Pregnancy at Risk

The Federation of Obstetric and Gynaecological Societies of India

 Pregnancy at Risk
A Practical Approach to High Risk
Pregnancy and Delivery
FIFTH EDITION
Editors
Usha Krishna MD DGO FICS FICOG
Past president, FOGSI, MOGS, Ex-Hon. Prof. KEM Hospital and GS Medical College
Consultant, Obstetrician and Gynecologist, Bhatia General Hospital
Director, Clinic for Women, Laburnum Road, Gamdevi, Mumbai, Maharashtra, India

Duru Shah MD FRCOG FCPS FICS FICOG FICMCH DGO DFP

Chairman: Gynaecworld
Professor and Consultant Obstetrician and Gynecologist
Breach Candy Hospital and Research Center
Jaslok Hospital and Research Center
Sir Hurkisondas Nurrotumdas Hospital and Research Center
Mumbai, Maharashtra, India

Vinita Salvi MD DNBE FCPS DGO DFP

Consultant Obstetrician and Gynecologist
SevenHills Hospital, Mumbai
Ex-Professor of Obstetrics and Gynecology and Officer in-Charge
ICMR Regional Center for Research in Human Reproduction
Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Nozer Sheriar MD DNBE FCPS DGO

Consultant Obstetrician and Gynecologist
Breach Candy, Holy Family, Masina and Parsee General Hospitals
Gynecological Endoscopist, Bhatia and BARC Hospitals
Deputy Secretary General: FOGSI
Mumbai, Maharashtra, India

Kaizad R Damania MD DNBE FCPS DGO DFP

Professor of Obstetrics and Gynecology
Seth GS Medical College and Nowrosjee Wadia
Maternity Hospital, Mumbai, Maharashtra, India

A FOGSI Publication

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Pregnancy at Risk: A Practical Approach to High Risk Pregnancy and Delivery

2010, The Federation of Obstetric and Gynaecological Societies of India

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First Edition : 1993

Second Edition : 1995
Third Edition : 1997
Fourth Edition : 2001
Reprint : 2004
Fifth Edition : 2010

ISBN 978-81-8448-959-0

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 Contributors

Abhishek Pachchigar MBBS DMRD Alokendu Chatterjee FRCOG FICS

Fellow in Ultrasound and Doppler Formerly, Head, Department of Obstetric
Department of Radiology and Gynecology
KEM Hospital and GS Medical College NRS Medical College, Kolkata, West Bengal, India
Parel, Mumbai
Maharashtra, India Ambrish Dalal MD
Honorary Sonologist
Adarsh Bhargava MS (Obs/Gyn) FICOG FIMCH Bombay Hospital, Mumbai, Maharashtra, India
Visiting Faculty, Rajasthan University of Health Science
Advisor, Govt, IVF and Stemcell Research Center Ameet Patki MD DNB FCPS FICOG FRCOG (UK)
SMS Medical College, Jaipur Medical Director ReGenesis, Center for Assisted
Retired Head of Department (Obs/Gyn) Reproduction, Endoscopy and Fetal Medicine
SMS Medical College, Jaipur Reliance Life Sciences, Mumbai
Rajasthan, India Hon Associate Professor
Mumbai, Maharashtra, India
Adi E Dastur MD FICOG FCPS DGO DFP
Medical Head Ameya C Purandare MD DNBE FCPS DGO DFP MNAMS
Nowrosjee Wadia Maternity Hospital and Former MICOG
Honorary Professor of Obstetrics and Gynecology Assistant Honorary Obstetrician and Gynecologist
Seth GS Medical College and Nowrosjee Wadia K J Somaiya Medical College and Hospital, Mumbai
Maternity Hospital Masina Hospital, Mumbai
Mumbai Naigaon Municipal Maternity Hospital
Maharashtra, India Mumbai, Maharashtra, India

Ajanta Narvekar Amit Chakravarty MSc PhD MSCG (USA)

Consultant Gynecologist and Infertility Specialist Consultant Geneticist
Narvekar Infertility and Endoscopy Clinic Birth Defects Center
Patel Chambers, Opera House Mumbai, Maharashtra, India
Mumbai
Maharashtra, India Amit Sudhakar Kulkarni DPM DNB
Consultant Psychiatrist Research officer
Ajay Mehta MD DGO Dr RN Cooper Municipal General Hospital
Consulting Obstetrician and Gynecologist, Mumbai Mumbai, Maharashtra, India
Visiting Sonologist
Nowrosjee Wadia Maternity Hospital, Mumbai Anahita Chauhan MD DGO
Maharashtra, India Associate Professor of Obstetrics and Gynecology
Seth GS Medical College and KEM Hospital
Alka Gogate MD Mumbai, Maharashtra, India
Professor and Head
Department of Microbiology, LTM Medical College and Anita Soni MD DNB FCPS DGO
General Hospital, Mumbai, Maharashtra, India Consultant Obstetrician and Gynecologist
LH Hiranandani Hospital
Alka Kriplani MBBS MD FICOG FICMCH FIMSA Mumbai, Maharashtra, India
Professor and Head Unit II
Department of Obstetrics and Gynaecology Anirudh Kohli MD DNB DMRD
All India Institute of Medical Sciences Breach Candy Hospital
New Delhi, India Mumbai, Maharashtra, India
vi Pregnancy at Risk

Ashwini Bhalerao Gandhi MD DGO DFP FCPS DNB Chander Lulla

FICOG Consultant Sonologist
Consultant Gynecologist Ria Clinic, Mumbai, Maharashtra, India
PD Hinduja National Hospital and Medical Research
Center, Mahim, Mumbai, Maharashtra, India Chinmayee Patra
Ex Associate Professor Senior Resident
TN Medical College and BYL Nair Hospital TNMC and BYL Nair Ch. Hospital
Chairperson, Adolescent Health Committee of FOGSI Mumbai, Maharashtra, India
(2004-08)
Secretary, Mumbai Obstetrics and Gynecology Society Chittaranjan N Purandare MD (BOM), MA Obst (Ireland),
Mumbai, Maharashtra, India DGO, DFP, D. Obst. RCPI (Dublin), FICOG, FICMCH, PGD,
MLS (Law)
Ashwita Aiyer MBBS President FOGSI, Assoc. Editor Journal FOGSI
Chowpatty Medical Center Consultant Obstetrics and Gynecology
Mumbai, Maharashtra, India St. Elizabeth Hospital and BSES Hospital, Mumbai
Ex. Hon. Professor Obstetrics and Gynecology
Avan Dadina Grant Medical College and JJ Hospital
Consultant Obstetrician and Gynecologist Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Chopra S MBBS
Basil T Lyngdoh Resident, Obstetrics and Gynecology
Senior Resident
Department of Obstetrics and Gynecology Dilip R Karnad MD FACP FRCP (Glasg)
All India Institute of Medical Sciences Consultant, Critical Care Medicine
New Delhi, India SevenHills Hospital, Mumbai
Adjunct Professor of Medicine
Bhaskar Pal MD DGO DNBE MRCOG Baylor College of Medicine, Houston, Texas
Consultant Obstetrician and Gynecologist
Apollo Gleneagles Hospital Divakar H MD
Kolkata, West Bengal, India Consultant Obstetrician
Divakars Speciality Hospital
Bhavisha Bafna JP Nagar II Phase
MSc in Pharmaceutical Sciences with Management Bengaluru, Karnataka, India
Studies
Senior Research Officer Duru Shah MD FRCOG FCPS FICS FICOG FICMCH DGO DFP
Chowpatty Medical Center Chairman: Gynaecworld
Mumbai, Maharashtra, India Professor and Consultant Obstetrician and Gynecologist
Breach Candy Hospital and Research Center
Behram S Anklesaria MD DGO DFP ATMF (USA) Jaslok Hospital and Research Center
Honorary Professor of Obstetrics and Gynecology Sir Hurkisondas Nurrotumdas Hospital and Research
LG Hospital NHL Medical College and Center, Mumbai, Maharashtra, India
KM School of Postgraduate Medicine
Ahmedabad Feroze R Soonawala MD
Gujarat, India Consultant Obstetrician and Gynecologist
Mumbai, Maharashtra, India
B Shakuntala Baliga MD (AIIMS) FICOG
Professor of Obstetrics and Gynecology Firuza R Parikh MD DNBE FCPS DGO
Lady Hardinge Medical College Director, Department of Assisted Reproduction
New Delhi, India and Genetics
Jaslok Hospital and Research Center
Chabra S Mumbai, Maharashtra, India
Director and Professor Visiting Associate Professor of Obstetrics
Obstetrics and Gynecology and Gynecology
MGIMS, Sevagram Yale University School of Medicine
Wardha, Maharashtra, India New Haven, USA
 Contributors vii
Gautam N Allahbadia MD DNBE FCPS DGO Hrishikesh Pai MD FCPS MS Clinical Embryology (USA)
Honorary Assistant Obstetrician and Gynecologist Consultant Gynecologist- Babies an US
Bombay Hospital Institute of Medical Sciences IVF Centers, Mumbai
Mumbai, Maharashtra, India Consultant Gynecologist
Fortis La Femme Hospital
Geetha Balsarkar MD FCPS DGO DNB Delhi, Chandigarh, India
Associate Professor
Nowrosjee Wadia Maternity Hospital and Indrani Lodh MS
Seth GS Medical College, Parel Senior Consultant Gynecologist and Laparoscopic
Mumbai, Maharashtra, India Surgeon
Apollo Gleneagles Hospital
Gita Arjun FACOG Kolkata, West Bengal, India
Chennai, India
Indrani Suresh MD
Harshad Parasnis MD DNB FCPS DGO FICOG Associate Director
Consultant Gynecologic Oncologist Mediscan Systems
Hon. Associate Professor Diagnostic Ultrasound and Research Center
Bharati Vidyapeeths Medical College Chennai, TN, India
Pune
Chairman, Oncology and Trophoblastic Tumours Ishita Pateria BA (Psy)
Committee, FOGSI Research Coordinator
Vice President Department of Psychiatry Research
Pune Obstetrics and Gynecology Society, India Jaslok Hospital and Research Center

Hema Purandare MBBS MS MSCG (USA) Jaideep Malhotra MD FICMCH FICOG

Consultant Geneticist Consultant Obstetrician and Gyecologist
Birth Defects Center Center for woman Care and Research
Mumbai, Maharashtra, India Agra, UP, India

Hetal H Parekh MD DNB Jasmine Lopez MD (BOM) DGO

Associate Consultant Dean, Padmashri Dr DY Patil Education
Center for Human Reproduction Enterprises Pvt Ltd, Mumbai
Dr LH Hiranandani Hospital, Powai Ex. Associate Professor and Unit Incharge
Mumbai, Maharashtra, India Grant Medical College and
JJ Group of Hospitals
Himangi Sudhakar Warke Mumbai, Maharashtra, India
Lecturer, Department of Obstetrics and Gynecology
Seth GS Medical College, KEM Hospital Jaydeep D Tank MD DNBE FCPS DGO
Parel, Mumbai, Maharashtra, India Asstt Honorary Consultant (Obstetrics and Gynecology)
KJ Somaiya Medical College and Research Center
Hiralal Konar MBBS (Cal), MD (PGI), DNB MNAMS FACS Mumbai
FRCOG (London) Consultant
Department of Obstetrics and Gynecology Ashwini Maternity and Surgical Hospital
NRS Medical College and Hospital Center for Endoscopy and IVF
Vice President, FOGSI, 2008 Mumbai, Maharashtra, India
Kolkata, West Bengal, India
JB Sharma MD FRCOG
Hosamani P Associate Professor
Clinical Research Co-ordinator Department of Obstetrics and Gynecology
Divakars Speciality Hospital All India Institute of Medical Sciences
JP Nagar II Phase 9/22 AIIMS
Bengaluru, Karnataka, India New Delhi, India
viii Pregnancy at Risk

Jesse M Levi MD FCPS DGO DFP Kuldeep Singh MBBS FAUI FICMCH
Consultant Obstetrician and Gynecologist Consultant Ultrasonologist
Mumbai, Maharashtra, India Special interest in Obstetric Sonology in detailed Fetal
Anomaly
Joshita Singh DNB DMRD Scanning and Color Doppler for management and
Breach Candy Hospital Gynecological Scanning
Mumbai, Maharashtra, India Dr Kuldeeps Ultrasound and Color Doppler Clinic
266, Prakash Mohalla
Joydev Mukherjee MD East of Kailash
Formerly, Head, Department of Obstetrics New Delhi, India
and Gynecology, RG Kar Medical College
Kolkata, West Bengal, India Kumud M Ingle
Ex-Dean
Kaizad R Damania MD DNBE FCPS DGO DFP Nowrosjee Wadia Maternity Hospital
Professor of Obstetrics and Gynecology Mumbai, Maharashtra, India
Seth GS Medical College and Nowrosjee Wadia
Maternity Hospital Kurush P Paghdiwalla MD DNBE
Mumbai, Maharashtra, India Honorary Assistant Obstetrician and Gynecologist
Parsee General Hospital and Masina Hospital
Kaushal Kadam MD Mumbai, Maharashtra, India
Rotunda-CHR, Bandra
Mumbai, Maharashtra, India Madhavi Panpalia
Clinical Assistant
Kedar N Ganla MD DNBE FCPS DGO DFP Department of Assisted Reproduction and Genetics
Consultant (Infertility), Hiranandani Hospital Jaslok Hospital and Research Center
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Ketan S Parikh Mahendra N Parikh MD DGO DA FICOG

Consultant Anesthetist Professor Emeritus
Mumbai, Maharashtra, India Obstetrics and Gynecology
Seth GS Medical College and Nowrosjee Wadia
KP Sanghavi Maternity Hospital
Neonatologist Mumbai, Maharashtra, India
Jaslok Hospital and Research Center
Prince Aly Khan Hospital Mahesh Balsekar MD DCH
Saifee Hospital, Mumbai Consultant Pediatrician
Maharashtra, India Breach Candy Hospital
Sir Hurkisondas Hospital
K Coyaji MD Mumbai, Maharashtra, India
Director and Head
Department of Obstetrics and Gynecology Mala Arora FRCOG (UK), FICOG, FICMCH, DA (UK),
KEM Hospital Pune/Honorary Professor DObst (IRE)
Department of Obstetrics and Gynecology Chairperson FOGSI Quiz Committee
BJ Medical College President Faridabad Obstetrics and
Pune, Maharashtra, India Gynecological Society
Director Noble Hospital
Krishnakumar S MD DGO Sector-14, Faridabad, Haryana, India
Consultant, Gynecologist and Obstetrician
IVF Specialist Mandakini Megh MD
Wockhardt Hospital Professor of Obstetrics and Gynecology
Kumars Maternity and Surgical Nursing Home, Grant Medical College
Dombivli (E) Medical Superintendent
Nirmiti Fertility and IVF Center, Thane (W) Cama and Albless Hospital
Mumbai, Maharashtra, India Mumbai, Maharashtra, India
 Contributors ix
Mangala Ketkar MBBS DGO Mumtaz Sharif MD DNB
Obstetrics and Gynecologist Assistant Professor
Ketkar Hospital, Nagpur, Maharashtra, India DY Patil Medical College
Neural, Navi Mumbai
Manju Puri Maharashtra, India
Professor, Department of Obstetrics and Gynecology
Lady Hardinge Medical College and Smt SK Hospital Nadeem Rais MD
New Delhi, India Consultant Endocrinologist
Breach Candy Hospital
Manorama Purwar MD DGO MS (USA) Mumbai, Maharashtra, India
Project coordinator and Liaison officer
WHO PLGF TRIAL OBGY Nalini S Shah
GMCH Nagpur, Maharashtra, India Professor and Head
Department of Endocrinology
Mansi Parikh MS (OBGY) DNB Seth GS Medical College and KEM Hospital
Consultant Obstetrician and Gynecologist Mumbai, Maharashtra, India
Dr. Medhekars Clinic
Mahim, Mumbai, Maharashtra, India Narendra Malhotra MD FRSH
Consultant Obstetrician and Gynecologist
Meena S Bhattacharya MS Center for Women Care and Research
Ex-Professor and Head Agra
Department of Obstetrics and Gynecology UP, India
Seth GS Medical College and Nowrosjee Wadia
Maternity Hospital, Mumbai, Maharashtra, India Narhari Malegaonkar MD DGO
Clinical Fellow ReGenesis
Milind R Shah MD DGO DFP Reliance Life Sciences
2nd Vice President Elect FOGSI 2001 Mumbai, Maharashtra, India
Past Chairman-Rural Obstetrics Committee of FOGSI-
2004-2008 Nayna A Dastur MD FICOG DGO DFP
Prof. and HOD, Department of OBGY, Gandhi Natha Former Professor, Obstetrics and Gynecologist
Medical College, Solapur Seth GS Medical College
Naval Nursing Home, 199, South Kasba Honorary Consultant, Obstetrician and Gynecologist
Solapur, Maharashtra, India Nowrosjee Wadia Maternity Hospital
Consultant, Sir HN Hospital
Mirudhubashini Govindarajan FRCSC Breach Candy Hospital
Honorary Professor of Obstetrics and Gynecology Mumbai, Maharashtra, India
Institute of Medical Sciences and Research
Coimbatore, TN, India Neetha N Pujari MD MRCOG
Lecturer
MJ Jassawalla MD FCPS DGO DFP Department of Obstetrics and Gynecology
Honorary Assistant Professor of Obstetrics and Seth GS Medical College and KEM Hospital
Gynecology Mumbai, Maharashtra, India
Seth GS Medical College and
Nowrosjee Wadia Maternity Hospital, Mumbai Nisha Sana Ahmad
Honorary Obstetrician and Gynecologist Chief of Lab Services
Parsee General Hospital and Masina Hospital Metropolis Health Services
Mumbai, Maharashtra, India
Nitin Narvekar
MS Nanawati MD MNAMS FCPS DGO DFP Hon. Associate Obstetrician and Gynecologist
Honorary Associate Professor of Obstetrics and Nowrosjee Wadia Maternity Hospital
Gynecology Hon. Associate Professor of Obstetrics and Gynecology
Seth GS Medical College and Seth GS Medical College
Nowrosjee Wadia Maternity Hospital Hon. Endoscopic Surgeon Bhatia General Hospital and
Mumbai, Maharashtra, India Jagjivan Ram Hospital
x Pregnancy at Risk

NK Hase Pradnya Parulekar MD DGO

Professor and Head Department of Nephrology Consulting Obstetrician and Gynecologist
Seth GS Medical College and KEM Hospital Bhatia Hospital and Raheja Fortis Hospital
Parel, Mumbai, Maharashtra, India
Prakash Pispati MD FRSM (London)
Nozer Sheriar MD DNBE FCPS DGO Senior Consultant Rheumatologist Jaslok
Consultant Obstetrician and Gynecologist (Head of the Department) and Saifee Hospitals
Breach Candy, Holy Family, Masina and Parsee Mumbai, Maharashtra, India
General Hospitals Master and Honorary Member- Asia Pacific League of
Gynecological Endoscopist Associations for Rheumatology (APLAR)
Bhatia and BARC Hospitals Past President- APLAR and Indian Rheumatology
Deputy Secretary General: FOGSI Association
Mumbai, Maharashtra, India
Prakash Trivedi
Pakhee Aggarwal MD Prof and Head of Department Rajawadi Hospital and
Senior Resident DY Patil Medical College, Mumbai
Department of Obstetrics and Gynecology Director: NILES and Aakar IVF ICSI Center
All India Institute of Medical Sciences Dr Trivedis Total Health Care Centre, Mumbai
New Delhi, India Chief Gynaec Endoscopist: Jaslok and BARC Hospital
Mumbai, Maharashtra, India
Paresh P Choksi MD
Lecturer of Obstetrics and Gynecology Pranay Shah MD DGO
KJ Somaiya Medical College and Research Center Consultant Obstetrician and Gynecologist
Mumbai, Maharashtra, India Mumbai
Maharashtra, India
Parikshit D Tank MD DNBE FCPS DGO DFP MNAMS
MICOG MRCOG Pratap Kumar MD DGO FICS FICOG FICMCH
Honorary Clinical Associate Professor of Obstetrics and Gynecology
Nowrosjee Wadia Maternity Hospital Kasturba Hospital
Parel, Mumbai Manipal, Karnataka, India
Consultant
Ashwini Maternity and Surgical Hospital, Center for Pratima Anjaria MD DGO
Endoscopy and IVF, Mumbai, Maharashtra, India Consultant Obstetrician and Gynecologist
Mumbai, Maharashtra, India
Partha Guha Roy MD DGO
Senior consultant Pravin N Mhatre MD FCPS DGO DFP
Fertility Clinic and IVF Center Honorary Associate Professor of Obstetrics
Mumbai, Maharashtra, India and Gynecology
Seth GS Medical College and Nowrosjee Wadia
Piclu Choudhury MD Maternity Hospital
Assistant Professor, Chittaranjan Seva Sadan Mumbai, Maharashtra, India
Kolkata, West Bengal, India
Prerna Gupta MD DNB
Piyush Jain DM Neonatology Senior Resident
Consultant Neonatologist Department of Obstetrics and Gynecology
Department of Neonatology All India Institute of Medical Sciences
Fortis Hiranandani Hospital New Delhi, India
Navi Mumbai, Maharashtra, India
Purnima Satoskar MD DNBE MRCOG
PK Shah MD FCPS DGO DFP Professor of Obstetrics and Gynecology
Professor of Obstetrics and Gynecology Seth GS Medical College and KEM Hospital
Seth GS Medical College and KEM Hospital Mumbai
Mumbai, Maharashtra, India Maharashtra, India

Rachita Nanda MBBS MD
Assistant Professor
Department of Clinical Biochemistry
SCB Medical College
Cuttack, Orissa, India
Rajen Y Daftary MD DA
Consultant Anesthesiologist, Breach Candy Hospital
Masina Hospital
Mumbai, Maharashtra, India
Rajesh M Parikh MD DNBE DPM FICP
Consultant Psychiatrist and Neuropsychiatrist
Jaslok Hospital and Research Center
Mumbai, Maharashtra, India
Rajesh V Darade DNB MD FCPS FICMCH FICS (USA),
DGO DFP DGOcps (Mum) MNAMS MICOG (Ind)
Associate Professor Department of Obstetrics and
Gynecology
Government Medical College
Latur, Maharashtra, India
Rakhi Sahu
Lecturer, Department of Obstetrics and Gynecology
Seth GS Medical College, N Wadia Hospital
Mumbai, Maharashtra, India
Rama Vaidya MD DGO DFP PhD
Consultant Reproductive Endocrinologist
SPA Research Center
Mumbai, Maharashtra, India
Ramesha KN
Kerala Registry of Epilepsy and Pregnancy
Department of Neurology
Sree Chitra Tirunal Institute
Thiruvananthapuram
Kerala and Indian Epilepsy Society
New Delhi, India
Rana J Khan FCPS DGO DFP
Clinical Assistant
PD Hinduja Hospital and Research Center, Mahim
Mumbai, Maharashtra, India
Rashid Merchant MD
Consulting Neonatologist, Nanavati Hospital
Mumbai, Maharashtra, India
Reena J Wani MD MRCOG FICOG DNBE DFP DGO
Associate Professor, I/C Family Welfare Program
TNMC and BYLNair Ch. Hospital
Mumbai, Maharashtra, India
Contributors xi
Reva Tripathi MD
Professor of Obstetrics and Gynecology
MAM College, Delhi, India
Rishma Dhillon Pai MD DNB DGO FICOG
Consultant Gynecologist
Jaslok and Lilavati Hospitals, Mumbai
Medical Director- Every woman Cliniqs
Mumbai, Maharashtra, India
Ritu Joshi
Head of the Department, Gynecology and Obstetrics
Monilek Hospital and Research Center, Jaipur
Chair-person Family Welfare Com. FOGSI (09-12)
Rohit V Bhatt MD DCH FAMS FICOG
Chief Department of Obstetrics and Gynecology
Bhailal Amin General Hospital
Vadodara, Gujarat, India
Ruchita Sarda DNB DGO
Obstetrician and Gynecologist
Planet Women Hospital
Ahmedabad
Gujarat, India
Rupinder Kaur Ruprai
Ass. Professor
Department of Obstetrics and Gynecology
Kasturba Hospital
Manipal, Karnataka, India
Rustom P Soonawala MD FRCS
Emeritus Professor of Obstetrics and Gynecology
Seth GS Medical College and Nowrosjee Wadia
Maternity Hospital, Mumbai
Consultant Obstetrician and Gynecologist
Breach Candy Hospital
Mumbai, Maharashtra, India
Sadhana Desai MD FRCOG DGO
Professor and Head
Department of Obstetrics and Gynecology
Bombay Hospital Institute of Medical Sciences
Mumbai, Maharashtra, India
Sakshi Tomar
Agra, UP, India
Samir R Shah MD DM (Gastro)
FCPS Consultant Gastroenterologist
Jaslok Hospital and Research Center
Breach Candy Hospital
Mumbai, Maharashtra, India
xii
Samir S Shah
Consultant hematologist
Kokilaben Dhirubhai Hospital
Sanjay Rao MD DNBE MRCOG FCPS DGO
Consultant Obstetrician and Gynecologist
Sanjeev V Thomas
Department of Neurology
Sree Chitra Tirunal Institute for Medical Sciences
and Technology, Thiruvananthapuram, Kerala, India
Saradha Jaganathan MD DNB FNB
Consultant in Obstetrics
Gynecology and Feto-Maternal Medicine
Womens Center, Coimbatore
Tamil Nadu, India
Sarita Bhalerao MD DGO FCPS DNB DFP MRCOG
Obstetrician and Gynecologist
Bhatia, Saifee, Wadia Maternity Hospitals
Mumbai
Chairperson FOGSI Quiz Committee 2009 2010
Seeru Agarwal MBBS DGO
Obstetrician and Gynecologist
Mumbai, Maharashtra, India
Shailesh Kore MD DNB MNAMS FCPS DGO DFP DICOG
MICOG
Associate Professor and Unit Head
LTM Medical College
Sion, Mumbai, Maharashtra, India
Shakun Tyagi
Assistant Professor, Department of Gynecology
LN Hospital, New Delhi, India
Shalini Fusey MBBS MD DGO
Associate Professor
Department of Obstetrics and Gynecology
Government Medical College and Hospital
Nagpur, Maharashtra, India
Shamsah Sonawalla
Consultant, Jaslok Hospital
Mumbai, Maharashtra, India
Sharad Gogate MD FCPS DGO DFP FICS
Consultant Obstetrician and Gynecologist
Mumbai, Maharashtra, India
Pregnancy at Risk
Sharda Patra
Assistant Professor
Department of Obstetrics and Gynecology
Lady Hardinge Medical College and Smt SK Hospital
New Delhi, India
Shefali Pandey
Global hospital and Research Center
Andheri (W), Mumbai
Maharashtra, India
Shyam Vijay Desai MD DGO DFP FCPS MNAMS
Honorary Associate Professor of Obstetrics and
Gynecology
Grant Medical College and Nowrosjee Wadia Maternity
Hospital, Parel, Mumbai
Maharashtra, India
Smriti Agarwal MD (Obs/Gyn), DNB
Senior Research Associate
Department of Obstetric and Gynecology
CSM Medical University (KGMC)
Lucknow, UP, India
Subhas Nargolkar MD DGO FICOG FICMCH
Consultant Obstetrician and Gynecologist
Pune, Maharashtra, India
Suchitra N Pandit MD DNBE FRCOG FICOG MNAMS
Consultant Kokilaben Dhirubhai Ambani Hospital
Suhas Otiv
Associate Consultant Obstetrician and Gynecologist
KEM Hospital, Pune
Maharashtra, India
Sukhpreet Patel MD DNB FCPS DGO PGDMLS
Program Director, Gynaecworld Assisted Fertility Unit
Consultant Obstetrician and Gynecologist
Gynaecworld
Sukirti Jain MBBS DNB (Obstetrics and Gynecology)
Assistant Professor
Department of Obstetrics and Gynecology at Terna
Medical College and Mother and Child Hospital
Navi Mumbai, Maharashtra, India
Sulbha Arora
Deccan Fertility Clinic and Keyhole Surgery Center
Shivaji Park, Mumbai
Maharashtra, India
 Contributors xiii
Suneeta Mittal MD FAMS FICOG FRCOG FIMSA FICMCH Tejas C Purandare
Head, Department of Obstetrics and Gynecology and Obstetrician and Gynecologist
Director In-charge Bhatia Hospital, Tardeo
WHO-CCR in Human Reproduction Mumbai, Maharashtra, India
All India Institute of Medical Sciences
New Delhi, India Trupti Nadkarni MD DNB DGO FCPS
Lecturer Nowrosjee Wadia Maternity Hospital
S Suresh MD Mumbai, Maharashtra, India
Director
Mediscan Systems Tushar R Bandgar
Diagnostic Ultrasound and Research Center Associate Professor
Chennai, Tamil Nadu, India Department of Endocrinology
Seth G S Medical College and KEM Hospital
Sushil Shah MD DPB Mumbai, Maharashtra, India
Fellow of Cornell Medical Centre (USA)
Consultant Pathologist Umakanta Nanda MBBS MS FICS FICMCH
Breach Candy Hospital and Research Center, Mumbai Former Professor and Head
Chairman, Metropolis Health Services Department of Obstetrics and Gynecology
Medical College of Cuttack
Suvarna S Khadilkar MD DGO FICOG Behrampur and Burla, Orissa, India
Associate Professor and Head of the Unit in Obstetrics
and Gynecology Usha B Saraiya MD DGO FIAC FICS FICOG
Grant Medical College and Cama and Albless Hospital Former Professor of Obstetrics and Gynecoloy
Mumbai Cama and Albless Hospital, Mumbai
Secretary, Mumbai Chapter, Indian Menopause Society President FOGSI 2002
Assistant Secretary, Editorial Board Chairman ICOG 2006-9
Journal of Obstetrics and Gynecology of India, FOGSI
Chairperson Menopause Committee, MOGS Usha Krishna MD DGO FICS FICOG
Joint Secretary AMWI, Mumbai Past president, FOGSI, MOGS
Maharashtra, India Ex-Hon. Prof. KEM Hospital and GS Medical College
Consultant, Obstetrician and Gynecologist
SV Kotwaliwale MS FAIMS Bhatia General Hospital
Consultant Geneticist Director, Clinic for Women
Genetic Diagnostic Center Laburnum Road, Gamdevi
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Swati G Allahbadia MD DGO Vanaj Mathur

NWMH, Parel, Mumbai Consultant
Asian Heart Research Institute, BKC Agra, UP, India
Bandra (E), Mumbai
Rotunda Nursing Home, Wadala Vandana Bansal MD DGO DNB MRCOG FNB
Mumbai, Maharashtra, India (High Risk Pregnancy and Perinatology)
Lecturer, Obstetrics and Gynecology
Swati R Daftary MD DA Seth GS Medical College and
Consultant Anaesthesiologist Nowrosjee Wadia Maternity Hospital
Jaslok Hospital, Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Tambe P MD Vandana R Walvekar

Consultant, Gynecologist and Obstetrician
IVF Specialist
Nirmiti Fertility and IVF Center, Thane (W)
Kumars Maternity and Surgical Nursing Home,
Dombivli (E)
Mumbai, Maharashtra, India
Former Dean Nowrosjee Wadia Maternity Hospital
Professor, Seth GS Medical College, Parel
Mumbai
Honorary Consultant, Bhatia Hospital
Tardeo
Mumbai, Maharashtra, India
xiv Pregnancy at Risk

Vanita S Raut MD DGO Vinod Saxena MD

Consultant Obstetrician and Gynecologist Medical Advisor
Hiranandani Hospital Reckitt and Colman of India Ltd
Ex Professor of Obstetrics and Gynecology New Delhi, India
Seth GS Medical College and KEM Hospital
Mumbai, Maharashtra, India VN Purandare MD FRCS (EDIN) FICOG
Professor Emeritus Obstetrics and Gynecology
Vasanthi Jayaraj MD Seth G S Medical College and KEM Hospital
Consultant Mother Hospital Mumbai
Thrissur 12, Kerala, India Editor Emeritus Journal of Obstetrics and
Gynecology of India
Veerbala N Parikh MD FICOG
Consultant Obstetrician and Gynecologist VP Paily MD FRCOG
NM Wadia Charitable Hospital, Solapur Professor of Obstetrics and Gynecology
Maharashtra, India Jubilee Mission Medical College Hospital
Thrissur, Kerala
Vihang N Vahia MD DPM MAPA Consultant Mother Hospital
Consultant Psychiatrist Breach Candy Thrissur 12, Kerala
Lilavati and Hurkisondas Hospitals, Mumbai
Formerly Professor and HOD Psychiatry Yasmin Kazi
Dr RN Cooper Hospital and Seth GS Medical College Consultant Obstetrician and Gynecologist
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Vinita Das YS Nandanwar

Professor and Head of Department of Obstetrics and Professor and Head
Gynecology Department of Obstetrics and Gynecology
King George Medical College (ISO 9001-2000 Certified), LTMMG College
Lucknow, UP, India Sion, Mumbai, Maharashtra, India

Vinita Salvi MD DNBE FCPS DGO DFP

Consultant Obstetrician and Gynecologist
SevenHills Hospital, Mumbai
Ex-Professor of Obstetrics and Gynecology and Officer
in-charge, ICMR Regional Center for Research in
Human Reproduction
Seth GS Medical College and KEM Hospital
Mumbai, Maharashtra, India
 Preface to the Fifth Edition

While pregnancies and child birth are natural events, they often require medical interaction and intervention. It would
be fair to say that every pregnancy has some degree of potential risk. To paraphrase George Orwell, in clinical practice
some pregnancies are more at risk than others. This book is about these Pregnancies at Risk, where medical understanding,
vigilance and care is the difference between safety and catastrophe.
Pregnancy at Risk Current Concepts was first published in 1993 as a companion volume to a landmark conference
of the same name organized by FOGSI. The volume had a series of upgrades over the years that also expanded its
scope and coverage of topics. That it is in its fifth edition, stands testimony to its continued relevance and popularity
for practitioners and students of obstetrics. It aims to cover a focused clinical areahigh-risk pregnancyby
amalgamating evidence and practices, giving the benefits of a monogram and handbook rolled into one.
This fifth edition of Pregnancy at Risk A Practical Approach to High Risk Pregnancy and Delivery is published to keep
our readers, practicing colleagues and postgraduate students alike updated with the most recent developments in what
is now differentiated and defined as perinatology. Its purpose is to provide and ensure pregnant women under our
care the very best of available treatment. The scope of the book continues to extend beyond routine obstetrics. It continues
this by a coverage of various subjects such as genetics, infections, and medical complications as also problems and
risks related to labor and delivery. It does this with a special emphasis on understanding their most recent clinical
concepts and technological advances that are applicable for diagnosis and management.
In spite of the rapid technological progress in recent years, the role of interpersonal interaction and clinical acumen
remains central to patient care. The importance of an insightful history, thorough examination and proper counseling
with genuine involvement of patients and their families is even more essential as we deal with high-risk pregnancy
and delivery. Technology is no substitute for a caring, empathetic and conscientious physician. Interaction starts early
with preconception counseling, continues with vigilant antepartum care and carries forward to appropriate and judicious
intrapartum management of normal and abnormal labor. A team approach with selected professional colleagues is
an asset in providing multidimensional care and is essential to manage potential medical and surgical complications.
The team could include physicians and intensivists, surgeons and anesthetists, neonatologists and perinatologists,
endocrinologists and immunologists, pathologists and sonologists, psychiatrists and counselors as required. Their
experience and inputs help to give the best well-rounded professional care in Pregnancies at Risk.
We owe this publication to and are most grateful to each of our handpicked contributors who have put in unstinted
effort to contribute chapters, appropriately referenced and embellished with personal experiences. This is a multiauthored
book and the views expressed herein are those of the authors. We acknowledge the support and commitment of our
publishers over the years for making this, one of their first publications for FOGSI so successful. We would also like
to acknowledge the support of our families for allowing us to take time away from them to give to this academic endeavor.
For us, editing this volume has been a labor of love. It is our tribute to the brave women who put themselves at
risk as they give birth to the next generation. To them, we dedicate this book.

Usha Krishna
Duru Shah
Vinita Salvi
Nozer Sheriar
Kaizad R Damania
 Preface to the First Edition

Pregnancy and childbearing are attended by certain risks to the mother as well as the fetus. The aim is to improve
our management of the high risk situations and optimize the outcome of pregnancy. This book covers various factors
which put the fetus at risk and presents the current concepts in evaluation, monitoring and management of various
medical disorders in pregnancy, perinatal infections, placental insufficiency and the immunological, endocrine and
anatomical disorders.
Fetomaternal medicine is under constant discussion, experimentation and evaluation. There is a revolution in the
care of the fetus and the newborn. New options are being developed in gene control, drug therapy and immunotherapy.
The womb is no longer considered an isolated dark chamber. The fetus is accessible today with increasing clarity with
sophisticated monitoring tools such as ultrasonography, magnetic resonance imaging, chorion villus sampling, amniotic
fluid studies, Doppler blood flow studies, etc. The concept of the fetus as The unborn patient has elevated the
importance of prenatal diagnosis and treatment.
There are many ethical considerations in the practice of fetomaternal medicine. Our objective is to avoid preventable
death, disease or disability in children. However, we have to remember that the benefit to the mother will remain our
primary obligation. It is only with the agreement of the pregnant woman that the physician should make the decisions.
We must also remember that diagnostic machines cannot substitute a good physician. A pregnant patient is in
a sensitive phase of her life, therefore, an excellent rapport and an empathetic attitude are most essential. Counseling
is an important aspect of management of a high risk pregnancy. It is not only the investigations and assessment but
the compliance and cooperation of the patient which are necessary for good results.
In most of the high risk pregnancies, good antenatal care and close monitoring of the factors arising during labor
and just after, give rewarding results. In the better equipped centers with sophisticated monitoring tools, the
cardiovascular statusboth structural and functional can be assessed. Biomarkers for assessing fetal and maternal
therapy can be studied.
Low dose aspirin for prophylaxis in pre-eclampsia and intrauterine growth retardation, glucocorticoid therapy for
fetal lung maturation, maternal immunization to prevent fetal and neonatal infection and pharmacologic therapy for
fetal arrhythmias are now well established. However, we still have limitations to fetal therapy specially in the area
of fetal surgery. The greatest success of fetal therapy is in the area of rhesus immunization.
Rapid progress in the understanding of the etiopathology, neonatal management and prophylaxis in high risk
pregnancy is due to the teamwork of hematologists, sonologists as well as obstetricians and pediatricians. Success
in fetomaternal medicine can be achieved only by the collaborative efforts of physicians, microbiologists, biochemists
as well as the experts in imaging science and laboratory medicine.
In spite of the technical developments there has been some disillusionment with the results of their clinical
application. Proper interpretation with clinical correlation and consideration of many factors are necessary for decision
making. We must therefore consider each case carefully and individually before undertaking any aggressive management
or invasive procedure.
We are conscious that in a developing country like ours, the majority of the deliveries are conducted by traditional
birth attendants. The Safe Motherhood programs therefore envisage training and equipping these traditional birth
attendants, so that they become able to identify high risk pregnancies and refer them in time to the appropriate hospitals.
We are most grateful to all the contributors for sparing their valuable time to write these chapters. This is
multiauthored book and the views expressed herein are those of the authors. We have tried to select the chapters and
contributors to offer the reader a comprehensive view of the growing experience in investigations and management.
xviii Pregnancy at Risk

We specially thank the co-editors, Duru Shah, Nozer Sheriar, Vinita Salvi and Kaizad R Damania who have spared
no pains to help us with all the aspects of publication of this book. It is the cooperation and goodwill of all our colleagues
and some silent workers which has made it possible to compile this book. We hope this book will stimulate the interest
of the readers in minimizing every possible risk in pregnancy and childbirth. We also hope that the book is constantly
updated as current concepts will always keep changing.

Usha Krishna
Shirish Daftary
 Contents

SECTION ONE: EARLY PREGNANCY AT RISK

1. Physiology of the Luteal Phase ................................................................................................................................... 3
Shakun Tyagi, Reva Tripathi
2. Cytogenetics of Early Pregnancy Wastage ................................................................................................................ 8
SV Kotwaliwale, Mangala Ketkar
3. Early Pregnancy Wastage in Assisted Reproduction ........................................................................................... 14
Kedar N Ganla, Hetal H Parekh
4. Pregnancies after Embryo Reduction ...................................................................................................................... 21
Nitin Narvekar, Ajanta Narvekar
5. Current Status of Surgical and Nonsurgical Management of Ectopic Pregnancy ......................................... 26
Gautam N Allahbadia, Kaushal Kadam, Sulbha Arora, Swati G Allahbadia
6. Ovarian Hyperstimulation Syndrome in Pregnancy ............................................................................................ 34
Rishma Dhillon Pai, Hrishikesh Pai

SECTION TWO: RECURRENT PREGNANCY LOSS

7. Management of Congenital Uterine Abnormalities ............................................................................................. 41
Nozer Sheriar
8. Acquired Uterine Abnormalities Leading to Pregnancy Risk ............................................................................ 49
Krishnakumar S, Tambe P
9. The Incompetent Cervix ............................................................................................................................................. 59
VN Purandare, Ameya C Purandare
10. Antiphospholipid Syndrome ...................................................................................................................................... 68
Mala Arora
11. Immunotherapy for Recurrent Abortion ................................................................................................................. 77
Pranay Shah

SECTION THREE: INFECTIONS IN PREGNANCY

12. Toxoplasmosis in Pregnancy ..................................................................................................................................... 85
Anita Soni, Seeru Agarwal
13. Rubella in Pregnancy .................................................................................................................................................. 92
JB Sharma, Prerna Gupta
14. Perinatal Viral Infections ........................................................................................................................................... 96
Shyam Vijay Desai, Jesse M Levi, Pradnya M Parulekar
15. Syphilis ......................................................................................................................................................................... 106
MS Nanavati, Jesse M Levi
16. Mycoplasma and Chlamydia in Pregnancy ......................................................................................................... 109
Alka Gogate, Sharad Gogate
17. AIDS: Its Effects on Pregnancy and the Newborn ............................................................................................ 113
Mandakini Megh
18. Maternal Infections: A Laboratory Review .......................................................................................................... 122
Nisha Sana Ahmad, Sushil Shah
xx Pregnancy at Risk

19. Malaria in Pregnancy ................................................................................................................................................ 127

Manorama Purwar, Shalini Fusey
20. Amebiasis, Giardiasis and Intestinal Helminthic Infections ........................................................................... 138
Umakanta Nanda, Rachita Nanda
21. Hepatitis in Pregnancy .............................................................................................................................................. 146
Samir R Shah
22. Pregnancy and Tuberculosis ................................................................................................................................... 151
Suvarna S Khadilkar, Usha B Saraiya

SECTION FOUR: INVESTIGATIONS IN THE PREGNANCY AT RISK

23. Early Pregnancy Assessment ................................................................................................................................... 163
Pratap Kumar, Rupinder Kaur Ruprai
24. Role of Genetic Investigations and Counseling .................................................................................................. 172
Hema Purandarey, Amit Chakravarty
25. Transvaginal Obstetric Ultrasound ........................................................................................................................ 183
PK Shah, Neetha N Pujari
26. Color Flow Imaging in Obstetrics: Understanding its Art, Science and Technology ................................. 196
Narendra Malhotra, Jaideep Malhotra, Vanaj Mathur, Kuldeep Singh, Sakshi Tomar
27. Clinical Applications of Color Doppler ................................................................................................................. 208
Adi E Dastur, Nayna A Dastur, Parikshit D Tank
28. Biophysical Methods for Assessing Fetal Well-being ........................................................................................ 212
Kaizad R Damania, Vandana Bansal
29. Intrapartum Monitoring ............................................................................................................................................ 223
Pravin N Mhatre
30. Antenatal Ultrasound Screening for Fetal Malformations ................................................................................ 228
S Suresh, Indrani Suresh
31. Fetal MRI ..................................................................................................................................................................... 232
Anirudh Kohli

SECTION FIVE: ENDOCRINE DISORDERS IN PREGNANCY

32. Pregnancy Complications Associated with PCOS ............................................................................................... 237
Duru Shah, Ruchita Sarda
33. Gestational Diabetes Mellitus ................................................................................................................................. 245
Tushar R Bandgar, Nalini S Shah
34. Thyroid Disorders in Pregnancy ............................................................................................................................. 252
Nadeem Rais, Ashwita Aiyer, Bhavisha Bafna
35. Adrenal Diseases in Pregnancy .............................................................................................................................. 262
Rama Vaidya, Shefali Pandey

SECTION SIX: MEDICAL DISORDERS IN PREGNANCY

36. Anemia in Pregnancy ................................................................................................................................................ 271
Suneeta Mittal, Pakhee Aggarwal
37. Maternal and Fetal Outcome in Heart Disease .................................................................................................. 280
Kurush P Paghdiwalla
38. Management of Seizures during Pregnancy ........................................................................................................ 285
Ramesha KN, Sanjeev V Thomas, Vinod Saxena
 Contents xxi
39. Nutritional Deficiency in Pregnancy ..................................................................................................................... 295
Hiralal Konar, Piclu Choudhury
40. Liver Disease in Pregnancy ..................................................................................................................................... 301
Adarsh Bhargava
41. Pregnancy in Underlying Renal Disease .............................................................................................................. 311
NK Hase
42. Psychiatric Disorders in Pregnancy ....................................................................................................................... 319
Vihang N Vahia, Amit Sudhakar Kulkarni
43. Collagen Vascular Disorders and Pregnancy ...................................................................................................... 324
Prakash Pispati
44. Pregnancy Complicated by Malignancy ................................................................................................................ 330
Saradha Jaganathan, Mirudhubashini Govindarajan
45. Thalassemia and Sickle Cell Disease in Pregnancy ......................................................................................... 338
Samir S Shah

SECTION SEVEN: PLACENTAL INSUFFICIENCY

46. Management of Hypertension in Pregnancy ....................................................................................................... 347
Meena S Bhattacharya, Vanita S Raut, Parikshit D Tank
47. Fetal Growth Restriction ........................................................................................................................................... 354
Suhas Otiv, K Coyaji
48. Prophylaxis for Pregnancy-induced Hypertension and
Intrauterine Growth Restriction with Low-Dose Aspirin .................................................................................. 368
Usha Krishna, Pradnya M Parulekar
49. Postdatism .................................................................................................................................................................... 374
Pratima Anjaria

SECTION EIGHT: DRUGS AND ENVIRONMENT

50. Teratology .................................................................................................................................................................... 381
Shailesh Kore, Mansi Parikh
51. Hazards of Drug Usage in Pregnancy and Lactation ........................................................................................ 392
MJ Jassawalla, Geetha Balsarkar
52. Substance Abuse in Pregnancy .............................................................................................................................. 403
Ritu Joshi
53. Fetal Dysmorphology ................................................................................................................................................. 411
Ajay Mehta
54. Impact of Environment on Reproductive Health ................................................................................................ 426
Rohit V Bhatt

SECTION NINE: FETAL THERAPY

55. Medical Therapy to the Fetus ................................................................................................................................. 437
Rashid Merchant, Mumtaz Sharif
56. Fetal Surgery ............................................................................................................................................................... 444
Chittaranjan N Purandare, Jasmine Lopez
57. Prenatal Interventional Procedures ........................................................................................................................ 460
S Suresh, Indrani Suresh
58. Obstetric Decisions for Fetal Malformations ....................................................................................................... 476
B Shakuntala Baliga
xxii Pregnancy at Risk

SECTION TEN: OBSTETRIC COMPLICATIONS

59. Pregnancies at Extremes of Reproductive Age ................................................................................................... 487
Reena J Wani, Chinmayee Patra
60. Placenta Previa ........................................................................................................................................................... 493
Anahita Chauhan
61. Pregnancy Following ART ........................................................................................................................................ 501
Sadhana Desai, Partha Guha Roy
62. Abruptio Placentae ..................................................................................................................................................... 505
Geetha Balsarkar, Kumud M Ingle, Ajay Mehta
63. Preterm Premature Rupture of Membranes ........................................................................................................ 512
Manju Puri, Sharda Patra
64. Etiology and Early Diagnosis of Preterm Labor .................................................................................................. 519
Parikshit D Tank
65. Prevention of Preterm Labor ................................................................................................................................... 525
Divakar H, Hosamani P
66. Pregnancy Loss in the Second Half of Gestation ............................................................................................... 535
Himangi Sudhakar Warke
67. Hydramnios ................................................................................................................................................................. 543
Vinita Das, Smriti Agarwal
68. Rh-Isoimmunization .................................................................................................................................................. 549
Vinita Salvi
69. Nonimmune Hydrops Fetalis .................................................................................................................................. 556
Ashwini Bhalerao Gandhi, Bhaskar Pal
70. Pregnancy with Prolapse .......................................................................................................................................... 563
YS Nandanwar
71. Benign Adnexal Masses in Pregnancy ................................................................................................................. 566
Basil T Lyngdoh, Alka Kriplani

SECTION ELEVEN: LABOR AND DELIVERY IN PREGNANCY AT RISK

72. Induction of Labor ..................................................................................................................................................... 573
Suchitra N Pandit, Sanjay Rao, Rana J Khan
73. Labor Analgesia in High-Risk Pregnancy ............................................................................................................ 583
Rustom P Soonawala, Ketan S Parikh, Feroze R Soonawala
74. Intrapartum Fetal Distress ....................................................................................................................................... 591
Jaydeep D Tank
75. Dysfunctional Labor .................................................................................................................................................. 597
Vandana Bansal, Kaizad R Damania
76. Contemporary Instrumental Delivery .................................................................................................................... 608
Subhash Nargolkar, Nozer Sheriar
77. Breech Presentation ................................................................................................................................................... 618
VP Paily, Vasanthi Jayaraj
78. Cesarean Section in Present Day Practice .......................................................................................................... 628
Ameet Patki, Narhari Malegaonkar
79. Modern Management of Obstructed Labor ......................................................................................................... 632
Mahendra N Parikh, Veerbala N Parikh, Paresh P Choksi
80. Postpartum Hemorrhage ........................................................................................................................................... 641
Sarita Bhalerao, Trupti Nadkarni
81. Sudden Postpartum Collapse .................................................................................................................................. 646
Purnima Satoskar, Yasmin Kazi
 Contents xxiii
82. Rupture Uterus ........................................................................................................................................................... 655
Behram S Anklesaria, Indrani Lodh
83. Management of Critically Ill Patients in Labor .................................................................................................. 662
Alokendu Chatterjee, Joydev Mukherjee
84. Obstetric Patient in ICU ........................................................................................................................................... 671
Rajen Y Daftary, Swati R Daftary
85. Fluid and Electrolyte Balance in Pregnancy and Labor .................................................................................... 679
Dilip R Karnad

SECTION TWELVE: MULTIPLE PREGNANCIES

86. Embryo Reduction ...................................................................................................................................................... 687
Ambrish Dalal
87. Managing Multiple Pregnancies ............................................................................................................................. 690
Vandana R Walvekar, Geetha Balsarkar, Tejas C Purandare
88. Twin to Twin Transfusion Syndrome ................................................................................................................... 695
Chander Lulla, Abhishek Pachchigar
89. High Order Pregnancy .............................................................................................................................................. 701
Madhavi Panpalia, Firuza R Parikh
90. Rural Obstetrics .......................................................................................................................................................... 709
Milind R Shah, Rajesh V Darade
91. High-Risk Pregnancy in Low Resource Settings ................................................................................................. 718
Chabra S, Chopra S

SECTION THIRTEEN: MISCELLANEOUS

92. Preconceptional Counseling and Antenatal Care ............................................................................................... 727
Gita Arjun
93. High-Risk Neonate ..................................................................................................................................................... 734
Mahesh Balsekar
94. Gestational Trophoblastic Disease ......................................................................................................................... 741
Harshad Parasnis
95. The Role of Stress in First Trimester Miscarriage ............................................................................................. 751
Ishita Pateria, Rajesh M Parikh, Shamsah Sonawalla, Firuza R Parikh
96. Surrogacy ...................................................................................................................................................................... 754
Sukhpreet Patel, Duru Shah
97. Perinatal Asphyxia and Hypoxic-ischemic Encephalopathy ............................................................................ 757
KP Sanghvi
98. Neurologic Outcome and Fetal Well-Being .......................................................................................................... 765
Sukirti Jain, Vinita Salvi, Piyush Jain
99. Management of Autoimmune Thrombocytopenic Purpura in Pregnancy .................................................... 771
Avan Dadina
100. Fetal MonitoringRevisited ..................................................................................................................................... 778
Pravin N Mhatre, Rakhi Sahu
101. Laparoscopy in Pregnancy ....................................................................................................................................... 790
Prakash Trivedi

Index .............................................................................................................................................................................. 799