tetramers of y chains which areas hemo globin B art's (y ) (Fig. 3 I. 2). This condition rto severe anemia. This condition is incompatible r

and the pregnancy usually ends prematurely in a i

Normal hemoglobino-chain production

s' s'

s' e'

A-Thalassaemia silent carrier

s' s'

s' s'

A-Thalassemia trait heterozygous

s' s'

s' e'

A-Thalassemia intermedia (Hbh)

5'3,s' e,

Hemoglobin Barts

Fig. 31.2: Dlfferent forms of alpha thalassemiaFig. 31.1 : Normal hemoglobin

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IndexPage numbers followed by/refer to figure, / refer to table, and b refer to box.

AAbdomen 37L,324

engagement of 54examination 319lower 446palpation of 356

Abdominal circumferenc e 143, I4S, 146f,270,272,320,320f

Abdominal examination 43, 51, 364, 368,370,374

Abdominal muscles, contraction of 341Abdominal pain, lower 440Abdominal rotte 345, 442Abdominal trauma 311, 316Abdominalwall 342

anterior 31

ABO incompatibility BtAbortion 93-95, 97, 312, 3Lg

septic 97services, safe 112spontaneous 79therapeutic 729,150tubal 102

unsafe 110Abruptio placenta 2OB-210, 252

types of 20B,2OgAbscess 233

development of 233Acetyl-cholinesterase 156Acid-base disturbances 126Acid producing lactobacilli 229Acidosis L78,403,420Acoustic stimulation 324

test 324Acrosomal membrane, outer 14Acrosomal sac containing enzyrnes 14Acrosome reaction 18

Acupressure 131

Adhesion molecules 186Adnexal mass IO3, 232, 238I,SIIAdrenal axis l2BAdrenal gland 62, 63Adrenal hyperplasia, congenital 157Adrenaline 412fAedesaegypti IBg

Airwaypatency 409Alcohol 120

intake g5

Alpha methyldopa, dose of 220Alpha thalass emia 282, 2B2f

types of 15ffAmenorrhea 48,54

period of 243Amino acid 168

chelates 168Amniocentesis L54,242Amniotic bands 322Amniotic cavity B5l 86/

formation of 85/Amniotic fluid lE4, 2bO, 2BS, ZZL

assessment of 146composition of 86Iibroblast 284formation of 86index 251,225,32Linfusion 265percentiles 321jF

pressure of 341production, dlmamics of 250quantity of 252volume 2I8,324

Amniotic index 321Amniotomy 330,33IAmphetamine abuse 208Ampicillin 313Ampulla of tube tOtAmpullary pregnancy, unruptured 102Anal epithelium 392Analsphincter 32,396f

end-to-end repair of 394/repair of 394/

Analgesia 358,361,408epidural 358regional 358

Androgen binding globulin t3Android pelvis 41Anemia 163, 165, 166, 186, 209,444

aplastic 164classification of 164dimorphic 170hemolltic 299,30r

in adolescen/boys, reduce 115girls, reduce 115

inpregnancy 165

management of I6Zfmediterranean 170megaloblastic 169physiological dilutional 120severe 186

postpartum 168Anesthesia

general 36I,44Lregional 361

Aneuploidy 95Aneurysm rupture 137Angiotensin infusion test 219Anhydramnios 263Anogenital warts 23IAnopheles mosquito lB5, 185, 190Antenatal corticosteroids 260Antenatal management 22O, 246, 2Bg,

2B9tAntenatal problems 419Antenatal screening

routine I93tests 193,

Anthropoid pelvis 4tAntibiotics 224,292Antibodies

antinuclear B0antithyroid B0

Anticardiolipin antibodies 96, 2T 4Anticholinergics 129Antihistamines 129Antihypertensive 22Lt

drugs 220,225,3O1Anti-inflammatory drugs 302Antimiillerian hormone 5, 15Antioxidants 219Antiphospholipid

antibodies 80,97slmdrome 300

Antithl,r'oid drugs, dose of 292Anxiety I40,278,445Aorta 326f

coarctation of 225compression of a2\f

Essentia ls of Obstetrics

Aortic dissection 139

Apgar score 408,Apnea 422

primary 408

Appendicitis l25,3llacute 102,312

Apt's test 211

Arteriovenous malformation 137

Arterysingle umbilical 418

umbilical l41f, 2IB, 325, 326f, 327fwaveforms 325

Asherman's sy,ndrome 99, 440

Asphyxia 420

Assisted breech delivery 376

Assisted reproductive techniques 101

Asthma 140, 290,301bronchial 290,291in pregnancy, management of

bronchial 290

medication 301

Atelectasis 290

Atrial septal defects 2BB

Autoimmune vasculitis 216

Autonomic nerves 32

Avascularseptum 95

Axillaryadenopathy 440

B

B lymphocltes 77

Babylarge 444

macrosomic 121

Bacilli Calmette-Guerin 291

Backache 138

Bacterial vaginosis 195, 228

Bacteriuria, asl,rnmetric 165

Bag maskventilation 412

Balloon catheters 427

Barker's hlpothesis 275

Bartholin's cysts 233

Bartholin's gland 31

ducts 25

Beta human chorionic gonadotropin 102,

151

Beta thalassemia 282, 283

Biopsy, gastric 124

Birthasphlxia 278

canal 385,390axis of 35/

defects 130

injuries 415

preterm 236,255process of 407

Bishop score 329,Bladder

care of 435

injury 206

Blastocyst 83/implantation of 204

Bleeding 164,330control of 351

corpusluteum 102

pervagina, profuse 396

Bloodclot 413

constituents 59

colonts 442dyscrasias 439

flow 59,60ffree provision of I 13

gases, arterial 140

glucoselevels 180,182self-monitoring I79

group 152

incompatibilities BIRh negative 2B4t

loss 164,426assessment of 204

significant 413

pressure 58, 59, lzL, 122, 216, 422

controlof 222

normal 216,324routine monitoring of 179

storage facilities 112

stream 440

suSar

control 179

monitoring 179

profile 179

transfusion 167, 168, 446ofinfected 205

values 166/velocity, analysis of 285

viscosity 218

B-lynch stture 428, 429fBody mass index 138, 206

Bone 416marrow 1BB

mineral densiry loss of 300

Bony pelvis 27

Bowel sl,ndrome, irritable 136

Bowel, care of 435

Brachialplexus 416Brain 127,326Brandt-Andrews technique 424, 425J

Breast 439

abscess 441

cancer 128

care of 435

changes 49,49f,51,52discomfort 49

emptying of 440

engorgement 440

feedingrates 114

infection of 441

milk 441preparation of 436

problems 441

size 62

stimulation 330

Breastfeeding 122, 17 l, 296, 3O4

Breath, ketotic odor of 126

Breathlessness, causes of 140,

Breech delivery 380

head of 384management of 380

Breech extraction 376

Breech presentation 261, 372-371.causes of 373b

Breech, types of 373,373fBreech, uncomplicated 374

Bronchiectasis 291

Bronchitis 291

chronic 291

Bronchocele, congenital 368

Bulbourethralgland 17

Burns-Marshallmethod 378procedure 379/

Buttoch mechanism with 374

cCalcium 164,297

carbonate 136

channelblockers 260

ions 19

Caldwell-Moloy classifi cation 4{Call-Exner body B

Caloric restriction 180

Cancer, endometrial 426

Caput succedaneum 40, 343

Carbamazepine 300

Carbohydrate 16

complexes 168

metabolism 174

Carbonyliron 168

Carcinoma ceritx 237

Cardiac disease Llg, 287 -289, 3l!lCardiac disorder 287, 2BB

Cardiac failure 169, 28Bfmanagement of 289

Cardiac murmur 443

Cardiac pulsation 148

Cardiomyopathy 140

Cardiovascular system 57, 135,

Carnitine 16

Carpal tunnel q,ndrome 139

Caviry abdominal 103

Cefuroxime 441

Cellanemia 158

free DNA 160

groups of 325mass, inner 83/

Central nervous system 135,137, I94,2lgt,42l

Cephalexin 441

Cephalic prominence 40, 368Cephalicreplacement 3BB

Cephalic version, external 122, 208, 372,375,375b

Cephalohematoma 415, 4L6f, Al&tCephalopelvic disproportion 45, 181,

384,404tests 46

Cerebral artery middle 148,275, 326fCerebrospinalfluid 138

Cervicalcarcinoma, undiagnosed 209cerclage, rescue 261dilatationcurve 348ectopic pregnancy l04J 105

erosion 233intraepithelial neoplasia 237laceration 395,430length 258malignancy 228tear 396

torn end, repair of 396/Cervicouterine injuries 99Cervicovaginal junction 97Cervix 50, 346, 348, 396, 425, 440

acquired abnormality of 233assessment of 329complete dilatation of 353congenital malformations of 233dilatation of 348,349fdisorders of 233effacement of 348tull dilatation of 380inspection of 396premalignant conditions of 228

Cesarean hysterectomy 205, 2OB, 387Cesarean section 17 I, 2O5, 221, 224, 329

delivery 249Chemoprophylaxis 187Chemotherapeutic agents 304Chest 439

complications 444pain 139,444

causes of 139fradiography 443

syndrome, acute 139

Chickenpox 196Child mortality 110

Childhood obesity 182

Chin 368Chlamydia 199,230

trachomatis 101, 230, 263t,434Chlamydial infections, treatment of 298

Cholecystitis 125

acute 311,313Cholelithiasis 125

Choleravaccines 201

Chondrodysplasia punctata 300

Chorioamnio nins 263, 264Choriocarcinoma BlChorionic villous sampling 155,247 ,283Chorionicity 243

determination of 243Chromosomal abnormalities 161

Chromosomal disorder, freqtency of 322Ciprofloxacin 443Circumvallate placenta 212Cleft lip 296Clindamycin 441

Clitoris 24

Clonus, signs of 218

Cloxacillin 441

Cocaine 208Collagen vascular diseases 225

Colles'fascia 31

Colporrhexis 394

Colposcopy 237

Congenital infection I52, L59tsequelae of 202

Congenital malformation 146, l4B, 2O9,

233,278,368, 370,371Constipation 136

causes of 136,simple 136

Contraction stress test 322, 323Cord compression 322

Cornual pregnancy, ruptured 105

Corticosteroids l3O, 246, 260, 302antenatal 259,265

Corticotropin releasing hormone 68, 70,

345Cough, productive 444Cowper's gland 17

Craigin's dictum 387

Crown-rump length 144, l44fCuboidal cells 18,26Culexmosquito 19LfCulex q uinquefasciatus l9OCutaneous stigmata 417Cutis marmorata 417

Cyanomethemoglobin 166

Cyanosis 218,443

Cyclophosphamide 305

Cysts 148/benign 227

C1'tokines 77

release of 298

Cltomegalovirus 159, 197, 25lb

D

Dacarbazine 305Das's forceps 379Decidual epithelial cells 21

Decubitus ulcer, development of 236

Dehydration LzO,4O3

Dehydroepiandrosterone 65

sulfate 65,66Delivery

mode of I19,265,404operative 177,403preterm 259, 260, 263, 2BB, 292, 298,

322route of 246

urgencyof 219

Denguefever 185, lB9

hemorrhagic 189

shock slmdrome 189

Dentalcaries 62

discoloration 297

Deoxpibonucleic acid 161

analysis 161

Dexamethasone injection 139

Diabetes 173, 17 4, l94t, 216complications of l77tgestational 173, 175, 17 5t, lB2macrosmia in l8lmellitus 119, l2l, I2B, L36, 156, L73,

179tDiarrhea 332

Diazepamtherapy 224

Diet 120,353Diethylstilbestrol 95

Dihydrotestosterone 5

Dimenhydrinate 130

Dimeric inhibinA 153

Dimethylarginine, aslmmetric 125

Diphenhydramine 130

Diphtheria 201

tetanus-pertussis 114

Disseminated intravascular coagulation99,208,2O9

Dizygotic twin 24I, 24ltDouble puncture technique 247Down's syndrome l2l, 153t, L56,246Doxylamine 130, 136