3

(ANC ) 4
(LR ) 5
(WCC ) 5
6
(MMR) 12
23
27
30
36
41
49
58
CPD 62
63
68
81

87
90
101
107
112
122
133
138
: 141
148
156
166
169
173
178

1

 186
188
193
200
211
214
218
220
224
227
/ 230
233
/ 236
/ 237

Guideline for Injury Prevention in Well Child Care 238
251

2


..











()

3

 (ANC )
1.
-
-
- 1 : 20
2.
2.1

2.2 ANC
- Multiple dipstick -
- 20 -
2.3 3 (5) ( 2557)
2.4
2.5

2.6 /
(Hct, CBC) , VDRL , / Albumin / Sugar /HBsAg, , blood gr Rh
2.7
- - Folic acid - -
2.8 (dT)
2.9 /
2.10 1
2.11
2.12 -
2.13
2.12
2.12.1 1
2.12.2
3.
3.1 ()
3.1.1 /
3.1.2 /
3.1.3 Multiple dipstick
3.2
3.2.1
3.2.2 /
3.2.3 /
3.2.4 30
3.3
4.
4.1.
5 Early ANC/Anemia //HIV/ DFIU
4.2. (CQI)
MCH Board Early ANC / ANC 5 /
Anemia/ /HIV/ DFIU
4

 (LR )
1.
2.
3.
4.
5.
6.
7.
8. 1 : 3
9.
30 1
10.
11. /
12.
13.

(WCC )
5 10

1.
2. .
3. TSH, Thai.,,
4.
5.

6.
7.
8.
9. 30
10. .
11.
12.
13. 1:10-15

5


Clinical Practice Guideline in Teenage Pregnancy

10-19
adolescents 15-19 younger
adolescents

10-14

Clinical Practice Guideline in Teenage Pregnancy
14 12.8 90%

1.

15-19

65

1,000 2010
15-19
2.
34.3

1,000


3.

10 ..2544 40
..2552 15-19 15-19 1,000 2553
56.1: 1000
1

-
-
-
-
- 5

-
-
-

- OSCC
-
- Safe abortion
-
-

: :
:

6

 2
** Prenatal Care -

- ANC

-
-
- (
- Ferrous fumarate(200mg) 1x 2 + Micronutriant
- Folic acid 1x1
-

-

- LR
-

- ,, ()

- ()
- ( )
- (Unintended)
- (Intended)
-

- 15 19 15-19
- 15 19
- < 15

< 50 : 15 19 1,000
< 10 ( 15 19 ) (unintended)
< 0.5 (<15 ) (unintended)

1.
()

2.

3.

4.

5.
/

6.
, ,
7. ()

8.

9.
10.

11.
12.
13.
14.

8

 1

- ()
- ( )
- (Unintended)
- (Intended)
-
- 15 19
15-19
- 15 19

- < 15

( Adolescent Birth Rate Age-specific Fertility Rate for women age 15 -19 )

15 19 15 19
50 15-19 1,000
15-19
15-16


1 A = 15-19 ()
2 B = 15-16 (

(A/B ) x 1000

9

 15-19
(Adolescent Fertility Proportion)
15-19
10 (unintended pregnancy)
15-19
15-19


1 A = 15-19 ()
2 B = ()
1 (A/B ) x 100

1)
2)
15
15
0.5 (unintended pregnancy)
15
15


1 A = 15 ()
2 B = ()
1 (A/B) x 100

10

 15 -19
15 -19 2
15 -19
10 (unintended pregnancy)
15 19

15 19


1 A = 15 19
2
2 B = 15 19
1 (A/B) x 100

-
- :

- : - .

11

 (
MMR) MCH board (MMR)




42

<15 : 100,000

(1) ..2547-2549 21.7,18.2,18.1
1000,000
1(2) 2552-2556
31.29, 23.83, 23.18, 12.82 19.80 1000,000 ,
,(preeclampsia and eclampsia)
1
2552 2553 2554 2555 2556
< 15:100,000 31.29 23.43 23.18 12.82 19.80
() (16) (12) (11) (6) (10)

2

1. 18 32.14
2. 4 7.14
3. 6 10.71
4. 1 1.79
5. 8 14.29
6. 4 7.14
7. 13 23.22
8. 2 3.57
56 100

1.

1.1 (
)
1.2

12

1
 2.
2.1 ANC

1.

2. ANC
3. Classifying Form

4. ( One stop service)

/ A S ./.
M1 M2 F1 F2 F3 .

1.


2.

3.
4. *
5. * *
6.
7. * *
8. * *
1
9. *


10.


: *
5.

6. () 24

7. 5
12 2-5 6 (/ 2 )

2 13

 2.2


A S M1 M2
/ F1 F2

1.
2.
3.
4.
5.

6.

7.
8.

9.
1:3
10. 24

11. Guide line

12.
13.

3.
3.1 ...
3.2
7 (3)
1. ,
2.
3.
4.
5.
6.
7.
( )
3.3

14 3

 3.4 CPR , NCPR , ,
3.5 ..
3.6 guide line
3.7


3.8 /
3.9
3.10
1. ,
2.
3. /
3.11 Case
4. (EMS)


5. (4)
5.1
1.

2.
3.
4.
5.2
1. Progress note ,
2. Specimen ,Tracing ,
3. Team authority CPR , Rapid Response Team
4. Autopsy / amniotic fluid embolism
6.
6.1
1.
2. 24
3. 3
* Case refer
6.2
1. -
2. Fetal monitor, monitor V/S
3. RCA
6.3
- ( ) MCH Board
4

15

 -
-
6.4
6.5
/
6.6
. 41
6.7

-

Defibrillator , EKG,
Pulse Oximeter Emergency
box

- /

/

- /.

- Risk report Form
72

//
Risk report Form
- //
24


/

16

 (Postpartum hemorrhage)(6)
(Postpartum hemorrhage : PPH) 500
1,000 (cesarean section) hematocrit 10%
hematocrit
3
1.
2.
3. 1 2 (Intractable postpartum hemorrhage)
1

Resuscitation Assess Etiology Laboratory

- - - CBC
- - - Bed side venous
vital signs - clotting time
- blood loss sponge forceps - (Group and crose
- RLS NSS AP retractors matching) 2 units
18 -
- (uterine inversion)
- oxygen mask
- vital signs -
uterine rupture
tenderness,
- Forley rebound tenderness
catheter (+/-) garding
-

BP drop 30

6 17

 2

Uterine atony Retained placenta or Laceration of Coagulation defect

- piece of placenta genital tract or -
- - uterine inversion
- fresh whole blood
oxytocin 20 units - Hematologist
1,000ml. - -
retained
Methergin 0.2 mg. piece of placenta uterine inversion
(
1015 urine
- bimanual uterine inversion)
compression -
20 30 uterine rupture
-
methergin 2

510
Nalador
500 g. -
1015
6 doses
Misoprostal
(cytotec) 200
1,000 g.
* WHO
Misoprostal (Cytotec)

* Nalador
( )
* Cytotec ..
Nalador M

18

 3 1 2
Intractable postpartum hemorrhage

*** Get Help

-

-
- ICU
- CVP line

Explore Laparotomy

Conservative Hysterectomy
Surgery

Post
Hysterectomy
Repair B lynch Bleeding
Laceration Ligate Vessels
- uterine
arteries
- internal iliac Abdominal Angiographic
areteries Packing Embolization
- ovarian
arteries

* Vg Packing

1. .. 2533-2549,
.. 2547-49. .
2.


. 1 ;2557:11-19

3.
,
,

..: -
; 2555:11-17
4. :;2556:20-22
5. WH, UNFPA, UNICEF, AMDD. Monitoring emergency obstetrics care: a handbook. Geneva: WHO Press;2009:6-9
6. http://healthdata.moph.go.th/kpi/2557/KpiDetail.php?topic_id=18 6 2557
8
19

 3 1 2
Intractable postpartum hemorrhage

Intervention
(Maternal Deaths Averted with
*** Get Help Full Use of Existing Interventions)
-

1. -


(Improved access to safe abortion services)

2.
-

ICU (Improved access to comprehensive
essential obstetric care) - CVP line
3. (Tetanus toxoid immunization)
4. iron deciency
5. (Drugs forLaparotomy
Explore preventing malaria)
6. Active management in third stage of labor
7. Magnesium sulphate pre-eclampsia
8. (Calcium supplements during pregnancy)
Hysterectomy
Conservative
9. bacterial vaginosis (Antibiotics for treating bacterial vaginosis)
Surgery
10. PROM (Antibiotics for preterm rupture of membranes)
Post
Hysterectomy
Repair B lynch Bleeding
Laceration Ligate Vessels
- uterine
arteries
- internal iliac Abdominal Angiographic
areteries Packing Embolization
- ovarian
arteries

* Vg Packing

1. .. 2533-2549,
.. 2547-49. .
2. . 1 ;2557:11-19
3. , , ..: -
; 2555:11-17
4. :;2556:20-22
5. WH, UNFPA, UNICEF, AMDD. Monitoring emergency obstetrics care: a handbook. Geneva: WHO Press;2009:6-9
6. http://healthdata.moph.go.th/kpi/2557/KpiDetail.php?topic_id=18 6 2557
8

20



-



1.

2.

3.
- Active management in the third stage of labour

- oxytocics ergometrine, Cytotec
30

-
-
-
-
-

-
( -
) -

-

- Calcium PIH.
-
- magnesium sulfate
-
-
cephalo pelvic
disproportion - 18
-

- partograph labor curve
-

21


-

-
-
-
- - () folate
-


- -
-
-
- HIV / AIDS -

: , (Reduction of maternal mortality)

22


(Perinatal Mortality Rate)
(Perinatal Mortality Rate)

(Perinatal mortality rate,PMR)

(Stillbirth) 7 1,000 (
1,000 )

(Perinatal Mortality Rate) 1,000 (

28 7 (Still
Birth) 7 (Early Neonatal) Perinatal Death Indicator ANC, LR
New born Care (7 )
2548 -2550 695,394 , 655,069 613,679
4,743 , 4,135 4,136 2548
35.47 15.97
2549 2550
35.58, 41.56 17.04
12.09 1
1 2548 2550

Wiggleworth classification 2

2 Wiggleworth classification

Wiggleworth classication
1. Normally formed - Macerated stillbirth (SB)
2. Congenital malformation - Stillbirth/Neonatal death
3. Conditions associated with immaturity - Neonatal death (NND)
4. Asphyxia developed in labour - Fresh SB/NND
5. Other specific conditions - e.g. Inborn error of
metabolism

23

 Wiggleworth classification 3
3 Wiggleworth classification
Path-physiological causes
1. Normally formed macerated (SB)
2. Congenital malformation(SB/NND)
3. immaturity(NND)
4. Asphyxia developed in labour(SB/NND)
5. Specific conditions
Implications for management
ANC+ background maternal factors
Social background , prenatal diagnosis facilities
Socio-economic background , neonatal
facilities , Obstetric care
Obstetric management
Specific medical care

1.
2.

3.

Summary of priority antepartum, intrapartum, and postnatal interventions for inclusion in programs of maternal and neonatal health care, based
Summary of priority antepartum, intrapartum, and postnatal interventions for inclusion in programs of maternal and neonatal health care,
onassessment of available evidence for impact on perinatal and neonatal health status.
based on assessment of available evidence for impact on perinatal and neonatal health status.

24


1.
2. 20 30 4 2 5

3.
4. Partograph
5.
6.
7.

1. Birth asphyxia
2.

1.
2.
3.


4.
5.

1. , . . : , ,
, . 1 2. 1. : ,2539:59-
86

25


1. (Prior to or During Pregnancy)
1.1 Nutritional Interventions
1.1.1 Cesar et al supplemented pregnant women in The Gambia with 900 additional calo-
ries per day, and reduced: Low birthweight by 35%,Stillbirths by 55%, Perinatal deaths by 49%,Neonatal
deaths by 40%(BMJ 1997 Sept 27;315(7111):786-90)
1.1.2 In Sri Lanka, iron supplementation along with antihelminthic therapy reduced:Low
birthweight by 50%, Perinatal deaths by 45%(Atukorala TM et al AJCN 1995 Aug;60(2):286-92
1.2 Malaria Prophylaxis
1.2.1 In Kili District, Kenya, an area of high malaria transmission, Shulman et al presump-
tively treated pregnant women with Fansidar which reduced: Perinatal deaths by 22%,Neonatal deaths by
38%(Shulman CE et al, Lancet 1999 Feb 20; 353(9153):632-6)
1.3 Maternal Immunization (Black RE et al Bull WHO 1980 58:927-930 & Shahid et al, Lancet
1995;346(8985):1252-7)
1.3.1 Maternal immunization with tetanus toxoid reduced neonatal mortality (from days 4
to 14) from 30/1000 to 10/1000, and reduced deaths for three years after vaccination.
1.3.2 Maternal immunization with pneumococcus produced antibody levels in infants twice
that of infants of unimmunized mothers.

2. (During Delivery)
2.1 Prevention and Management of Delivery Complications
2.1.1 A study in Shunyi, China reduced perinatal mortality by 34% and early neonatal mor-
tality by 25% by implementing the following interventions(Yan et al. Int J Gynaecol Obstet 1989
Sep;30(1):23-6):
- Training a community member to recognize early warning signs of pregnancy problems,
and refer the woman to a township doctor;
- Improvements in transportation services for referral;
- Education campaigns specically targeted at newly married couples and their families,
and the general public through television and radio messages.
2.2 Resuscitation of the newborn

3. (After Delivery)
3.1 Kangaroo Care Method
3.1.1 In Zimbabwe, Kangaroo Care babies had:Improved survival,Faster growth; higher
median weight and hospital discharge weight lower frequency of illness, and lower median duration of
hospital stay(Bergman & Jurisoo Trop Doct 1994;24(2):57-60 & Kambarami et al. Ann Trop Paediatr 1998
Jun;18(2):81-6.)
3.2 Breastfeeding and Nutritional Support
3.2.1 Breastfeeding protects against late neonatal deaths (from 8 - 28 days) which are pri-
marily due to infections, such as sepsis, ARI, meningitis, umbilical infection (omphalitis), and diarrhea.
3.3 Prevention and Management of Infections

26


()

30 1300 500-600

() ()

T-cell
humoral immunity

motor co-ordination

Hemoglobin 10.5 11 /.
Center of Disease Control (CDC) Hematocrit (Hct)
33 Hemoglobin (Hb) 11 /. Hct 32 Hb 10.5
/. Hct 33 Hb 11 /.
physiologic anemia

20-80

1
Hypoproliferative anemias
- Iron deficiency anemia
- Anemia of chronic disease
- Aplastic anemia
Megaloblastic anemias
- Folate deficiency
- Vitamin B12 deficiency
Hemolytic anemias
- Hemoglobinopathies
- Sickel cell anemia
- Thalassemia
- Other hemolytic anemias
- G6PD deficiency
- Hereditary spherocytosis
- Pyruvate kinase deficiency
- Extrinsic hemolytic anemia

27

 1,000 . 300 . , 500 .
200 .
(elemental Iron) 30-60 ./ ferrous gluconate, sulfate
fumarate 60-100 ./

200 ./ 2
(Severe anemia)
2
(Hb 6-7 /.)
(elemental 60 .
(preterm labor)
Iron)
(intrauterine growth retardation, IUGR)
Ferrous
fumarate
30 200
Ferrour gluconate 11 1,000 . 550
300 . , 500 .
Ferrous sulfate 20 300
200 .
(elemental Iron) 30-60 ./ ferrous gluconate, sulfate

fumarate

60-100 ./
1. Obimin
200 ./
VitA5,000
iu, vit D400
iu, vit E 10 iu, 2vit C 75 mg, vit B12 mg, vit B23 mg, vit B6 2.5 mg, vit

B12 3 mcg,
nicotinamide
2 20 mg,folic
acid
1
mg, Fefumarate 200 mg, Ca lactate 250 mg, iodine(as K iodate) 0.2 mg, Zn (as
Zn sulfate) 20 mg
(elemental 60 .
2. FBC 1 Ferrous Iron)fumarate 200 mg, vitamin B1 2 mg, vitamin B2 2 mg, vitamin B12 5 mcg, vitamin C
20 mg, niacin 10 mg, folic acid 100 mcg Calcium phosphate tribasic 100 mg
Ferrous fumarate 30 200
(anemia)
Ferrour gluconate 11 550
3. Triferdine Iodine 0.15 mg+Ferrous fumarate 60.81 elemental iron+Folic acid 0.4 mg
Ferrous sulfate 20 300
Triferdine : ()
Iron deficiency anemia

75
1. Obimin Vit A 5,000 iu, vit D 400 iu, vit E 10 iu, vit C 75 mg, vit B12 mg, vit B23 mg, vit B6 2.5 mg, vit

B12 3 mcg, nicotinamide 20 mg, folic acid 1 mg, Fe fumarate 200 mg, Ca lactate 250 mg, iodine(as K iodate) 0.2 mg, Zn (as

Zn sulfate) 20 mg
(glossitis) (cleilitis) Koilonychia
2. FBC 1 Ferrous fumarate 200 mg, vitamin B1 2 mg, vitamin B2 2 mg, vitamin B12 5 mcg, vitamin C

20 mg, niacin 10 mg, folic acid 100 mcg Calcium phosphate tribasic 100 mg
- Blood Smear
(anemia)
(Hypochromic, microcytic anemia)
3. Triferdine Iodine 0.15 mg+Ferrous fumarate 60.81 elemental iron+Folic acid 0.4 mg
(plasma iron) ( 30 /.)
Triferdine : ()
total iron binding capacity ( 400 /.)
Iron deficiency anemia
Serum ferritin ( 10 /.)
75
FEP (Free erythrocyte protoporphyria)


(glossitis) (cleilitis) Koilonychia

- Blood Smear
(Hypochromic, microcytic anemia)
(plasma iron) ( 30 /.)
total iron binding capacity ( 400 /.)
Serum ferritin ( 10 /.)
FEP (Free erythrocyte protoporphyria)

28


Ferrous sulfate 320 . 1-3 ( 180-300 ./)
500 . Hb 1 /


3-6

1.
2.
3.
4. 1
5. 2

(Treatment of IDA in pregnancy)

In women with slight to moderate IDA

(Hb 90105 g/L)

Rx : oral ferrous iron of 100 mg/day

Hb checked after 2 weeks

Increase > 10g/l

Continue oral iron

29





(Preterm labor) 28 -36+6
(Preterm delivery) 28 -36+6 2
34 36+6 (late preterm birth) 75 (early preterm birth) 25

1.
1.1
1.2
1.3
1.3.1
1.3.2
1.3.3

1.3.4
2.
2.1
2.1.1
asymptomatic bacteriuria
(pyelonephritis)

2.1.2
2.1.2.1 Bacterial vaginosis (BV) hydrogen peroxide-producing, lactobacillus-predominant
flora anaerobic Gardnerella vaginalis, Mobiluncus Sp.
Mycoplasmahominis BV

Metronidazole 1 g 7

2.1.2.2 Group B streptococoi (GBS) colonization 16-18
(amnionitis)

(GBS) (puerperal infection)
penicillin G 5 mU IV 1 g q 4 h
penicillin cefazolin 2 g IV 1 g q 8 h
2.1.2.3 20


2.1.3 (Peritodontal disease)
(oral prophylaxis and periodontal treatment) 50
2.2
24-28 35.2 8.3 . 33.7 8.5 .
25 .
22-24 35 18 50



1.
2.
3. inform consent progesterone ( 1)
20-36

30


1.
1.1 4 20 8 60
1.2 > 1
1.3 > 80 %

2
2.1
2.2 ( USG 26 )
USG
2.3 ( 3)
34 , GBS prophylaxis
active phase 5
36

Corticosteroid 24-34 Dexamethasone 6 mg IM q 12 h x 4
dose
single course steroid repeated dose
34 steroid 28-30 ( 1 )
Magnesium sulfate 32 neuroprotection
2.4
o
EFW > 2,0002,500 gm GBS prophylaxis active phase 5

EFW < 2,0002,500 gm IUGR 3
IUGR

2.5 GBS prophylaxis preterm active phase
1. Preterm Birth (< 37 complete weeks)
2. > 18 .
3. > 38 C
4. GBS + GBS culture
o First line Penicillin G 5 mU IV initial dose then 2.5 mU IV q 4 hrs
o Alternate Ampicillin 2 gm IV q 6 hrs
o penicillin
Anaphylaxis Cefazolin 2 gm IV q 6 hrs
Anaphylaxis Clindamycin 900 mg IV q 8 hrs
2.6 (Tocolytic drug)

1. Severe pre-eclampsia
2. Placental abruption
3. Fetal distress
4. Severe chorioamnionitis
5. Fetal anomaly incompatable with life
6. tocolytic
7. Cervical dilate > 4 cm
( dexamethasone )

31


1. Terbutaline (Bricanyl )
Terbutaline 2.5 mg (5 amp) + 5% D/W 500 ml (=5 g/ml) 5 g/min ( 15d/min 60cc/hr) 2.5 g/min 20
contraction 1 2.5 g/min contraction > 8
subcutaneous oral form ( 10 g/min 20 g/min )
subcutaneous form terbutaline 0.25 mg (1/2 amp) q 4 ) 6 dose
oral form terbutaline 2.5 mg 2 tab q 8 hr 1 tab oral q 6 hr

1. (structural heart disease, cardiac ischemia, dysrhythmia)
2. Hyperthyroidism
3.
4.
5. Severe hypovolemia
6.
2. Nifedipine
- 20 mg oral 30 60 mg 90 20 mg q 8 .
15 2
100 /60 . 120 / 180 mg/ 72
long acting nifedipine (Adalat RS) 30-60 7-10
- Nifedipine 10 mg oral 15 4 ( 40 mg 1 ) 4-6 Nifedipine 20 mg oral 8
( 7-10 )
( first line drug )

nifeipine terbutaline magnesium sulfate
3. MgSO4
4 g v push 20-30 maintenance 2-4 g/hr 1 g/hr
12 1 g/hr MgSO4
pre-eclampsia
4. Indomethacin
50 mg 25 mg 4-6 48
>32 premature closure ductus arteriosus
1

* u/s u/s TVU CL = tranvaginal ultrasound cervical length

32 2

Suspected preterm labor
 * u/s u/s TVU CL = tranvaginal ultrasound cervical length

Suspected preterm labor

EFM

Uterine contraction < 4 20 Uterine contraction > 4 20

False labor PV
Discharge

Cx >1 cm and Cx < 1 cm +

effacement > 80% effacement > 80%

Cervical EFM Bed rest 1-4 hr

Preterm labor
Progression PvPV(
(
))

No cervical progression

Regular Uterine No regular uterine

Threatened preterm labor contraction
contraction

False labor D/C

3
* < 36 wks ..

.. / .

36 , ploenta grading

2,500 2,500

33

1. Cunningham FG, Levono JK, Bloom LS, Spong YC, et al. Williams Obstetrics.24th ed. New York: McGraw-Hill, 2014; 829-61.
2. Mclntire DD, Levno KJ. Neonatal mortality and morbidity rates in late preterm births compared with birth at term. Obstet Gynecol 2008; III:


1. Cunningham FG, Levono JK, Bloom LS, Spong YC, et al. Williams Obstetrics.24th ed. New York: McGraw-Hill, 2014; 829-61.
2. Mclntire DD, Levno KJ. Neonatal mortality and morbidity rates in late preterm births compared with birth at term. Obstet Gynecol 2008; III:
35-41.
3. Spong CY. Prediction and prevention of recurrent spontaneous preterm birth. Obstet Gynecol 2007; 196: 405-15.
4. Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during pregnancy. Cochrane Database Syst Rev
2011;(1):CD002256.
5. Schneeberger C, Geerlings SE, Middleton P, Crowther CA. Interventions for preventing recurrent urinary tract infection during pregnancy.
Cocchrane Database Syst Rev 2011; 11: CD009279. Doi:101002/14651858.CD009279,Pub2.
6. Tor-Udom S, Tor-Udom P. Hiriote W. the prevalence of streptococcus agalactiae (group B) colonization in pregnant women at Thammasat
Hospital. J Med Assoc Thai 2006;89:411-4.
7. Xiong X, Buekenes P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy outcomes: A systemic review. BJOG
2006; 113:135-43.
8. Owen J, Yost N, Berghella V, Thom E, Swain M, Dildy GA 3rd, et al. Mid-trimester endovaginalsonography in women at high risk for
spontaneous preterm birth. JAMA 2001; 286: 1340-8.
9. ACOG practice bulletin. Management of preterm labor. Obstet Gynecol 2012;119:1308-17.

Evidence categories for interventions/strategies to prevent low birth weight and preterm births
Strong evidence of effectiveness

Modication of maternal lifestyle

- Smoking cessation and relapse prevention as a routine component of prenatal care, particularly interventions
that include intensive counselling, multiple contacts, provision of supportive material and follow up
Prevention or treatment of infections
- Intermittent prophylaxis or insecticide-treated nets for malaria in endemic regions for primigravida and second
gravida mothers
- Treatment of infection (urinary tract infection, syphilis, gonorrhea)
- Screening mothers with previous history of preterm/LBW births for infection and providing appropriate treat-
ment if infection is diagnosed
Promotion of a balanced, nutritious diet for all pregnant women
Treatment of maternal general medical conditions
Treatment of pregnancy-associated conditions
Reduction of multiple births following IVF or articial reproductive technologies
Treatment of infection
- Urinary tract infections
- Gonorrhea
- Syphilis
- Malaria

34



5.8
beta-streptococcus group B
tocolysis 2-7
(10) indomethacin

RDS, intraventricular hemorrhage

necrotizing enterocolitis 50 NIH ACOG
24-34
7 1 betamethasone suspen-
sion 12 . 24 2 dexamethasone 6 . 12 4

GBS (
)

tocolysis mentenance

periventricular
leukomalacia
(22)
Meta-analysis
prostaglandins inhibitor (indomethacin)
ductsus arteriosus betamimetics

17 alpha hydroxyprogesterone caproate 250 . IM 24
36
Natural progestogen 100 . 24 36

o
o
o Bacterial vaginosis, ureaplasma
o
o

o
o asymptomatic bacteriuria
o
o
o
o
o

35

 (Intrauterine growth restriction , IUGR)
Clinical Practice Guideline (CPG)
(Intrauterine growth restriction , IUGR)

(Intrauterine growth restriction)
ACOG practice bulletin 2013 (1) estimated fetal weight
10

(constitutionally small)

(fetal growth restriction or intrauterine growth restriction)

1.

2 (head-to-abdomen circumference ratio
: HC/AC) (2)
1. (Symmetrical IUGR)

HC/AC ratio

2. (Asymmetrical IUGR)

(uteroplacental insufficiency: UPI)
brain sparing phenomenon HC/AC ratio

36



,
hypoglycemia, hypocalcemia, polycythemia, hyperbilirubinemia, meconium aspiration syndrome,
infection, brain and behavioral development, preterm birth, fetal distress (25-50%) fetal death
delay development of cognition 2

, , BMI, ,,

preeclampsia, chronic vascular disease, heart disease chronic renal insufficiency,
nephropathies ; chronic hypoxia chronic hypertension, asthma ; antiphospholipid syndrome ;
infection (5-10%) (eg. Varicella, herpes zoster,HIV, rubella, CMV,protozoa)
multiple fetuses, chromosome abnormalities (eg. Trisomy13, 18), structural disorder (eg. Congenital
heart disease, gastroschisis)

poor placental perfusion, placental disorder (eg. abruption, infarction, circumvallate, hemangioma,
chorioangioma)
velamentous or marginal cord insertion, single umbilical artery

1.

IUGR (stillbirth)
IUGR
2. (Physical examination)
(symphysis-fundal height : SFH) GA 20-34 weeks
2
SFH 3 cm IUGR
3.
(ultrasound: US)
(Estimated fetal weight) : BPD, HC, AC FL
20% EFW 10 IUGR
(fetal biometry) AC AC
10 IUGR
(growth velocity) AC / EFW
IUGR 3-4 ( 2 )
HC/AC ratio : asymmetrical IUGR HC/AC +2SD

37

 FL/AC ratio : age independent 20 FL/AC
222% (212.3 ) 23.4 IUGR
IUGR
(Amniotic fluid volume) : IUGR oligohydramnios
renal perfusion oligohydramnios DVP < 2 cm AFI < 5 cm
Doppler velocimetry
Doppler umbilical artery improve
perinatal outcome absent or reverse end diastolic flow (AEDV and REDV) in umbilical artery
perinatal mortality timing of delivery AEDV
34 REDV 32 (7)
Doppler middle cerebral artery precordial
venous system IUGR improve perinatal
outcome

2 Umbilical artery doppler

review medical obstetrical history
IUGR 20%
ultrasonography surveillance
umbilical artery Doppler velocity antepartum testing NST BPP 28

34 corticosteroid improve preterm
neonatal outcome (3, 4) 32 magnesium sulfate
neuroprotection (5, 6)

38


1. Gynecologists ACoOa. ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol. 2013;121(5):1122-
33.
2. Cunningham L, Bloom, et.al. Williams Obstetrics. 24 ed. United State of America: McGraw-Hill Education; 2014.
3. Antenatal corticosteroids revisited: repeat courses. NIH consensus statement. 2000;17(2):1-18.
4. Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm
birth. Cochrane Database Syst Rev. 2006(3):CD004454.
5. American College of O, Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal M. Committee
Opinion No. 573: Magnesium sulfate use in obstetrics. Obstet Gynecol. 2013;122(3):727-8.
6. Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium
sulfate for the prevention of cerebral palsy. The New England journal of medicine. 2008;359(9):895-905.
7. , . . 2556;22(8):6-16.

39

40

 Antepartum Hemorrhage


Management of Antepartum
hemorrhage
( Placenta previa & Placental abruption )

3-4.8 (1+2)
31 22 47 (3)

( = + )



(Vaccuum extraction)
3


2-3 %
20 7
60
0.3-0.5% (2)

20 (4) 1%
20-40%
1 200 (5)

2556 116 25,578

28
( >20 ) 3-5%
28
( 28 ) (partial) (total)
(>20 )

fetal distress consumptive coagulopathy(6)
0.5-1 1 3
(7-8)

(9) :-
1. (10) : 24 eclampsia 10
2-.3 preeclampsia
2. : (8-11)

41

 3. (trauma)(12) (external cephalic
version) (cordocentesis)
4. (13-14)
5. (15-16)
6. thrombophillia factor V Leiden mutation(17)
7. (18-19)(20)
8. (parity) (21)
9. 10(9)

()
chorion
80(22)
4 (23)
1. Low-lying placenta lower segment internal os 2 . (
)(24)
2. Marginal placenta previa internal os os
os 2 .
3. Partial placenta previa internal os
4. Complet placenta previa internal os
: 1:200

1. 40 ((20)20)
2. ( 4-8(25)
3. ( 5 5 0.2 )(25)
4. (26-27) 10 4 (26)
5. (28)
6.
(29)
7. placenta membranacea

( )
95(30-31) (32)

double setup active
double set up

1. (admit)
2. (No PV, No PR)
3. ( excessive bloody show )

-
-
-
-
-
-

42


- Vital signs
- Shock
- Vulva
- (no PV, no PR)
-
- Leopold maneuver
- (duration, interval, intensity, tone tenderness)
- FHR monitoring NST
4.
5. CBC,PLT ,BUN ,Cr, LFT,PT,PTT,INR ,G/M ()
6. intake/output
7.
8. ()

1. hypovolemic shock ,anemia

2. consumptive coagulopathy
3. oxytocin
continuous fetal heart rate monitoring fetal distress
fetal distress
expectant ()
magnesium sulfate ()
4. ( atony)
5. NICU
6. Rh Rh immunoglobulin
7. Dexamethzone Ga 24-34 WK

GA 28- 35+6 WK GA 36 WK
No active bleeding Active bleeding Termination
u/s no retroplacenta blood Retroplacenta blood clot LTC/S indication
clot Fetal distress Amniotomy if vagina delivery
no fetal distress shock On EFM
no shock Notify NICU
-Conservatived treatment -Termination LTC/S indication
-dexamethzone (24-34 WK) -dexamethazone
-On EFM -GBS prophylacsis
- Notify NICU -On EFM
-Notify NICU

43

 Management of third trimester bleeding
With suspected placental abruption(5-33-34-35)
Admit, record VS, start iv.fluid, NPO
CBC, coagulogram , cross matching
Assess maternal & fetal conditions
U/S for detection of abruption ( not R/O if normal finding)

Other causes of bleeding Suspected or proved

Placental Abruption

Rx causes

GA<35+6 wks GA 36 wks Dead fetus

Monitor - maternal condition Beware of

- fetal condition coagulopathy

Reassuring fetal condition Non-reassuring fetal condition

andor
No maternal complication Maternal complication

Resuscitation to stabilize patient

Continue pregnancy -Termination of pregnancy

-Beware of further abruption

-Closed fetal monitoring

-Consider corticosteroid

* 24-34 wk C/S -Vaginal route (prefer)

(as OB indications) - Rupture of membrane as early as possible
-Continuous fetal monitoring (for alive fetus)
( oxytocin use caution)

Vaginal delivery

44



1. expectant

2.


3. fetal distress :/ aggressive expectant (
)
4. : os : os
: expectant ()
double setup

Expectant (vital signs)

12-24 2-3

5.

6.
7. Rh Rh immunoglobulin (4)

GA 28- 33+6 Wk GA 34-36+6 WK 37 WK

No active bleeding - Active bleeding Termination of pregnancy Termination
no fetal distress reassuring fetae - Non reassuringfetae Condition LTC/S of pregnancy
Condition
no shock - No Active Bleeding,
-Conservatived treatment -Termination LTC/S reassuring fetae condition ;
-dexamethzone -dexamethazone Expetan
-On EFM -GBS prophylacsis
- Notify NICU -On EFM - Active Bleeding, non
-Notify NICU reassuring fetae condition,
Termination

45

 Managementofthirdtrimesterbleeding
(5-23-33-35-36-37)
Withsuspectedplacentaprevia(
Admit,recordVS,startiv.fluid,NPOCBC,crossmatchingNoPV&PR
Assessmaternal&fetalconditions
. / .





MassivebleedingNomassivebleeding
UnstablepatientStablepatient
NonreassuringfetalconditionReassuringfetalcondition

Resuscitation

ContinuedNoactivebleeding
ActivebleedingStablepatient
OfNonreassuringReassuringfetalcondition
Fetalcondition

U/Sforplacentalsite&GA/

QuestionablePlacentaPreviaNoprevia

IndicationNoindicationLookforother

Fordeliveryfordeliverycausesofbleeding&Rx

Observe&reevaluate

C/SAssessmother&fetus


GA<34wksGA34<37wksGA37wks


PretermlaborNolaborInlabor

Emergency
C/S


TocolyticDrugExpectantRxStableuntil
(1stline=MgSO)Restrictactivity37wks
ConsidersteroidSteroidforGA<34wkswithpersistent
Assessmother&fetusAssessmother&fetusplacentaprevia
afterrepeatU/S

Ifanyconditions
Rebleedmaternallifethreatening
Nonreassuringfetal,GA28wks

EmergencyC/SElectiveC/S

46



1. Nimrod CA, Openheimer LW. Third-trimester bleeding. In: Reece EA, Hobbins JC,
editor.Medicin of the fe tus and maternal. 2nd ed.Philadelphia: Lippincott-Raven Plulishers,1999: 1497-505.
2. .. .
,2555:237-253.
3. Konje JC, TAYLOR DJ.Bleed in late pregnancy.In: Jams DK, Steer PJ, Weiner CP , Gonite B, editors.High risk
pregnancy:management options.2nd ed. London: WB Saunders, 1999 111-27.
4. ...,2555:145-156.
5. Cunningham FG,Leveno KJ. Bloom SL, Hauth JC, Rouse DJ, Spong CY.Williams obstetrics.23rd ed. New York: McGraw-
Hill,.2010:757-803.
6. Ananth CV, Berkowitz GS, Savitz DA, Lapinski RH. Placental abruption and adverse perinatal outcomes. JAMA 1999 Nov
3;282(17):1646-51.
7. Abdella TN, Sibai BM, Hays JM, Jr., Anderson GD. Relationship of hypertensive disease to abruptio placentae. Obstet
Gynecol 1984 Mar;63(3):365-70.
8. Karegard M, Gennser G. Incidence and recurrence rate of abruptio placentae in Sweden. Obstet Gynecol 1986
Apr;67(4):523-8.
9. Tikkanen M, Nuutila M, Hiilesmaa V, Paavonen J, Ylikorkala O. Prepregnancy risk factors for placental abruption. Acta
Obstet Gynecol Scand 2006;85(1):40-4.
10. Pritchard JA, Mason R, Corley M, Pritchard S. Genesis of severe placental abruption. Am J Obstet Gynecol 1970 Sep
1;108(1):22-7.
11. Spellacy WN, Handler A, Ferre CD. A case-control study of 1253 twin pregnancies from a 1982-1987 perinatal data
base. Obstet Gynecol 1990 Feb;75(2):168-71
12. Kettel LM, Branch DW, Scott JR. Occult placental abruption after maternal trauma. Obstet Gynecol 1988 Mar;71(3 Pt
2):449-53.
13. Vintzileos AM, Campbell WA, Nochimson DJ, Weinbaum PJ. Preterm premature rupture of the membranes: a risk
factor for the development of abruptio placentae. Am J Obstet Gynecol 1987 May;156(5):1235-8.
14. Major CA, de Veciana M, Lewis DF, Morgan MA. Preterm premature rupture of membranes and abruptio placentae: is
there an association between these pregnancy complications? Am J Obstet Gynecol 1995 Feb;172(2 Pt 1):672-6.
15. Salafia CM, Lopez-Zeno JA, Sherer DM, Whittington SS, Minior VK, Vintzileos AM. Histologic evidence of old intrauterine
bleeding is more frequent in prematurity. Am J Obstet Gynecol 1995 Oct;173(4):1065-70.
16. Rasmussen S, Irgens LM, Bergsjo P, Dalaker K. The occurrence of placental abruption in Norway 1967-1991. Acta
Obstet Gynecol Scand 1996 Mar;75(3):222-8.
17. Prochazka M, Happach C, Marsal K, Dahlback B, Lindqvist PG. Factor V Leiden in pregnancies complicated by placental
abruption. BJOG 2003 May;110(5):462-6.
18. Ananth CV, Cnattingius S. Influence of maternal smoking on placental abruption in successive pregnancies: a
population-based prospective cohort study in Sweden. Am J Epidemiol 2007 Aug 1;166(3):289-95.
19. Tikkanen M, Nuutila M, Hiilesmaa V, Paavonen J, Ylikorkala O. Clinical presentation and risk factors of placental
abruption. Acta Obstet Gynecol Scand 2006;85(6):700-5.

47

 20. Hoskins IA, Friedman DM, Frieden FJ, Ordorica SA, Young BK. Relationship between antepartum cocaine abuse,
abnormal umbilical artery Doppler velocimetry, and placental abruption. Obstet Gynecol 1991 Aug;78(2):279-82.
21. Ananth CV, Wilcox AJ, Savitz DA, Bowes WA, Jr., Luther ER. Effect of maternal age and parity on the risk of
uteroplacental bleeding disorders in pregnancy. Obstet Gynecol 1996 Oct;88(4 Pt 1):511-6.
22. Nyberg DA, Cyr DR, Mack LA, Wilson DA, Shuman WP. Sonographic spectrum of placental abruption. AJR Am J
Roentgenol 1987 Jan;148(1):161-4.
23. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and vasa previa. Obstet Gynecol 2006 Apr;107(4):927-41.
24. Oppenheimer LW, Farine D, Ritchie JW, Lewinsky RM, Telford J, Fairbanks LA. What is a low-lying placenta? Am J
Obstet Gynecol 1991 Oct;165(4 Pt 1):1036-8.
25. Obstet Gynecol 1991 Oct;165(4 Pt 1):1036-8.
26. Lavery JP. Placenta previa. Clin Obstet Gynecol 1990 Sep;33(3):414-21.
27. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol 1985
Jul;66(1):89-92.
28. Rose GL, Chapman MG. Aetiological factors in placenta praevia--a case controlled study. Br J Obstet Gynaecol 1986
Jun;93(6):586-8.
29. Meyer MB, Tonascia JA. Maternal smoking, pregnancy complications, and perinatal mortality. Am J Obstet Gynecol
1977 Jul 1;128(5):494-502.
30. Besinger RE, Moniak CW, Paskiewicz LS, Fisher SG, Tomich PG. The effect of tocolytic use in the management of
symptomatic placenta previa. Am J Obstet Gynecol 1995 Jun;172(6):1770-5.
31. Timor-Tritsch IE, Monteagudo A. Diagnosis of placenta previa by transvaginal sonography. Ann Med 1993 Jun;25(3):279-
83.
32. Farine D, Peisner DB, Timor-Tritsch IE. Placenta previa--is the traditional diagnostic approach satisfactory? J Clin
Ultrasound 1990 May;18(4):328-30.
33. Clark SL Placenta previa and abruption placentae IN:Creasy PK, Resnik R, editons.Maternal-fetal medicine. 5th ed.
Philadelphia:Saunders;2004.p.707-22.
34. Deering SH. Abruptio placentae. 2005. Available from:
35. OyeleseY. Ananth CV. Placental adruption. Obstet Gynecol 2006;108(4):1005-16.
36. Royal College of Obstetrics and Gynecology (RCOG),Clinical green top guidelines. Placenta previa and placenta previa
accrete: Diagnosis and management. Number 27, Revised October 2005.
37. American College of Obstericians & Gynecologists. Placenta accreta. ACOG Committee Opinioon. 2012;(529)

48


(Birth asphyxia)
1.
(Birth asphyxia)1 (Hypoxemia)
(Hypercapnia) (Ventilation) Pulmonary
perfusion

2

11 (..2555-2559) 3% (30
1,000 )3 (Cerebral palsy) (0-7 )
1.5-2.5 1,000 30
4 12.7 1,000
2556
2549, 2550 2551
5
17.0,11.4 10.4
6,7
(Apgar score) 6
(live birth) 1 5 7
2 (Severe) 3 (Mild or
moderate) 7

2.
8
2534 7 7
4 8
8
76
75 1,000 26
43 1,000 248
2549-2551
7.9,8.3 6.9 1,000 17.0,11.4 10.4
5 2531 40
(severe birth asphyxia) 14.3 9
7 259

(Apgar score 1 < 7) .. 2542-2556 .
60.93 1,000 2542 12.7 1,000
5,10-12
2556 ( 11
birth asphyxia < 30 1,000 3) (Ap-
13
gar score 1 < 7) 2552-2555 36,43,47 51 1,000
(Apgar score 1 < 7) 2552-255414 116,137 150 1,000

49

 birth asphyxia < 30 1,000 )
(Apgar score 1 < 7) 2552-255513 36,43,47 51 1,000

(Apgar score 1 < 7) 2552-255414 116,137 150 1,000


1
1
(Apgar score 1
(Apgar
< 7)score 1 <.
2542-2556 7) 2542-2556 .

5,10-12 5,10-12

2542 2543 2544 2545 2546 2547 2548 2549 2550 2551 2552 2553 2554 2555 2556

() 650,738 639,489 642,628 703,919 638,928 663,558 692,382 641,313 610,783 637,992 na na na na na
( 1,000 ) 60.9 39.4 35.3 32.6 28.9 30.7 26.6 24.4 28.7 28.6 na na 22.5 21.4 12.7
10.21 10.19 10.19 9.15 8.39 8.7 8.1 7.9 8.3 6.9 na na na na na
( 1,000 )
() 6,691 6,561 6,595 6,489 5,398 5,814 5,627 5,189 5111 4451 na na na na na

birth asphyxia() 21.08 24.25 23.00 14.22 15.32 16.3 16.0 17.0 11.4 10.4 na na na na na
birth asphyxia() 1405 1591 1517 623 827 947 900 882 583 463 na na na na na
5,10-12
:
: 5,10-12
: 2547 72 (94.7 %)
2548 68 (89.5 %)
: 2547 72 (94.7 %)
2549 70 (92.1 %)

2548 68 (89.5 %)
2549 3.
70

(92.1 %)


3.
8
5,8,9



3-21


5,8,9
8

15-16 3-21


" "

3.1)
(recognition of problems in
15-16

pregnancy/labor,
3.1) cultural
beliefs,
family decision-making),
(recognition of problems in pregnancy/labor, cul-
3.2)
tural beliefs, family decision-making),
(distance, transportation, road
infrastructure)
3.2) (distance, transportation, road infrastructure)
3.3) () (inadequate staffing, training, equipment,
3.3) () (inadequate stafng, training, equipment, clinical algorithms)
clinical algorithms)
4.
4.1

(Obstetrical Interven-
tions) 17
(Good maternal and newborn care) 17
- (Partograph) Use partograph for vigilant labor monitoring)
- (Allow companionship during labor and birth)
- 2 (Ensure support-
nd
ive 2 stage management based on fetal and maternal condition)
- (Avoid incorrect practices)
- (pre-eclampsia) (Manage pre-eclampsia correctly)
- (Ensure skilled attendance at
birth to prevent and manage asphyxia)
17
4.1.1 (partograph) (Use of the Partograph)

oxytocin
(chorioamnionitis)
4.1.1.1 ?

50

 .
. (Prevent prolonged labor)
. oxytocin (Prevents unnecessary augmentation
using oxytocin)
. (Prevents infection)
. (Ensure timely Cesarean)
. (Prevent hyperstimulation)
17
4.1.2 (Pre-eclampsia Management)
(Pre-eclampsia)
pre-eclampsia
(asphyxia)
4.1.2.1 / (severe pre-eclampsia)

. (Maternal seizure)
. (Severe hypertension)
. (Emergency Caesarean)
4.1.2.2 (Proper man-
agement of severe PE / Eclampsia)
. (Mg SO4 )
. (Treat hypertension: antihypertensives)
. (Ensure timely delivery)
. (Increase obstetrical monitoring )
4.1.3 Alternative positions17
(Position) (lithotomy)

4.1.4 (Labor Management)

(Hydration) (intravascular vol-
ume) (uterine placental perfusion)

4.1.5 (Labor augmentation)17

oxytocin (protocol) oxytocin (unmonitored)
17
4.1.6 2 (Second stage labor management)
- (Continue monitoring of fetal heart)
5 30

(Vacuum extraction)

51

 (breech delivery) (Twin delivery) 2 (management of 2nd twin) 17
(comprehensive review)
(specic obstetrical interventions) (intrapartum-related hypoxic injury)
(low resource settings)
(International Journal of Obstetrics and Gynecology)18 (obstetrical in-
terventions) (low-resource countries)
(antepartum period) (hypoxia)
(placental blood ow) ( (fetal movement counting), con-
traction stress or non-stressed fetal heart rate monitoring, ultrasound biophysical prole, and umbilical artery Doppler
blood ow) 19-20
antenatal detection methods (intrapartum-related mortal-
ity) 18
(intrapartum hypoxia)
(placental abruption), (fetal distress),
(umbilical cord complications) (malposition). 19,21

, (abnormal fetal heart rate patterns) (obstructed-pro-
19,21
longed labor)
continu-
ous electronic fetal heart rate monitors ( fetal
deaths) fetoscopes
(continuous fetal monitoring)
intrapartum related outcomes 22-25
fetoscope innovative
tools doptone
26
(obstructed labor)
(instrumental delivery) / (Cesarean
section)22

(prolonged labors) (intrapartum surveillance) 20,27-29
Cochrane review
(higher income) (low income settings)30
WHO prospective study
(South-East Asia)
(stillbirth)31

(relative risk [RR]: 0.33%, 95% condence interval [CI]: 0.10-0.5)22
(emergency obstetrical care)
(intrapartum-related birth outcomes)
(emergency obstetrical care)
neonatal encephalopathy (RR: 0.51%, 95% CI: 0.35-0.74) low 5-minute Apgar scores (RR:
0.50%, 95% CI: 0.26-0.9)32
(obstetrical drills), (checklists)

52

(perinatal audits) 33


20 positive
34,35
pressure ventilation
8,34-36

37-38

Fetal monitoring
39

5.
5.1 (Risk Factor) birth asphyxia41
5.1.1 (Antepartum risk factors)
5.1.1.1 (Primiparity)
5.1.1.2 (Febrile illness) (presumed malaria)
5.1.1.3 (Pregnancy induced Hypertension)
5.1.1.4 (Severe pre-eclampsia/eclampsia)
5.1.1.5 (Antepartum hemorrhage)
5.1.1.6 (Anemia)
5.1.2 (Intrapartum risk factors)
5.1.2.1 (Malpresentation)
5.1.2.2 (Prolonged labor)
5.1.2.3 (Maternal fever)
5.1.2.4 (Meconium-stained amniotic uid)
5.1.2.5 (Premature rupture of membranes)
5.1.2.6 (Oxytocin augmentation of labor)
5.1.2.7 (Umbilical cord prolapse)
5.1.3 (Infant/postnatal factors)
5.1.3.1 (Prematurity)
5.1.3.2 (Low birthweight)
5.1.3.3 (Intrauterine growth restriction)
. 2
(hydrops fetalis) 1,000-1,499
HIV (fetal
distress) 42

5.2
6,39,43 WHO
Partograph 4.7% 3.2%44

39

53

 OT ( occiput transverse) OP ( occiput posterior) Pethidine
Fetal monitoring
Intrapartum cardiotocographs (CTGS)
45
87


34
..2529
34
- 2532

5046


20 positive pressure ventilation34,35
8,34-36


Fetal monitoring 45

36 8,34-36
50

Curacao

47

(Birth asphyxia)
1. 20
1
2.

20
20


4-7
3. Apgar Score 1
8-10
4.
6

54

 Birth asphyxia
Birth asphyxia

Birth asphyxia :
1 (Antepartum risk factors)
1.1 (Primiparity)
1.2 (Febrile illness) (presumed malaria)
1.3 (Pregnancy induced Hypertension)
1.4 (Severe pre-eclampsia/eclampsia)
1.5 (Antepartum hemorrhage)
1.6 (Anemia)
2 (Intrapartum risk factors)
2.1 (Malpresentation)
2.2 (Prolonged labor)
2.3 (Maternal fever)
2.4 (Meconium-stained amniotic fluid)
2.5 (Premature rupture of membranes)
2.6 (Oxytocin augmentation of labor)
2.7 (Umbilical cord prolapse)
3 (Infant/postnatal factors)
3.1 (Prematurity)
3.2 (Low birthweight)
3.3 (Intrauterine growth restriction)

meconium
< 110 bpm
> 160 bpm

Oxytocin

> 5 10

24

- (Partograph)
- (Allow companionship during labor and birth)
- 2 (Ensure supportive 2nd stage
management based on fetal and maternal condition)
- (Avoid incorrect practices)
- (pre-eclampsia) (Manage pre-eclampsia correctly)
- (Ensure skilled attendance at birth to
prevent and manage asphyxia)
-
- (emergency obstetrical care)
- (obstetrical drills), (checklists) (perinatal audits)
fetal distress
vibroacoustic stimulation fetal scalp stimulation

Intrauterine resuscitation: Ringer Lactate
O2 mask with bag 6-10 L/ Oxytocin
Terbutaline 0.25 . uterine tachysystole ( 5 10 )
(Continuous EFM) 15

55


1. . . : , , , ,
, . 1. 2. : ;2540:246-53.
2. . (). : ,
, . , 1. : ;
2534:1-5.
3. .
.. 2555-2559. 1. .
4. , . . : , , , .
( 2), 1. : ;2540:238-42.
5. 2549 2551. 1. : ; 2553.
6. , .
. 3. : ;2542:1-26.
7. . Intervention of intrauterine asphyxia. , , . Neona-
tology for pediatricians. 1. : .. ;2542:14-25.
8. De L. Castello AM, Manandhar DS, Perinatal asphyxia in less developed countries. Arch Dis Child, 1994,74:F1-3.
9. . Neonatal resuscitation. : , , , . Birth as-
phyxia & Neonatal resuscitation. 1. : -
;2537:57-61.
10. . 2540-2544. 1.
: ; 2545.
11. . 2544-2546. 1. :
; 2547.
12. . 2547 2549 1. :
; 2550.
13. Obstetric Annual Report 2009-2012. .
14. Annual Report Maternal-Fetal Medicine 2009-2012.
+ .
15. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK , et al. Two million intrapartum-related stillbirths and
neonatal deaths: where, why, and what can be done. Int J Gynecol Obstet 2009;107:S5-19.
16. Moniruzzaman S, Andersson R. Age- and sec-specic analysis of homicide mortality as a function of eco-
nomic development: a cross national comparison. Scand J Public Health 2005; 33:464-71.
17. Smith JM. Improved Labor Care to Reduce Neonatal Asphyxia. Interventions for Impact in Es-
sential Obstetric and Newborn Care. Africa Regional Meeting, 21-25 February, 2011.
18. Hofmeyr GJ, Haws RA, Bergstrm S, Lee AC, Okong P, Darmstadt GL, et al. Obstetric care in lowre-
source settings: what, who, and how to overcome challenges to scale up? Int J Gynecol Obstet 107:S21-46,
2008.
19. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 38:1091-110, 1994.
20. Haws RA, Mohammad YY, Soomro T, et al: Reducing stillbiths: screening and monitoring during pregnancy and
labour. BMC Pregnancy Childbirth 2009;9:S5 (Suppl 1).
21. Darmstadt GL1, Yakoob MY, Haws RA, Menezes EV, Soomro T, Bhutta ZA. Reducing stillbirths; interventions
during labour. BMC Pregnancy Childbirth 2009;9:S6 (Suppl 1).
22. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned Caesarean section versus planned
vaginal birth for breech presentation at term: a randomized multicentre trial. Term Breech Trial Collaborative
Group. Lancet 2000; 356:1375-83.
23. Alrevic Z, Devane D, Gyte GM: Continuous cardiotocography (CTG) as a form of electronic fetal monitoring
(EFM) for fetal assessment during labour. Cochrane Database Syst Rev2006;3:CD006066.
24. Neilson JP: Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst Rev
2005;3:CD000116.

56

25. East CE, Chan FY, Colditz PB, Begg LM. Fetal pulse oximetry for fetal assessment in labour. Cochrane
Database Syst Rev 2007;2:CD004075.
26. Mahomed K, Nyoni R, Mulambo T, Kasule J, Jacobus E. Randomised controlled trial of intrapartum fetal heart
rate monitoring. BMJ 1994;308:497-500.
27. World Health Organization. partograph in management of labour. World Health Organization Maternal Health
and Safe Motherhood Programme. Lancet 1994;343: 1399-404.
28. Mathai M. The partograph for the prevention of obstructed labour. Clin Obstet Gynecol 2009;52:256-69.
29. Philpott RH. Obstructed labour. Clin Obstet Gynecol 1982; 9:625-640.
30. Lavender T, Hart A, Smyth RM. Effect of partogram use on outcomes for women in spontaneous labor at term.
Cochrane Database Syst Rev2008; 4:CD005461.
31. World Health Organization. Partograph in management of labor. World Health Association Mater-
nal Health and Safe Motherhood Programme. Lancet 1994;344: 1399-404.
32. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, et al. Does training in obstetric emergencies
improve neonatal outcomes?. Br J Obstet Gynaecol 2006;3: 177-82.
33. Pattinson R, Kerber K, Waiswa P, Day LT, Mussell F, Asiruddin SK, et al. Perinatal mortality audit: counting,
accountability, and overcoming challenges in scaling up in low- and middle-income countries. Int J Gynecol
Obstet 2009;107:S113-S122.
34. . Neonatal resuscitation. : , , , . Birth
asphyxia & Neonatal resuscitation. 1. : -
;2537:57-61.
35. Palme-kilander. Methods of resuscitation in low-Apgar-score newborn infants-a national survey. Acta Paediatr,
1992,81:739-44.
36. . Neonatal resuscitation: an update. : , ,
, , . 2. 1. :
;2540:130-1.
37. Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face
mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descrip-
tive observational study. Resuscitation 2012 ;83:869-73.
38. Basic Newborn Resuscitation: a practice guide. WHO/RHT/MSM/98.1.
39. .
2540-2542. 2543;23: 56-69
40. .
2540-2543. 2543; 23:90-105.
41. Wall SN, Lee AC, Carlo W, Goldenberg R, Niermeyer S, Darmstadt GL, et al. Reducing intrapartum-related neo-
natal deaths in low- and middle-income countries-what works?. Semin Perinatol 2010; 34:395-407.
42. . 8 2546; 11: 131-43.
43. . Perinatal asphyxia. , , . .
5. : ;2540:32-41.
44. . WHO Partograph
. 2540;14:202-9.
45. Murphy KW, Johnson P, Moorcraft J, Patttinson R, Russel V, Tumbull A. Birth asphyxia and the intrapartum
cardiotocograph. Br J Obstet Gynaecol 1990;97:470-9.
46. . . : , , , ,
, . 1. 2. : ;2540:203-14.
47. Wildschut HI, Wiedijk V, Nolthenius-Puylaert MT. Birth asphyxia and obstetric care in Vuracao Netherlands
Antille. Int J Gynecol Obstet 1990,32:177-22.

57




(Vacuum Extraction V/E )





1. (Vacuum cup) 2
1.1 rigid cup (stainless steel) 3 4,5 6 2
1.1.1malstrom cup
occiput

1.1.2 bird cup malstrom
traction bar occiput

1 rigid cup ( Aldo Vacca, ,2552:113 )

1.2 solf cup silicone polyethylene
1.2.1 silastic cup (chignon )

1.2.2 slic cup
1.2.3 CMI cup polyethelene

2 soft cup ( Aldo Vacca, ,2552:114 )

2. ( metal plate chain ) Malstrom metal plate chain
Bird plate
3. ( Traction bar or handle ) Bird

58

 4. ( suction tube ) 1
5. ( vacuum bottle )

6. ( vacuum pump ) 2
6.1 Hand foot pump

6.2 Electric vacuum pump

3 vacuum pump ( Aldo Vacca, ,2552:115 )

1.
1.1 2 ( Prolonged second stage of labor )
1.2 myasthenia gravis,
,,
2.
2.1 occiput posterior occiput transverse
2.2 fetal distrese

1.
2. ( absolute CPD )
3. (
silieone vac. station+2)
4. ()
5. ( fetal distress )
6. second twin
7.
8. ( fetal scalp blood sampling )

1. (station+2)
2.
3. engage
4.

59

 5.
6.
7.

1.
1.1 40,50 60 . 1
1.2 vacuum 2 15 30 . 100 .
1.3Traction handle 1
1.4 1
1.5 pudendal nerve block 1
2.
2.1
2.2 lithotomy
pudendal nerve block
3.
3.1 traction handle
traction handle

4 vacuum extraction( ,2533 )

60

 3.2 ( Application of vacuum extraction ) antiseptic cream hibitane cream

occiput
occiput
0.2 ./ .. 2 artificial caput succedaneum
0.6 0.8 ./.. 6 8 caput succedaneum

-
( Traction time ) 30

1.
1.1,,
1.2
2.
2.1 (Cephalhematoma)
12

2.2 cup ( caput succedaneum )

2 3
2.3 (ulceration and ecchymosis )
2.4 (Subgaleal hematoma ) subaponeurotic aponeurosis
( periosteum )
2 3 2 3 subgaleal
2.5 (Intracranial hemorrhage )

1.
1.1
1.2
1.3
1.4
2.

3.
4. 1 15 30
5.
6.

1.

2.

61

 3. 2
0.2 ./ 0.6 0.8 ./

4.

5.

6.
7.


1. 30 1 1
1.



2. 24


2. 3.









24
3. 4.


12
23




12
24



4. 5.





5. 6.

24



6.
7.



7. 8.







1. 9.









2. 10.





3.

4.








4
5.








CPD



4
6. 1.
5





2.

CPD






CPD 1
1. 3.
4 80
2.
4.
2


3. 5.
protraction
disorders arrest disorder
second
(Placenta previa)stage
disorders
(Abruptio placenta)



1.

.
(Diagnostic Guideline for Cesarean Section due to Cephalopelvic
1. 3 7
Disproportion or Failure to Progress of Labor). 2544; 10(2): 17-22
2.

62



(Clinical practice guideline of screening and treatment for anemia in

children ; WCC setting)
(Clinical practice guideline of screening and treatment for anemia in children ; WCC setting)

1 ()

(red cell mass) (hemoglobin, Hb)

cut off 2 (-2 SD) (mean) (
1)
1 (mean) -2SD Hemoglobin (Hb), Hematocrit (Hct) Mean
Corpuscular Volume (MCV)

From Oski FA: Pallor. In Kaye R, Oski Fa, Barness LA (eds): Core Textbook of Pediatrics, 3rd ed. Philadelphia,Lippincott, 1989,
p62.

(iron deficiency anemia)
(thalassemia syndrome) 2 6 3

6 -12 .. 2553 -2555

South East Asia Nutrition Survey (SENUTS) 41.7

63


26 5 .. 2546
6-8 46.7 9 -11 25.4 12 -14 15.7

50 (50% bioavailability)
6

1
1) (multiple gestation)
2)
3) cows milk 6


1. 1 - 2
2

2.
6
2-3
3.


3 1 (iron depletion) 2
(decreased transport) 3 (iron deficiency anemia) 1
1 (mental)
(motor) (behavior)

64


1. (hemoglobin, Hb) / (Hct) cut-off Hb
11 g/dL / Hct 33%
2. Iron saturation cut-off 10%
3. Serum ferritin cut off 10 ng/mL
4. Erythrocyte protoporphyrin (EP) EP cut-off 35 mcg/dL
5. reticulocyte hemoglobin content (CHr)
transferin receptor (TfR)

30 1

- 9-12
- 2 3
6
1-3
- cows milk 24 15-18
24
(positive test) 4 6 mg. of elemental iron/kg./day
(therapeutic trial of iron) 1 1 / . 3
2
hemoglobin electrophroresis (Hb type)

(mental) (motor)
(behavior) (cognitive function) IQ test



1. ferrous sulfate ferrous fumarate 4 6 mg. of elemental iron/kg./day 6-8
2
2.

3.






4.

(primary prevention) (iron supplement)

( WHO, Guideline for intermittent IS for children 2011 )

6 24 1 mg. of elemental iron/kg./ day
12.5 of elemental iron/wk.
25 60 2 mg. of elemental iron/kg./ day
25 mg.of elemental iron/wk.

65
() Iron
Elemental
Eurofer-Iron Eurodrug 50
(oral liquid) (Berli Jucker)
 ( WHO, Guideline for intermittent IS for children 2011 )
6 24 1 mg. of elemental iron/kg./ day
12.5 of elemental iron/wk.
25 60 2 mg. of elemental iron/kg./ day
25 mg.of elemental iron/wk.

() Elemental Iron
Eurofer-Iron Eurodrug 50
(oral liquid) (Berli Jucker)
Ferium Emcurephama 50
(oral liquid) (Alliance pharma)
Ferro-BC K.B. phama 3
(Syrup)
Kidiron Thaipharmed 18
(oral liquid)
Pediron ST Pharma 15 0.6
(oral drop)
Eurofer Eurodrug 100
(Teb) (Berli-Jucker)
Femarate Pharmasant Lab 65
(Tab)
Ferrotabs Thaipharmed 60
(Tab)
F-Tab Medicine product 65
(Tab)
: www.MIMs.com/Thailand

Flow chart 1 :

- 6 24 1 mg. of elemental iron/kg./day

6 5 15 mg.of elemental iron/wk.
(iron supplement) - 25 60 2 mg. of elemental iron/kg./day
25 mg.of elemental iron/wk.

6 12 . Hb/Hct
Hb Hct CBC CBC
( 1 ) Hn/Hct
CBC
Hb 11 g/dL Hb 11 g/dL
/ Hct 33 vol% / Hct 33 vol%

/

Therapeutic trial Ferrous sulfate
(iron 4 - 6 mg. of elemental ion/kg/day for 1 Mo.
supplement)
1
hemoglobin
Repeat Hb/Hct
electrophoresis Hb > 1g/dL or Hct > 3%

Flow chart 2 Iron deficiency anemia

- 2
-
- Hb/Hct

(iron supplement)

66



Flow chart 2

1. Guild line intermittent iron supplementation in preschool and schoolage children. (cited 2014
August 1)WHO 2011.Available from URL
http://apps.who.int/iris/bitstream/10665/44648/1/9789241502009eng.pdf.
2. .
.
3. Recommended Guideline for Preventive Pediatric Health Care by The Royal College of Pediatricians
of Thailand, 2014. .
4. ..Royal Thai Army Med J
2009;62:155159.
5. , ..(cited 2014 August 1)
. CPG .Available from URL
http://www.thaipediatrics.org/html/index.php.

67

800,000 30
240,000
5 67
..2553 3-5 30 .. 2554
IQ 6-15 98.8 100
4 .. 2551-52 20
18 1

80
15-20

(Birth Asphyxia)
2,500 (Low Birth Weight) 17
2,500 (Cognitive)
8 2,500 (Low Birth Weight) 10 ( 5,000
) 11 7
(Birth Asphyxia)

(Epilepsy) (Mental
Retardation, Cerebral Palsy) (Learning Disabilities)
8 Birth
Asphyxia 2.5 ( 1,250)
Down syndrome
microcephaly

(Early Detection)
(Early Intervention)

68

 2

1. (physical development) : (gross motor)

(fine motor)
2. (cognitive development)
: (language and communication )
: (fine motor and adaptive delopment)
3. (emotional development) (self esteem)
4. (social development)
5. (spiritual development)

( non appropriated development)

DSPM DAIM
( delayed development)
(development assessment) TEDA4I
( deviancy or deviation )

( regression )

I. ( Developmental surveillance)
The American Academy of Pediatrics (APP) The British Joint Working Party on Child Health Services
(primary physician)
2

(infant - 0-1 ) - 7 -7, 1, 2, 4, 6, 9 12
(early childhood- 1-5 ) (15), 18 , 2, (2 1/2), 3
7 (3 1/2) 4

69

 3

(red flag)
(Red Flag)
2 ( lack of fixation)

4 (lack of visual tracking )

(lack of steady head control while sitting )
6 ( failure to turn to sound or voice )
(lack of smiles or other joyful expressions )
9 (lack of babbling consonant sounds )
(lack of reciprocal/back-and-forth sharing
ofvocalization, smiles, or other facial expressions )
( inability to sit )
12 ( failure to respond to name when called )
( absence of babbling )
( lack of reciprocal gestures : showing,reaching,waving )
15 (lack of pro-declarative pointing orother
showing gestures )
(lack of single words )
18 ( inability to walk independently
(lack of simple pretend play )
(lack of spoken language/gesture combinations )
24 (lack of two-word meaningful phrases : without imitating or repeating )
36 ( failure to speak in three-word sentences )
( loss of previously acquired babbling,speech, orsocial
skills )
: Gerber RJ,2010 Wilks T,2010 Gerber RJ,2011

5
1.
2.
3.
4.
5.

1. (-5 ) (Developmental Surveillance
and Promotion Manual:DSPM) ( 1)
2. Birth asphyxia / Low birth weight
(Developmental Assessment for Intervention Manual: DAIM) Birth asphyxia
/ Low birth weight ( 2)

70

 4

3. Birth asphyxia / Low birth weight

(Developmental Assessment for Intervention Manual: DAIM)
( 3)
Down syndrome, microcephaly ,chromosome abnormality, CNS anormaly
hypoglycemia , neonatal jaundice, neonatal seizure, , meningitis, polycytemia ,
7

- 1 2 1
1 / 2 / 3
- (developmental screening
test)

II. (developmental screening)

(developmental assessment)
9,18,30,42

III (developmental evaluation or assessment )

71

 6

1 (-5 )

.././

./. (DSPM)


1

.././

./.

1 (DSPM)


././
(DSPM)
./.

- 2


- .**/./.
(TEDA4I/TDSI 145 )

/
3

./.
3
1)


2) ./.
(TEDA4I)
/

4


3) TDSI 654 TDSI
./. CPG

5

: -
- 9, 18, 30 42
- .** TEDA4I /TDSI 145

72

 6

( 5 )

1. DSPM
5 (Well Child Clinic) /
./././. (DSPM)

1 (DSPM)
../ . /./. 2

-
- 9, 18, 30, 42
-
/
/ 5 /

-

(DSPM) 1

2 (DSPM)

(TEDA 4I)

3 (TEDA 4I)
. /./.
-
3

-
/
5 /

-
5 (TDSI 654 ) CPG
7
./.


4 5 (TDSI 654 )

5 (TDSI 654 ) /
( Home Program)
3

5 CPG

CPG
5 (TDSI 654 )

73

2 Birth asphyxia / Low birth weight

LR (LCDIP 1) PP / NB/ NICU (LCDIP 2)

 9

2 Birth asphyxia / Low birth weight

LR (LCDIP 1) PP / NB/ NICU (LCDIP 2)

- -
-

- 1. (BA,LBW)
2. ,HRNB
-
LCDIP3



././.
DAIM (DAIM)

././. (DAIM)

1

././. (DAIM)
DAIM

.**/ ././
TEDAI 14 / (TEDAI : 14 ) ( )

/

3

././

(TEDAI :14 ) ( )
TEDAI (14 ) /

- /
DSPM654

././ /
- CPG

- / 5
(TDSI: 654) (
)
- /
/

.** TEDA4I

74

 8

Low Birth Weight /

BirthAsphyxia()
(Low Birth Weight) / (Birth Asphyxia)
(Lanna Child Development Integration Project)

1 LCDIP1 ././.

48 .

2 LCDIP2 ././.

././. 2,500 /
LCDIP2 ()

(Developmental Assessment For Intervention Manual : DAIM) 7
48

3 (Developmental Assessment
For Intervention Manual : DAIM ) ././. LCDIP 3

2,500 /
LCDIP 3 ( Birth Asphyxia / Low Birth Weight) Well child
clinic (WCC ) High Risk Newborn (HRNB)

-
-
1

- ././

4 (TEDA 4I)
././
(TEDA 4I) / 3

-

- ././ 5

75

 9

5 5 (TDSI 654 )
././ TDSI 654
CPG

(Birth Asphyxia and/or Low Birth Weight)

1. LCDIP 1 (LR)
- APGAR 7 1, 5, 10 ()
- LBW (BW < 2500 g)
2. LCDIP 2
2.1 (1) 1
() - P.P ()
(2) 5 -
(Discharge status) - Nursery ()
(/)
2.2 (1) 5
- P.P ()
-
- Nursery ()
(/)
- Sick Newborn
- NICU ()
3. LCDIP 3
3.1 (1) ,
HRNB
(Developmental Assessment
For Intervention Manual; -
DAIM) -
-
- ( DAIM)
TEDA4I 145
TDSI 654
3.2 (1)
TEDA4I 145 -
(2) -
TDSI 654 -

76

 10

.

.. .
. LCDIP 1 LCDIP 2

(LCDIP 3)
case
./. LCDIP 1 LCDIP 2
case .

(LCDIP 3)
case
refer case .
case
case

LCDIP

. case

.

case
MCH
case
MCH

77

 14

3

DAIM

././.
DAIM (DAIM)


(DAIM)
././.

1

././. (DAIM)
DAIM

.**/ ././
TEDAI 14 / (TEDAI : 14 ) ( )

/

3

././

(TEDAI :14 ) ( )
TEDAI (14 ) /

TDSI 654 - /

././ /


- CPG

- / 5
(TDSI: 654) (

)
- /

.** TEDA4I

78

 12

3
Down syndrome, microcephaly ,chromosome
abnormality, CNS anormaly hypoglycemia , neonatal
jaundice, neonatal seizure, , meningitis, polycytemia , 7
(Early intervention)
1 DAIM ../././.
-
-
-
/
/ 5 /

-
(DAIM)
1
2 (DAIM)

(TEDA 4I)
3 (TEDA 4I)
. /./.
-
3

-
/
5 /

-
5 (TDSI 654 ) CPG
./.
4 5 (TDSI 654 )
5 (TDSI 654 ) /
( Home Program)
3
5 CPG
CPG
5 (TDSI 654 )

79

 13


1. , , .,. .
:.
2. , , ,.Guideline in Child HealthSupervision.
:,2557
3. , , , , , ,
, , . 4 2551-52. .
.: ; 2553.
4. :
0-5 . : ; 2551.

80



Clinical Practice Guideline for Children with Delayed Speech
Clinical Practice Guideline for Children with Delayed Speech

5-8 National Health

Examination Survey
203 ..2550 1-3 4-5
78.2
90

1. 2 50 24
2. * 50 36
(* )

1. 15
2. 3 ** 18
(** _ )

(Developmental surveillance)

1.1
1.2

1.3

81

 1.4 9, 15-18 24-30


1.5 ,
, Systematic review

2 /
2.1


2.2





1. (Hearing Impairment)
sensorineural loss 60 7 70
(Autosomal recessive) 75 (Autosomal dominant)
10-20 (syndromic hearing loss)
sensorineural hearing loss
Congenital Cytomegalovirus, Toxoplasmosis , Rubella
Fetal alcohol syndrome aminoglycoside

2.
( fine-motor
adaptive)
3. (Autistic Spectrum Disorder)

4. (Developmental language disorder DLD) (Specific
language impairment SLI) (nonverbal
intelligence)
(mix receptive-
expressivelanguage disorder)

3
OAE
Auditory Brainstem Response (ABR) objective test

82

 4
4.1

cochlear implantation

(Developmental language disorder DLD)

1.
2.

3.

4.

4.1

4.2

5.

4.2

1.
2. 1-2
3.

5 /

83

 6 /
1.

2. 6

3.

4. 9 18 24-30
1-2

*

(Screening For
Autistic 10
18 )

(Audiogram)

* Dx Hearing impairment



2-3 2-3





DDx Autism
- Globally delayed
development

Dx (Developmental
Dx language disorder (DLD)
+ DLD

* 1 74 ( (-5 ))
*

84


1. , , . .
, . 1 .
: ; 2550. 168-9.
2. Dixon SD. Two years: Language leaps. In Dixon SD, Stein MT. eds. Encounter with children:
Pediatric behavior and development. 4 th ed, Philadelphia: Mosby-Elsevier; 2006. p 385-6.
3. Coplan J. Normal speech and language development: an overview. Pediatr Rev 1995 ; 16(3) :
91-100.
4. Simms MD, Schum RL. Preschool children who have atypical patterns of development.
Pediatr Rev 2000; 21(5) : 147-158.
5. Feldman HM. Evaluation and management of language and speech disorder in preschool
children. Pediatr Rev2005;26(4):131-41.
6. American Academy of pediatrics, Council on Children with disabilities. Identifying infants
and young children with developmental disorders in the medical home: an algorithm for
developmental surveillance and screening. Pediatrics 2006 ; 118 : 405-20.
7. Joint committee on infant hearing. American Academy of Pediatrics. Year 2007 position
statement: principles and guidelines for early hearing detection and intervention programs.
Pediatrics 2007; 120:898-921.
8. Doyle KJ ,Ray RM. The otolaryngologists role in management of hearing loss in infancy
and childhood. MRDD Research Reviews 2003;9:94102.
9. Simms MD,Schum RL. Language development and communication disorder. In : Behrman
RE, Kliegman RM., Jensen HB,Stanton BF. Eds. Nelson Textbook of Pediatrics 18th ed.
Philadelphia : WB Saunders, 2007 : p152-62.
10. Teplin SW. : Autism and related disorders. In : Levine MD, Carey WB, Crocker AC. Editors.
Developmental-Behavioral pediatrics. Philadelphia : WB Saunder ; 1999 .p594-5.
11. Mawhood L., Howlin P., Rutter M. Autism and developmental receptive language disorder
a comparative follow up in early adult life. I: Cognitive and language outcomes. Journal of
Child Psychology and Psychiatry.2000; 41: 54759.
12. Clegg J, Hollis C, Mawhood L, Rutter M. Developmental language disorders a follow-up
in later adult life. Cognitive, language and psychosocial outcomes . Journal of Child
Psychology and Psychiatry.2005; 46(2 ):12849.
13. Rapin I . Practitioner Review: Developmental language disorder : a clinical update. J Child
Psychol Psychiat 1996;88:1211-8.

85



86



RTCOG Guideline : Prenatal Care

.. -
..
..-
..

(Prenatal
care)
















8 87

 .
(

-
)

(
-
)

ABO Rh

. (urine analysis)

(Last

menstrual period, LMP)
.
. .

.


(Ferrous
Fumarate )
. -
-

)
o -
o
o

9
88

. .

.
(Ferrous
Fumarate )
-
-

( )
(presentation)
( )

.


-

(induction of labor)




(external cephalic version)


10 89




()

()
(-)

()
-
- . . / (-)
(Dietary Reference Intake: DRI)
- , /()

90 8

P_8 8 9/3/13, 15:19






(Pre-eclampsia) (,)

FAO/WHO
FAO/WHO
.. () .. () .. ()
(/) (/) (/)

- ,
> , , ()

<
-
,
,
,
}
( )

<
-
,

,
, }

/(,)
/()
Calcium carbonate Calcium citrate (oral
bioavailability -%)() Calcium carbonate elemental calcium
Calcium citrate
(High dietary fiber)()
/ /() ( )

9
91

P_8 9 9/3/13, 15:19
 : ()

Elemental Calcium Content of Calcium Salts

Calcium salt % Calcium mEq Ca++/g

Calcium citrate 21 10.6

(Ca++
Calcium acetate 25 12.6
10.5 ./ )
Tricalcium phosphate 39 19.3
(Ca++
Calcium carbonate 40 20
12 ./)
1 mEq of elemental calcium = 20 mg

: elemental calcium contents

Calcium salt12,13 Content Total elemental Ca Packing

Calcium citrate 1500 mg 315 mg
950 mg 200 mg
Calcium acetate 1000 mg 253 mg
Calcium carbonate 625 mg, 1250 mg 250 mg,
500 mg
1000 mg,1500 mg 400 mg,
600 mg
835 mg 334 mg
Others Ca lactate-gluconate 1 g +
Ca carbonate 327 mg + vit C 1 g 260 mg Effervescent tab
Ca carbonate 1415 mg + Ca 600 mg Chewable tab
citrate 100 mg + Ca
gluconate 50 mg
Ca lactate-gluconate 1132 mg + 500 mg Effervescent tab
Ca carbonate 875 mg

92 10

P_8 10 9/3/13, 15:19
 : ()

(/ ) (/ )

, , ,
,
, , ,
,
, ,
, ,
, ,
,
, UHT
, ,
,
, UHT ,
,
, ,
,
, ,
,

()
Neural Tube Defects (NTDs)(-) ( Cleft lip,
Cleft palate, Congenital heart defects Limb defects )(,)

.


.

11 93

P_8 11 9/3/13, 15:19
 . (Recommended Dietary
Allowance : RDA)()
. /()

. . /
()
NTDs ()
(,,)
. NTDs NTDs, , clomiphene,
insulin dependent diabetes, BMI > 35 kg/m2 /
(-)

water soluble B-complex vitamin DNA
synthetic and most stable form
Recommended Dietary Allowance() /
/ NTDs()
()
: ()

(/ ) (/ )





.
() .

.



.
.

94 12

P_8 12 9/3/13, 15:19


glomerular filtration rate ()
. /() (WHO)
/() U.S. Institute of Medicine (IOM)
/ /() The American
Thyroid Association /
()
()

.
.
. -
/(,)
: WHO IOM

(/)

() WHO() IOM()

: ()

(/ ) (/ )

13 95

P_8 13 9/3/13, 15:19

(/) (/)

()
-

()
()
()


(-)
(-)

. /(,)
. (elemental iron) /(,)
()
. Homozygous E, Heterozygous E
()
. /
(iron
store) (,)
.
.

(citrus fruit) . .
(,)
. (,)


. (,)
.
/()

96 14

P_8 14 9/3/13, 15:19
 . stool examination,
Hb typing, serum ferritin
. Homozygous -thal -thal/HbE
Hemochromatosis

elemental iron /()
()

:
Elemental iron content of iron salts()
Iron % Iron
Ferrous gluconate
-

Ferrous sulfate
Ferrous fumarate
Polysaccharide-iron complex

Ferrous
Ferrous sulfate . elemental iron .
Ferrous fumarate . elemental iron .
Ferrous gluconate . elemental iron .
: ()

(/ ) (/ )

. , , .
, . , .
. .
(), . ,, .
, . , , .
.
.
,

15 97

P_8 15 9/3/13, 15:19

(/) (/)

, . , .
, . .
, . .
, . .
, . .
, , UHT .

, .
.
, .
, .
, .

()

Dietary Reference Intakes (DRIs)

Recommend Dietary Allowances (RDAs)

Estimated Average Requirements (EARs)

Adequate Intakes (AIs)

Tolerable Upper Intake Levels (ULs)

RDAs
( -)

EARs
( ) RDA (RDA
EARs+2SD)
AIs
RDAS
ULs

98 16

P_8 16 9/3/13, 15:19

. Ladipo OA. Nutrition in pregnancy: mineral and vitamin supplements. Am J Clin Nutr 2000; 72 (1 Suppl)
:280S-90S.
. Institute of Medicine. DRI dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and
fluoride. Washington DC: National Academy Press; 1997. Available from: http://www.nap.edu/
openbook.php?record_id=5776.
. Given M, Macy I. The chemical composition of the human fetus. J Biol Chem 1933;102:7-17. Available from:
http://www.jbc.org/content/102/1/7.full.pdf
. Prentice A, Jarjou LM, Cole TJ,Stirling DM, Dibba B, Fairweather-Tait S. Calcium requirements of
lactating Gambian mothers: effects of a calcium supplement on breast-milk calcium concentration,
maternal bone mineral content, and urinary calcium excretion. Am J Clin Nutr 1995;62(1):58-67.
. . 5. :
; 2546.
. Pongchaiyakul C, Charoenkiatkul S, Kosulwat V, Rojroongwasinkul N, Rajatanavin R. Dietary calcium
intake among rural Thais in Northeastern Thailand. J Med Assoc Thai 2008 ;91(2):153-8.
. . . : ; 2546.
. Institute of Medicine. Dietary Reference Intakes for calcium and vitamin D. 2010: Available from:
http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-
D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf
. FAO/WHO. Human vitamin and mineral requirements. Report of a joint FAO/WHO expert consultation.
Bangkok, Thailand. Food and nutrition Division, FAO, Rome. 2002.
. Prentice A. Calcium in pregnancy and lactation. Annu Rev Nutr 2000; 20:249-72.
. Borgsdorf LR, Cada DJ, Cirigliano MD, Covington TR, Generali JA, Hussar DA, et al. Drug facts and
comparison. Missouri: Wolters Kluwer Health, 2009:13.
. Borgsdorf LR, Cada DJ, Cirigliano MD, Covington TR, Generali JA, Hussar DA, et al. Drug facts and
comparison. Missouri: Wolters Kluwer Health, 2007:14.
. Fun WL, Evangelista FL, Francisco JC, Flores RMC, Fajayan LJA. MIMS Thailand. (123rded.), 2011;288-290.
. Booker C. Prenatal nutrition. 2010: Available from: http://emedicine.medscape.com/article/259059-overview.
. Wilson RD, Johnson JA, Wyatt P, Allen V, Gagnon A, Langlois S, et al. Pre-conceptional vitamin/folic
acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the
prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can 2007;
29(12):1003-26.
. De-Regil LM, Fern?ndez-Gaxiola AC, Dowswell T, Pe?a-Rosas JP. Effects and safety of peri-concep-
tional folate supplementation for preventing birth defects. Cochrane Database Syst Rev 2010;(10):CD007950.
. Czeizel AE, Dudas I. Prevention of the first occurrence of neural-tube defects by periconceptional
vitamin supplementation. N Engl J Med 1992; 327(26):1832-5.
. Berry RJ, Li Z, Erickson JD, Li S, Moore CA, Wang H, et al. Prevention of neural-tube defects with folic
acid in China. China-U.S. Collaborative Project for Neural Tube Defects Prevention. N Engl J Med 1999;
341(20):1485-90.
. CDC. Recommendations for the use of folic acid to reduce the number of cases of spina bifida and
other neural tube defects. MMWR Recomm Rep 1992;41(RR-14):1-7.
. WHO. Prevention of neural tube defects, Safer DoMP; 2006 : Available from: http://www.who.in
reproductivehealth/ publications/maternal_perinatal_health/neural_tube_defects.pdf
. Blencowe H, Cousens S, Modell B, Lawn J. Folic acid to reduce neonatal mortality from neural tube
disorders. Int J Epidemiol 2010; 39 Suppl 1:i110-21.
. Goh YI, Bollano E, Einarson TR, Koren G. Prenatal multivitamin supplementation and rates of congenital
anomalies: a meta-analysis. J Obstet Gynaecol Can 2006; 28(8):680-9.
. Norsworthy B, Skeaff CM, Adank C, Green TJ. Effects of once-a-week or daily folic acid supplementation
on red blood cell folate concentrations in women. Eur J Clin Nutr 2004 ;58(3):548
17 99

P_8 17 9/3/13, 15:19
 . Ministry of Health. Food and nutrition guidelines for healthy pregnant and breastfeeding women : a
background paper. Wellington: Ministry of Health, 2006.
. The Centers for Disease Control and Prevention (CDC). Preventing neural tube birth defects: a
prevention model and resource guide. 1998; Sixth printing: 2009: Available from: http://www.cdc.
gov/ncbddd/ orders/pdfs/09_202063A_Nash_Neural%20Tube%20BD% 20Guide% 20FINAL 508.pdf
. . 12. : , 2529.
. Dafnis E, Sabatini S. The effect of pregnancy on renal function: physiology and pathophysiology. Am J
Med Sci 1992;303:184-205.
. . .
2001;24(3):79-87.
. World Health Organization, United Nations Childrens Fund, International council for the control of iodine
deficiency disorders. Assessment of iodine deficiency disorders and monitoring their elimination. 3rd ed.
Geneva: WHO, 2007.
. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium,
copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium and zinc. Washington DC:
National Academy Press, 2001. Available from: http://www.nap.edu/ catalog/10026.html
. Becker DV, Braverman LE, Delange F, Dunn JT, Franklyn JA, Hollowell JG, et al. Iodine supplementation
for pregnancy and lactation-United States and Canada: recommendations of the American Thyroid
Association. Thyroid 2006;16(10):949-51.
. Lazarus J, Smyth PA. Iodine deficiency in pregnancy: Iodine deficiency and supplementation in
pregnancy. In: Preedy VR, Burrow GN, Watson R (eds.) Comprehensive handbook of iodine. Elsevier
Inc, 2009:469-76.
. Berbel P, Obreqon MJ, Bernal J, Escobar del Rey F, Morreale de Escobar G. Iodine supplementation during
pregnancy: a public health challenge. Trends Endocrinol Metab 2007;18(9):338-43.
. . . : , 2544.
. . 2554.: , 2554.
. DeMaeyer E, Adiels-Tegman M. The prevalence of anemia in the world. World Health Stat Q 1985;38(3):302-16.
. Stolzfus R, Dreyfuss M. Guideline for the use of iron supplements to prevent and treat iron deficiency
anemia. Washington DC: ILSI Press, 2005. Available from: http://www.who.int/ nutrition/publications/
micronutrients/guidelines_for_Iron_ supplementation.pdf.
. WHO. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva,
2003. Available from: http://www.who.int/maternal_child_adolescent/documents/corrections_rev2_2009.pdf.
. Lozoff B. Methodologic issues in studying behavioral effects of infant iron-deficiency anemia. Am J Clin
Nutr 1989;50(3 Suppl):641-51; discussion 52-4.
. WHO. Postpartum care of the mother and newborn: a practical guide. Technical Working Group. Birth
1999; 26(4):255-8.
. Xiong X, Buekens P, Alexander S, Demianczuk N, Wollast E. Anemia during pregnancy and birth
outcome: a meta-analysis. Am J Perinatol 2000;17(3):137-46.
. WHO. Iron and folate supplementation. Standards for maternal and neonatal care. Integrated Manage-
ment of Pregnancy and Childbirth (IMPAC). Vol. 1.8, Geneva, Switzerland: WorldHealth Organization.
Department of Making Pregnancy Safer(MPS), 2006: 16.
. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Sponh CY . Williams Obstetrics. 23rd
edition, The McGraw-Hill Companies, Inc. Available from: http://www.amazon.com/Williams-Obstetrics-
Edition-F-Cunningham/ dp/0071497013#reader_0071497013.
. WHO. Iron deficiency anaemia assessment, prevention and control: a guide for programme managers.
Available from: http://whqlibdoc.who.int/hq/2001/who_NHD_01.3.pdf
. Institute of Medicine. Nutrition during pregnancy and lactation: an implementation guide. Washington,
D.C.: National Academy Press, 1992.

10018

P_8 18 9/3/13, 15:19

-
-

..

.. -

.




(,)

9 101

 .
-
glucose metabolism
(overt DM)

.

(two-step approach)
(one-step approach)
. 50-g 1-h glucose challenge test (GCT)


. 100-g oral glucose tolerance test (OGTT)

(
) fasting plasma glucose

,
. 75-g oral glucose tolerance test (OGTT)
OGTT fasting plasma
glucose

.
50-g 1-h glucose
challenge test (GCT) /

. 100-g oral glucose tolerance test (OGTT)
. 75-g oral glucose tolerance test (OGTT)
one-step approach
()

. 50-g 1-h GCT /
> / 100-g OGTT , ,
/

102 10

 . -
/ two-step approach one-step approach

. fasting plasma glucose (FPG) HbA1C random
plasma glucose
FPG > / HbA1C > .% random plasma glucose

> / overt DM

FPG > / /

(GDM)
FPG < / 75-g 2-h OGTT -

. - 75-g 2-h OGTT

FPG > / overt DM

FPG < / GDM

11 103

 ( IADPSG)

. .. OSullivan Mahan() 100-g OGTT

( ) fasting plasma
glucose ,
whole blood , , /

type 2 diabetes
. .. Osullivan () 50-g 1-h GCT
100-g OGTT
. .. National Diabetes Data Group (NDDG)()
OSullivan Mahan()
thresholds .. Carpenter and Coustan()

thresholds , , , /
the American Diabetes Association (ADA)
.. ()
. The Fourth International Workshop-Conference on Gestational Diabetes Mellitus (
.. )
()

104 12


()

glucose intolerance
()
() (morbid obesity) (type 2)
impaired glucose metabolism

. Two-step approach 50-g 1-h GCT 2-h 75-g 3-h 100-g OGTT
. One-step approach 75-g OGTT
The American Diabetes Association American College of Obstetricians and Gyne-
cologists (ACOG)(,)
one-step two-step approach 75-g OGTT
, /

. WHO .. - ()
one-step 2 h OGTT ( FBS FBS
> / 2 hr > /



50-g 1-h
GCT /
. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group
(HAPO study) The International Association of Diabetes and Study Group (IADPSG)
.. HAPO ()

, 75-g OGTT -
random ( FPG level > /
2-h plasma glucose > / random plasma glucose >
/ < /) FPG
> , -, -, -, -, - < /

(thresholds)

IADPSG() HAPO
study Odd ratios (OR) outcome
. OR
. overt DM
- FPG > /
- HbA1C > . %
- Random plasma glucose > / FPG
HbA1C

13 105

 . GDM HAPO 75-g OGTT
- FPG > /
- 1-h plasma glucose > /
- 2-h plasma glucose > /
GDM
IADPSG
. FPG HbA1C random plasma glucose

. overt DM
. FPG > / / GDM
. FPG < mg/dL 75-g 2-h OGTT -
. - 75-g 2-h OGTT
. FPG > / overt DM
. 1 FPG < / GDM
.

. Weeks JW, Major CA, De Veciana M, Morgan MA. Gestational diabetes: does the presence of risk
factors influence perinatal outcome? Am J Obstet Gynecol 1994; 171: 1003-7.
. Poyhonen-Alho MK, Teramo KA, Kaaja RJ, Hiilesmaa VK. 50 gram oral glucose challenge test
combined with risk factor-based screening for gestational diabetes. Eur J Obstet Gynecol Reprod Biol
2005;121:34-7.
. OSullivan JB, Mahan CM. Criteria for oral glucose tolerance test in pregnancy. Diabetes 1964; 13: 278-85.
. OSullivan JB, Mahan CM, Charles D, Dandrow RV. Screening criteria for high-risk gestational diabetic
patients. Am J Obstet Gynecol 1973; 116: 895-900.
. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories
of glucose intolerance. Diabetes 1979; 28: 1039-57.
. Carpenter MW, Coustan DR. Criteria for screening tests for gestational diabetes. Am J Obstet Gynecol
1982; 144: 768-73.
. American Diabetes Association. Gestational Diabetes Mellitus. Diabetes Care 2000; 23: S77-9.
. Metzger BE, Buchanan TA, Coustan D, et al. Summary and recommendations of the Fifth International
Workshop-Conference on gestational diabetes mellitus. Diabetes Care 2007; 30: S251-9.
. American Diabetes Association. Gestational diabetes mellitus. Diabetes Care 2003; 26(Suppl 1): S103-5.
. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics: ACOG
Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30, September
2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol
2001; 98: 525-38.
. World Health Organization: Definition, Diagnosis and Classification of Diabetes Mellitus and Its
Complications. Report of a WHO Consultation. Geneva: World Health Organization; 1999.
. The HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcomes. N
Engl J Med 2008; 358: 1991-2002.
. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International


Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and
classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82.

106 14




(1)

(2)

1. (Impaired maternal fetal oxygen-

ation delivery)

Fick equation
VmO2 = Hbm x Qm x (SaO2 - SvO2)
Hbm =
Qm = intervillous space
(SaO2 - SvO2) =
oxyhemoglobin dissociation curve

oxyhemoglobin dissociation curve glycosylated hemoglobin (HbA1c)
P50O2
0.3 . 1 HbA1c (3)
(pregestational diabetes)
35-50

diabetic
ketoacidosis (DKA)
2,3 DPG
pH
2,3 DPG (4)

107

16

2552
 2. (placental - fetal oxygen transfer)
Fick diffusion equation
VO2 = Kp O2 X A (Sm O2 - SfO2)/L
Kp O2 = (placental oxygen diffusion constant)
A = villi
(Sm O2 -SfO2) = (placental membranes)

L = (basement membranes)
villi
thrombosis
(basement membranes)

3. (Impaired oxygen consumption)


4.
vasoconstriction
thrombosis villi


nonreassuring fetal status
pregestational DM
36 DKA 1
36 (nucleated RBC)

erythropoietin
HbA1C
erythropoietin (5)
erythropoietin HbA1C
(hematocrit) (neonatal polycythemia)
6 1
(nucleated RBC)
erythropoietin
ferritin transferrin free erythrocyte protoporphyrin
(neonatal hyperbilirubinemia) (1)

108

17 2552
 (6,7)

(neonatal hypoglycemia)
anaerobic metabolism
(polycythemia) 3

(nadir) 30- 90
90-180
hypoglycemia .. 2500
30 / 72 .
20 / ( 2,500 )

36 / 2-3
hypoglycemia 45 /
15 2 .
(transient) (permanent)

irritability

(early breast feeding) 2-4 .

3-4 . 6-8 //
3.6-4.8 /. / 10% dextrose solution 45 /

(7)

1 50
48-72 .
7 /
calcitonin

109

18
2552
 parathyroid (PTH)
calcitonin 1,25-(OH)2 cholecalciferol active form

(jitteriness) (generalized
convulsion)


2 10% calcium gluconate
10
24 .
2-3

(7)

adenylate cyclase PTH
functional hypoparathyroidism PTH
HbA1C

hyperexcitability

sinoauricular /
atrioventricular block

1

bone marker osteoclast osteoblast
(8)

110

19 2552

1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC. Wenstrom KD. Williams
obstetrics 22nd ed., New York, McGraw Hill 2005;1169-88.
2. Mimouni GS. Fetal oxygenation and mineral metabolism in diabetic pregnancy. In: Hod
M, Jovanovic L, Carlo Di Renzo, Alberto de Leiva, Langer O, eds. Diabetes and preg-
nancy. Martin Dunitz: London 2003:253-261.
3. Madsen H, Ditzel J. Blood oxygen transport in first trimester of diabetes pregnancy. Acta
Obstet Gunecol Scand 1984; 63:317-20
4. Bellingham AJ, Detter JC, Lenfant C. The role of hemoglobin affinity for oxygen and red
blood cell 2,3-diphosphoglycerrate in the management of diabetic ketoacidosis. Trnas
Assoc Am Phys 1970;83:113-20.
5. Widness JA, Terramo KA, Clemons GK, et al. Direct relationship of antepaetum glucose
control and fetal erythropoietin in human type 1 diabetic pregnancy. Deabetologia 1990;
33:378-83.
6. Lindsay CA. Pregnancy Complicated by Diabetes mellitus. In: Martin RJ, Fanaroff AA,
Walsh MC, eds. 8th ed. Neonatal perinatal medicine. Philadelphia: Elsevier; 2006;1: 321-
330.
7. Rigo j, De Curtis M. Disorders of calcium, phosphorus, and magnesium metabolism.
In: Martin RJ, Fanaroff AA, Walsh MC, eds. 8th ed. Neonatal perinatal medicine.
Philadelphia: Elsevier; 2006;1: 1491-1522.
8. Demarini S, Specker BL, Sierra RI, et al. Evidence of increased intrauterine bone
resorption in term infants of mothers with insulin-dependent diabetes. J Pediatr 1995;
126:796-8.

( )

111

20 2552

..-
..
..-
..

electronic fetal monitoring (EFM)
EFM
()

112 5


()
EFM
EFM

. EFM
.. EFM(,) National
Institute of Child Health and Human Development American College of Obstetricians and
Gynecologists Society for Maternal-Fetal Medicine
(baseline fetal heart rate) (variability)
(acceleration)
(deceleration) (periodic change)
.

(frequency)
(duration) (intensity) (relaxation time)



tachysystole

hyperstimulation hypercontractility
tachysystole (fetal heart
rate deceleration) deceleration
recurrent
tachysystole

6 113

 . fetal heart rate
(baseline fetal heart rate)
(periodic episodic
changes) (variability)

(tachycardia)

(bradycardia)

(baseline variability)


(absent)

(minimal)

(moderate) -

(marked)

Acceleration

acceleration

acceleration

Prolonged acceleration acceleration

acceleration

Early deceleration
(symmetrical)




Late deceleration

114 7






Variable deceleration



Prolonged deceleration


Sinusoidal pattern
sine -
. fetal heart rate tracings (classification)



(category I) : (normal)



-
(moderate variability)
late variable deceleration
acceleration

(category II) : (indeterminate)

(intrauterine resuscitation) (ancillary tests)



Bradycardia
Tachycardia

Minimal baseline variability
8
115

 Absent baseline variability recurrent decelerations
Marked baseline variability
Accelerations
acceleration

Periodic or episodic decelerations

Recurrent variable decelerations minimal moderate baseline

variability
Prolonged deceleration

Recurrent late decelerations moderate baseline variability

Variable decelerations
(overshoots)
deceleration (shoulders)
(category III) : (abnormal)


tachysystole



Recurrent late decelerations

Recurrent variable decelerations

Bradycardia

Sinusoidal pattern

. EFM ()
EFM
NICHD category I : normal
(continuous EFM)
NICHD category II :
indeterminate*
Baseline FHR changes - - +
( -
baseline variability
) - #
occipitoposterior

116 9

 EFM
FHR variability - +
FHR variability (fetal hypoxia) -
deceleration (acidemia) EFM
FHR variability minimal
marked continuous EFM

internal monitoring
-
#
(fetal hypoxia) - +
(acidemia) - oxytocin
-
#
FHR decelerations Variable decelerations : - +
FHR variability -
(amnioinfusion)
recurrent variable
decelerations
Late decelerations : - +
uteroplacental insufficiency - oxytocin
epidural block -
tachysystole #
NICHD category III : uteroplacental insufficiency - +
abnormal - oxytocin
(fetal hypoxia) - #
(acidemia)

Recurrent late
decelerations
Recurrent variable
decelerations
Bradycardia
Sinusoidal pattern

EFM = Electronic fetal monitoring; NICHD = National Institute of Child Health and Human Development;
FHR = fetal heart rate
* category II FHR tracings
+
(fetal pH) acoustic stimulation
#
10 117

 .
. Admission cardiotocography
Mires G () EFM
continuous EFM epidural block
(neonatal outcome)
(,) meta-analysis Gourounti K () admission
cardiotocography
Apgar (level of evidence : I)
admission cardiotocography


admission cardiotocography (low risk)
(level of evidence : IA)
. (Intermittent auscultation) or continuous EFM

meta-analysis Alfirevic Z ()
continuous EFM intermittent auscultation continuous EFM
(perinatal mortality)
cerebral palsy continuous EFM
(level of evidence : I) Nelson KB ()
positive predictive value non-reassuring pattern cerebral palsy
, .
(level of evidence: II-2) cerebral palsy
cerebral palsy
Intermittent auscultation NICE/RCOG guideline .. ()
doptone stethoscope - first stage of labor
second stage of labor
(recommendation grade : C)
(intermittent
auscultation) continuous EFM
(recommendation grade: B)
.
oxytocin
continuous EFM (recommendation
grade : B)

118 11





non-stress test (NST) isoimmunization


epidural block


()

*
( clinical guidelines-algorithm-
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists)()

12 119

 .
.. EFM

first stage of labor second stage of labor
first stage of labor second
stage of labor()
.. EFM (variability of assessment)
fetal heart rate tracing
-(,) (Level of evidence: III)

.. EFM
EFM


continuous EFM
EFM deceleration bradycardia
tachycardia minimal or absent baseline variability() (level of evidence II-2)
(intrauterine resuscitation)

.. EFM

()

Narcotics Variability acceleration equivalent doses : mg
meperidine = mg morphine = . mg fentanyl = mg nalbuphine
Cocaine Long-term variability
Corticosteroids Betamethasone variability

Magnesium Short-term variability
sulfate (acceleration)
Terbutaline tachycardia

120 13


. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl
Vital Stat Rep 2003;52:1-113.
. Low JA, Pickersgill H, Killen H, Derrick EJ. The prediction and prevention of intrapartum fetal asphyxia
in term pregnancies. Am J Obstet Gynecol 2001;184:724-30.
. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and
Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation,
and research guidelines. Obstet Gynecol 2008;112:661-6.
. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics. 23rd ed.
New York: Mc Graw-Hill, 2010:654-8.
. Bailey RE. Intrapartum fetal surveillance. In: Leeman L, ed. Advanced Life Support in Obstetrics Program:
Provider Course Syllabus. Leawood, Kan. : American Academy of Family Physicians; 2009.
. Mires G, Williams F, Howie P. Randomised controlled trial of cardiotocography versus Doppler
auscultation of fetal heart at admission in labour in low risk obstetric population. BMJ 2001;322:1457-60.
. Cheyne H, Dunlop A, Shields N, Mathers AM. A randomized controlled trial of admission electronic fetal
monitoring in normal labour. Midwifery 2003;19:221-9.
. Impey L, Reynolds M, MacQuillan K, Gates S, Murphy J, Sheil O. Admission cardiotocography: a
randomized controlled trial. Lancet 2003;361:465-70.
. Gourounti K, Sandall J. Admission cardiotocography versus intermittent auscultation of fetal heart rate:
effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumental
delivery--a systematic review. Int J Nurs Stud 2007;44:1029-35.
. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal
monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006,
Issue 3. Art. No.: CD006066.
. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in
predicting cerebral palsy. N Engl J Med 1996;334:613-8.
. The NICE clinical guideline 55. Intrapartum care: care of healthy women and their babies during
childbirth. September 2007.
. The RANZCOG Intrapartum fetal surveillance. Clinical guideline. 2nd ed. May 2006.
. ACOG practice bulletin. Clinical management guidelines for Obstetricians-Gynecologists Number 106.
Obstet Gynecol 2009;114; 192-202.
. Nielson PV, Stigsby B, Nickelsen C, Nim J. Intra- and inter-observer variability in the assessment of
intrapartum cardiotocograms. Acta Obstet Gynecol Scand 1987;66:421-4.
. Beaulieu MD, Fabia J, Leduc B, Brisson J, Bastide A, Blouin D, et al. The reproducibility of intrapartum
cardiotocogram assessments. Can Med Assoc J 1982;127:214-6.
. Ayoubi JM, Audibert F, Vial M, Pons JC, Taylor S, Frydman R. Fetal heart rate and survival of the very


pretmature newborn. Am J Obstet Gynecol 2002;187:1026-30.

14 121



()
- ()
(evidence-based)

(intrauterine growth restriction, IUGR)
(, )

(constitutionally small) (functional
definition) IUGR
() IUGR
(small-for-gestational-age, SGA)
(, , ) severe IUGR
()

(symmetrical)
-(, )
(, , -)
(head circumference: HC) (abdominal circumference: AC) [HC/AC ratio]
(asymmetrical)
HC/AC ratio
(brain sparing)(, , )

6
122

P_6 6 28/8/13, 13:36
 -(, ) (uteroplacental
insufficiency: UPI) (, , ) IUGR
IUGR ()

. -
() IUGR(, , ) (stillbirth)
IUGR
. -
.

.
( C)()
. (symphysis-fundal
height: SFH) - SFH
+ ()
(, ) ( C)() SFH
(, , )
.
. triple test quadruple test
preeclampsia
IUGR(, , ) Royal College of Obstetricians and Gynaecologists (RCOG)

SGA ( B)()
()
. (growth curve)
customized growth curve


(, ) growth curve
( C)()

7
123

P_6 7 28/8/13, 13:36
 . (ultrasound: US)
. IUGR US
crown-to-rump length ()
US


()
. IUGR
() US
- (, , ) ( C) ()
. (fetal biometry) parameters
biparietal (BPD)
(HC) (AC) femur (FL) AC
IUGR asymmetrical
parameters (, ) AC
IUGR(, ) ( A)()
. (estimated fetal weight: EFW)
IUGR parameters . EFW
-() EFW
IUGR ( A)()
EFW AC IUGR biometry
(gold standard) ()
. (growth velocity) AC /
EFW IUGR
AC EFW - (, , )
(false-positive) IUGR ( C)()
. (body proportions) HC/AC ratio
+2SD IUGR
UPI (asymmetrical)(, , ) AC, EFW ()
FL/AC ratio . asymmetrical IUGR(, )
- US
()
IUGR (, )
maximum vertical pocket US

8
124

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RCOG ( A)()
4-quadrant amniotic fluid index (AFI)
quadrants
. Doppler velocimetry
- IUGR
Doppler US uterine IUGR

- () RCOG
Doppler uterine (, , -)
SGA ( A)()
-
( A)()
SGA
( C)() Society for
Maternal-Fetal Medicine Publications Committee (SMFM) Doppler
IUGR ( A, Evidence
Levels II & III)()
-
Doppler US (umbilical artery: UA) IUGR
UPI UA Doppler
SGA IUGR()

(, ) UA Doppler
UA Doppler AEDV, REDV
(, ) ()
Doppler US middle cerebral (MCA)

IUGR
MCA () Doppler
- biophysical
(, ) RCOG MCA Doppler
IUGR
( B)() IUGR UA Doppler MCA
Doppler PI <

9
125
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 ( C)() MCA Doppler
( C)()
Doppler US ductus venosus (DV) DV waveform

DV Doppler
- biophysical profile ()
- ()
RCOG DV Doppler
( A)() IUGR UA Doppler
DV Doppler ()
Doppler US (umbilical vein: UV)
UV (pulsations)(, )
UA AEDV REDV ()
arterial venous Doppler
arterial Doppler
IUGR venous Doppler () American
College of Obstetricians & Gynecologists (ACOG)() SMFM()
Doppler MCA DV IUGR
( C, Evidence Levels II & III)()

Doppler ()

Uterine artery pulsatility index (PI) , notching IUGR
UPI
Umbilical artery PI systolic/diastolic (S/D) ratio
absent end-diastolic velocity (AEDV) Neurological impairment
reversed end-diastolic velocity (REDV)
Middle cerebral end-diastolic flow S/D ratio
artery Neurological impairment
Ductus venosus a-wave decreased, absent reversed flow

Umbilical vein (pulsations)

10
126
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28/8/13, 13:36
 US
()
(, -) IUGR ( A)()
US (, -)
UA Doppler - ( B)()

. - IUGR (, , )
Doppler uterine artery () IUGR
( C)() symmetrical IUGR IUGR -
(, )
IUGR trisomy 18()
. - IUGR -(, ) cytomegalovirus (CMV)
toxoplasmosis
HIV(-, ) / US
/ ventriculomegaly
TORCH titer titer DNA (, )
() ()
RCOG CMV toxoplasmosis IUGR ( C)()

IUGR
(, )


()
. ()


. IUGR
()
()
perinatal benefit()

11
127
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(fetus) (neonate)
()
IUGR
()
.
()
. (cardiotocography: CTG)
non-stress test (NST) reactive NST
() contraction stress test (CST)
respiratory reserve CST
()
(computerized analysis) short-term variability ( A)()
FHR variability
FHR variability
decelerations () CTG
IUGR ( A)() CTG short-term
variability DV Doppler
(, )
. biophysical profile (BPP)
()
(, -) RCOG BPP
( A)() BPP
() - IUGR UA
Doppler AEDV, REDV
(, )
. Doppler US
- UA Doppler IUGR ( A(, ),
Evidence Levels I()) -
- UA Doppler (
B)()
- UA Doppler PI +2SDs end-diastolic flow
AEDV/REDV
BPP Doppler (, )

12
128
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28/8/13, 13:36
 - ACOG UA Doppler NST /
BPP IUGR ( A)()
.

( A)(, ) RCOG -+
course ( C)() ACOG
MgSO4 (neuroprotection) ( A)()
. IUGR

plasma volume
expansion aspirin heparin
(, -, , ) ( A)(, )
IUGR /
( A)() aspirin
IUGR IUGR
(, ) RCOG preeclampsia
IUGR ( C)()
( A)()
. IUGR
( C)() ()

(, )

IUGR
(, )
/
(, ) RCOG IUGR UA Doppler
( A)()
IUGR ()

- - periviable

13
129
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()
- > - < UA Doppler
AEDV (reassuring)
REDV
( C)()
- -

()
(ACOG -+ ()) isolated IUGR
- () (ACOG
-+ ())
(
) ()()
()
ACOG IUGR ( C)() RCOG
IUGR AREDV UA Doppler
PI end-diastolic flow
( B)()
UA
Doppler AEDV/REDV late decelerations
IUGR (, )
.



meconium aspiration

14
130
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 IUGR(, , )

15
131
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28/8/13, 13:36

. American College of Obstetrician & Gynecologist (ACOG) Practice bulletin no. 134: fetal growth
restriction. (Joint with the Society for Maternal-Fetal Medicine). Obstet Gynecol 2013;121(5):1122-33.
. Baschat AA, Galan HL, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Niebyl JR,
Simpson JL, Landon MB, Galan HL, Jauniaux ERM, Driscoll DA,editors. Obstetrics: Normal and
Problem Pregnancies, 6th ed. Saunders Elsevier, Philadelphia, 2012. p. 706-41.
. Ross MG. Fetal growth restriction. [Internet] 2013 [updated 2013 Mar 8; cited 2013 May 25].
Available from: http://emedicine.medscape.com/article/261226-overview#showall.
. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics,
23rd ed. The McGraw-Hill company, United States of America 2010. p.189-214, 842-53.
. Resnik R, Creasy RK. Intrauterine growth restriction. In: Creasy RK, Resnik R, Iams JD,
Lockwood CJ, Moore TR, editors. Creasy & Resniks Maternal-Fetal Medicine: Principles and
Practice, 6th ed. Sauders Elsevier. Philadelphia 2009. p.635-50.
. Lausman A, McCarthy FP, Walker M, Kingdom J. Screening, diagnosis, and management of
intrauterine growth restriction. J Obstet Gynaecol Can 2012;34(1):17-28.
. Divon MY. Overview of causes of and risk factors for fetal growth restriction & Diagnosis of fetal
growth restriction. Up-To-Date version 23.0. [Internet] 2013 [updated 2013 May 17; cited 2013
May 25]. Available from: http://www.uptodate.com
. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No.31. The
investigation and management of the small-for-gestational-age fetus. 2nd ed. Feb 2013. Available
from: http://www.rcog.org.uk/files/rcog-corp/22.3:13GTG31SGA.pdf
. Figueras F, Gardosi J. Intrauterine growth restriction: new concepts in antenatal surveillance,
diagnosis, and management. Am J Obstet & Gynecol 2011;204(4):288-300.
. Resnik R. Fetal growth restriction: evaluation and management. Up-To-Date version 23.0. [Internet]
2013 [updated 2013 May 2; cited 2013 May 25]. Available from: http://www.uptodate.com
. Society for Maternal-Fetal Medicine Publications Committee, Berkley E, Chauhan SP, Abuhamad
A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol.
2012;206(4):300-8.
. Bamfo JE, Odibo AO. Diagnosis and Management of Fetal Growth Restriction. J Pregnancy.
2011;2011:640715. Epub 2011 Apr 13. Available from: http://www.hindawi.com/journals/jp/2011/
640715/

16
132
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- ()



..
- ()



() sub-Saharan African .
. ()
.()
(.. -)()

-

Perinatal morbidity
and mortality(-), low birth weight and premature
babies(-), stillbirths(,), anemia(,), eclampsia() (psychosocial) Klein
HIV

(
)
(,) -

() ()

-

7 133







(, )
(-)



-







Burt

. billion

dollars .. billion dollars
(,)
.. ()






(-)




(,-)
















()

134 8








()




(..
-)












(-)

. Definitions in Adolescent Pregnancy. 2004, Department of Reproductive Health and Research,

World Health Organization Geneva. P5.
. Phupong V. Adolescent pregnancy. In: Reproductive health in extreme ages: how to approach. Bangkok
: Royal Thai College of Obstetricians and Gynecologists; 2005:180-9.
. Darroch JE, Singh S, Frost JJ. Differences in teenage pregnancy rates among five developed countries:
the roles of sexual activity and contraceptive use. Fam Plann Perspect 2001; 33: 244-50.
. Isaranurug S, Mo-suwan L, Choprapawon C. Differences in Socio-Economic Status, Service Utilization
and Pregnancy Outcomes between Teenage and Adult Mothers. J Med Assoc Thai 2006;89 (2):145-51.
. Delivery summary, Department of Obstetrics and Gynecology, Bhumibol Adulyadej Hospital 2009-10.
. .
9 135

 . Bee H. The growing child. New York: Harper Collins Publishers; 1995: 325-403.
. Ziadeh S. Obstetric outcome of teenage pregnancies in North Jordan. Arch Gynecol Obstet 2001;265: 26-9.
. Olausson PO, Cnattingius S, Haglund B. Teenage pregnancies and risk of late fetal death and infant
mortality. Br J Obstet Gynecol 1999; 106: 116-21.
. Bukulmez O, Deren O. Perinatal outcome in adolescent pregnancies: a case-control study from a Turkish
university hospital. Eur J Obstet Gynecol Reprod Biol 2000; 88: 207-12.
. Reichman NE, Pagnini DL. Maternal age and birth outcomes:data from New Jersy. Fam Plann Perspect
1997;29:268-7.
. Gortzak-Uzan L, Haiiak M, Press F, Katz M, Shoham-Vardi I. Teenage pregnancy: risk factors for
adverse perinatal outcome. J Matern Fetal Med 2001;10:393-7.
. Golding J, Shenton T. Low birth-weight and pre-term delivery in South-east-Asia. The WHO International
Collaborative Study of Hypertensive Disorders of Pregnancy. Soc Sci Med 1990; 30: 497-502.
. Watcharaseranee N, Pinchantra P, Piyaman S. The Incidence and Complications of Pregnancy at Chonburi
Hospital. J Med Assoc Thai 2006;89:118-23.
. Demir SC, Kadyyfcy O, Ozgunen T, Evruke C, Vardar MA, Karaca A, et al. Pregnancy outcomes in
young Turkish women. J Pediatr Adolesc Gynecol 2000;13:177-81
. Smith GCS. Teenage pregnancy and risk of adverse perinatal outcomes associated with first and second
births: population based retrospective cohort study. BMJ2001;323:476-80.
. Osbourne GK, Howat RC, Jordan MM. The obstetric outcome of teenage pregnancy. Br J Obstet
Gynaecol 1981;88:215-21.
. Geist RR, Beyth Y, Shashar D, Beller U, Samueloff A. Perinatal outcome of teenage pregnancies in a
selected group of patients. J Pediatr Adolesc Gynaecol 2006;19:189-93.
. Eure CR, Lindsay MK, Graves WL. Risk of adverse pregnancy outcomes in young adolescent parturient
in an inner-city hospital. Am J Obstet Gynecol 2002;189:918-20.
. Mayor S. Pregnancy and childbirth are leading causes of death in teenage girls in Developing countries.
BMJ 2004;328 :1152-6.
. Makinson C . The health consequences of teenage fertility. Fam Plann Perspect1985; 17 (3): 132-9.
. , .
. Thai Pharm Health Sci J 2008;3(1):97-102.
.Klein L. Antecedents of teenage pregnancy. Clin Obstet Gynecol 1978; 21:1151-9.
. Furstenberg F, Brooks-Gunn J, Morgan S. Adolescent mothers and their children in later life. Fam Plann
Perspect 1987;19:142-51.
. Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: effects on education,
psychological status and subsequent pregnancy. Fam Plann Perspect 1989;21:248-55.
. Dott AB, Fort AT. Medical and social factors affecting early teenage pregnancy. Am J Obstet Gynecol
1975; 125:532-5.
.Singh SA, Torres A, Forrest JD. The need for prenatal care in the United States: evidence from the 1980
national nationality survey. Fam Plann Perspect 1985; 17:118-34.
. American Academy of Pediatrics. Committee on Adolescence and Committee on Early Childhood and
Adoption, and Dependent Care. Pediatrics 2001; 107 (2): 429-34.

136 10

.Hofferth SL, Reid L. Early Childbearing and Childrens Achievement and Behavior over Time.
Perspectives on Sexual and Reproductive Health 2002;34 (1): 41-3.
. Crockenberg S . Predictors and correlates of anger toward and punitive control of toddlers by adolescent
mothers. Child Dev 1987;58 (4): 964-75..
. Van Eyk N, Allen LM, Sermer M, Davis VJ. Obstetric outcome of adolescent pregnancies. J Pediatr
Adolesc Gynecol 2000; 13: 96.
.LeGrand TK, Mbacke CS. Teenage pregnancy and child health in the urban Sahel. Stud Fam Plann 1993:
24: 137-49.
. East PL, Felice ME. Outcomes and parent-child relationships of former adolescent mothers and their
12-year-old children. J Dev Behav Pediatr 1990; 11: 175-83.
. Teenage pregnancy. The problem that hasnt gone away. New York: Alan Guttmacher Institute, 1981.
. Trussell J. Teenage pregnancy in the United States. Fam Plann Perspect 1988;20:262-72.
. United States and cross national trends in teenage sexual and fertility behavior. New York: Alan Guttmacher
Institute, 1985.
.Burt M, Hoffner, D. Teenage childbearing: how much does it cost? A guide to determining the local costs
of teenage childbearing. Washington, DC: Center for Population Options, 1986.
. Elster A, Panzarine S. Unwed teenage fathers: emotional and health educational needs. J Adolesc Health
Care 1980; 182:116-20.
.Vaz R, Smolen P, Miller C. Adolescent pregnancy: involvement of the male partner. J Adolesc Health Care
1983; 4:-246-50.
. Hendricks LE, Howard CA, Caesar PP. Black unwed adolescent fathers: a comparative study of their
problems and help-seeking behavior. J Natl Med Assoc 1981; 73:863-8.
. Hendricks LE, Howard CS, Caesar PP. Help-seeking behavior among select population of black unmarried
adolescent fathers: implications for human service agencies. Am J Public Health 1981;71:733-5.
. Korenbrot CC, Showstack J, Loomis A, Brindis C. Birth weight outcomes in a teenage pregnancy case


management project. J Adolesc Health Care 1989; 10:97-104.

137




- (Adolescent birth rate)

(Millennium Development Goals, MDGs)()



( )

.. -



()










( )





138 6




MDGs

(Proxy indicator)















( )

(, )

Proxy indicator







-

7 139


. United Nations. Official list of MDG
indicators. [cited November
]. Available from: http://mdgs.un.org/
unsd/mdg/resources/attach/indicators/
officiallist2008.pdf.
. .

...
,
editor: ; .
. World Health Organization. World Health
Statistics 2013, Indicator compendium.
Geneva: World Health Organization; .
. World Health Organization. Reproductive
Health Indicators Guidelines for their
generation, interpretation and analysis
for global monitoring: World Health
Organization; .

( , )
A (.) <
B (.) -
C (.) -
D (.) -
E (.) >

( , )
A (.) .
B (.) .-.
C (.) + .
D (.) .-.
E (.) .

140 8



(/)- (/) (late preterm birth)
(early preterm birth)
functional maturity

, ,
., . . ,
. , ()

. (spontaneous preterm birth)
. (indicated preterm birth)
/

. (preterm ruptured of membranes)

. .

6
141
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. ()
() ( )
.
.

()

______ .
______ .
.
.
.
.

perinatal mortality rate (PMR)
, ( )()
PMR


necrotizing enterocolitis cerebral palsy, neurosensory
impairment

7
142
P_6-12 7

24/4/13, 17:54


.

.
asymptomatic bacteriuria
(pyelonephritis) (,)
.
Ureaplasma urealyticum Mycoplasma hominis
(microbial invasion of amniotic cavity, MIAC) mycoplasma
()
Bacterial vaginosis (BV) hydrogen peroxide-producing, lactobacillus-predominant
flora anaerobic Gardnerellavaginalis, Mobiluncus species
Mycoplasma hominis BV

metronidazole

Group B streptococci (GBS, Streptococci agalactiae) colonization
-(,) GBS (amnionitis)

GBS
(puerperal infection) Penicillin G
. Ampicillin
cefazolin



()
. (periodontal disease) ()
(oral prophylaxis and periodontal treatment)
(RR 0.5; 95% CI 0.20-1.30)()

8
143
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 .

. + . . . + . .
() .
-
()
()
-

. fetal fibronectin
Fetal fibronectin hepatocytes, fibroblasts
fetal amnion fetal
fibronectin (intracellular adhesion) decidual
cervicovaginal choriodecidual
cervicovaginal stromal remodeling
fetal fibronectin
cervicovaginal
fetal fibronectin
(negative predictive value) -
fetal fibronectin
()

. (Public educational interventions)


. (Public and Professional policies)



. (Nutritional supplements)

9
144
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.-, .- -.


-()
. (Pre-conceptional care for
women with risk)

.




. 17 - hydroxyprogesterone caproate
-

. micronized progesterone gel capsules
( )


. (Cervical cerclage)

(conization, loop electrosurgical excision procedure, diethylstilbestrol

10
145
P_6-12 10

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 exposure ) -


()

.


.
-

.


.
. fetal fibronectin bacterial vaginosis


.

. McIntire DD, Leveno KJ. Neonatal mortality and morbidity rates in late preterm births
compared with births at term. Obstet Gynecol 2008; 111: 35-41.
. Spong CY. Prediction and prevention of recurrent spontaneous preterm birth.Obstet Gynecol
2007; 110: 405-15.
. McManemy J, Cooke E, Amon E, Leet T. Recurrence risk for preterm delivery. Am J Obstet
Gynecol 2007; 196: 576. El-6.
. Bakketeig LS, Hoffman HJ. Epidemiology of preterm birth: Results from a longitudinal
study of births in Norway. In: Elder MG, Hendricks CH, eds. Preterm Labor. London;
Butterworths, 1981: p. 17.

11
146
P_6-12 11

24/4/13, 17:54
 . MacDorman MF, Munson ML, Kirmeyer S. Fetal and perinatal mortality- United States,
2004. Natl Vital Stat Rep 2007; 56(3): 1-19.
. Vazquez JC, Abalos E. Treatments for symptomatic urinary tract infections during
pregnancy.Cochrane Database Syst Rev 2011;(1):CD002256.
. Schneeberger C, Geerlings SE, Middleton P, Crowther CA. Interventions for preventing
recurrent urinary tract infection during pregnancy.Cochrane Database Syst
Rev2012;11:CD009279.doi: 10.1002/14651858.CD009279.pub2.
. Romero R, Espinoza J, Chaiworapongsa T, Kalache K. Infection and prematurity and the
role of preventive strategies. Semin Neonatol2002;7:259-74.
. Tor-Udom S, Tor-Udom P, Hiriote W. The prevalence of streptococcus agalactiae (group B)
colonization in pregnant women at Thammasat Hospital.J Med Assoc Thai 2006; 89: 411-4.
. Kovavisarach E, Ying WS, Kanjanahareutai S.Risk factors related to group B streptococcal
colonization in pregnant women in labor.J Med Assoc Thai 2007; 90:1287-92.
. Swadpanich U, Lumbiganon P, Prasertcharoensook W, Laopaiboon M. Antenatal lower
genital tract infection screening and treatment programs for preventing preterm
delivery.Cochrane Database Syst Rev2008:(2); CD006178.
. Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S.Periodontal disease and adverse
pregnancy outcomes: a systematic review. BJOG 2006;113:135-43.
. Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, et al.The length of the cervix
and the risk of spontaneous premature delivery. National Institute of Child Health and
Human Development Maternal Fetal Medicine Unit Network. N Engl J Med1996; 334: 567-72.
. Owen J, Yost N, Berghella V, Thom E, Swain M, Dildy GA3rd, et al. Mid-trimester
endovaginalsonography in women at high risk for spontaneous preterm birth. JAMA
2001;286:1340-8.
. Berghella V, Roman A, Daskalakis C, Ness A, Baxter JK. Gestational age at cervical
length measurement and incidence of preterm birth. Obstet Gynecol 2007; 110(2 Pt 1): 311-7.
. Iams JD.Prediction and early detection of preterm labour. Obstet Gynecol 2003;101: 402-12.
. Carmichael S, Abrams B, Selvin S. The pattern of maternal weight gain in women with
good pregnancy outcomes.Am J Public Health 1997;87:1984-8.
.Drakeley AJ, Roberts D, Alfirevic Z.Cervical stitch (cerclage) for preventing pregnancy loss


in women.Cochrane Database Syst Rev2003;(1):CD003253.

12
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 OHP-C

()
dysfunctional uterine Proluton Depot
bleeding, endometrial hyperplasia, .
amenorrhea . Oral preparation



() film-coated tablet
()


natural :
(threatened miscarriage)
micronized progesterone (Utrogestan) ,
(recurrent pregnancy loss)
. synthetic: dydrogesterone (Duphaston)

.

. Vaginal preparation

(soft capsule) pessary
. Intramuscular preparation

- hydroxyprogesterone caproate
(,)
( OHP-C)
vaginal preparation

vaginal preparation
(gestational diabetes) pessary

vaginal progesterone
() (,)

148 6


Utrogestan (soft capsule) ,
; Cyclogest 400 (pessary)
. Crinone (gel)
mg/applicator (Crinone %) dydrogesterone
.
Threatened miscarriage ()



Cochrane review
Preterm labor



( )



()

Recurrent pregnancy loss
.
( /

(PPROM)) OHP-C .
thrombophilias -
anti-phospholipid syndrome
( )()
.
luteal phase defects, immunotole rance (, prophylactic
derangements cerclage, uterine malformation)
. (
immunomodulatory agent pessary) -

7 149


( ) .
. - (median = )
( (cervical length < .)
/ ) micronized .
progesterone . -
( )()
- .
-/
( )() (cervical length - .)
.
- /
/
. ( )()





OHP-C Society for Maternal-Fetal Medicine (SMFM)
vaginal progesterone(.) ()
OHP-C
OHP-C

150 8

 : Randomized trials of progesterone
Author Date, Site Subjects Primary Intervention Results
Outcome
da Fonseca 2003, Brazil 157 women at Preterm birth Intravaginal progesterone RR 0.49
et al6 high risk for <37 weeks (100 mg) or placebo from (95% CI
preterm birth 24 to 34 weeks 0.25-0.96)
Meis et al11 2003, USA 463 women Preterm birth 17 -hydroxyprogesterone RR 0.66
with prior SPTB <37 weeks caproate (250 mg weekly) (95% CI
or placebo from 16-20 to 0.54-0.81)
36 weeks
OBrien et al7 2007, 659 women with Preterm birth Daily vaginal progesterone RR 1.08
Multinational prior SPTB <32 weeks gel (90 mg) or placebo (95% CI
from 18-22 6/7 to 37 weeks 0.76-1.52)
Rai et al12 2009, India 150 women with Preterm birth Oral micronized progesterone RR 0.20
prior SPTB between 28-31 (100 mg bid) or placebo (95% CI
6/7 weeks from 18-24 to 36 weeks 0.05-0.73)
Fonseca et 2007, UK, 250 women with Preterm birth Nightly intravaginal capsule RR 0.56
al13 Brazil, CL <15 mm <34 weeks (200 mg micronized (95% CI
Greece progesterone) or placebo 0.36-0.86)
from 24 to 34 weeks
Rouse et al15 2007, USA 661 twin Preterm birth Weekly IM injection of 250 mg RR 1.1
pregnancies or fetal death 17 -hydroxyprogesterone (95% CI
<35 weeks caproate or placebo from 0.9-1.3)
16-20 to 35 weeks
Hassan et al14 2011, USA 458 singleton Preterm birth Daily vaginal progesterone gel RR 0.55
pregnancies, <33 weeks or placebo from 20-23 6/7 (95% CI
asymptomatic to 36 6/7 weeks 0.33-0.92)
short cervix
(10-20 mm)
RR, relative risk; CI, confidence interval; SPTB, spontaneous preterm birth; CL, cervical length; IM,
intramuscularly.

9 151

 : SMFM

Population Recommendation regarding use of progestogens

Asymptomatic
Singletons without prior SPTB No evidence of effectiveness
and unknown or normal TVU CL
Singletons with prior SPTB 17P 250 mg IM weekly from 16-20 wk until 36 wk
Singletons without prior SPTB Vaginal progesterone 90-mg gel or 200-mg suppository
but CL <20 mm at <24 wk daily from diagnosis of short CL until 36 wk
Multiple gestations No evidence of effectiveness
Symptomatic
PTL No evidence of effectiveness
PPROM No evidence of effectiveness
17P, 17-alpha-hydroxy-progesterone caproate; CL, cervical length; IM, intramuscularly; PPROM,
preterm premature rupture of membranes; PTL, preterm labor; SPTB, spontaneous preterm birth;
TVU, transvaginal ultrasound.

SMFM

10
152

 SMFM

Acute tocolysis


()

Adjunctive tocolysis
(universal screening)


threatened preterm

labor

-agonists ritodrine micronized

progesterone .

.

. (adjunctive

tocolysis) ritodrine



- agonists


(individual practitioners)
()

Maintenance tocolysis

preterm labor acute
()
tocolysis OHP-C .


(multiple
- /
pregnancies) PPROM

() vaginal

progesterone maintenance tocolysis

vaginal micronized natural progesterone
PPROM(,)
.

()

11 153

 . Rebarber A, Istwan NB, Russo-Stieglitz K,
Cleary-Goldman J, Rhea DJ, Stanziano GJ, et
al. Increased incidence of gestational diabetes in
women receiving prophylactic 17 -
acute, adjunctive
hydroxyprogesterone caproate for prevention of
maintenance tocolysis()
recurrent preterm delivery. Diabetes Care
. 2007; 30: 2277-80.
vaginal progesterone . Gyamfi C, Horton AL, Momirova V, Rouse DJ,
OHP-C Caritis SN, Peaceman AM, et al. The effect of
Vaginal progesterone 17 - alpha hydroxyprogesterone caproate on
the risk of gestational diabetes in singleton or
twin pregnancies. Am J Obstet Gynecol 2009;

201: 392.e1-5.

. Di Renzo GC, Rosati A, Mattei A, Gojnic M, Gerli
S. The changing role of progesterone in preterm
(USFDA) labour. BJOG 2005; 112 Suppl 1: 57-60.
vaginal progesterone . Bulletti C, de Ziegler D, Flamigni C, Giacomucci
luteal support E, Polli V, Bolelli G, et al. Targeted drug delivery
() in gynaecology: the first uterine pass effect. Hum
OHP-C Reprod 1997; 12: 1073-9.
. da Fonseca EB, Bittar RE, Carvalho MH, Sugaib

M. Prophylactic administration of progesterone by
vaginal suppository to reduce the incidence of
spontaneous preterm birth in
National Institute of Child Health and . women at increased risk: a randomized
Human Development placebo-controlled double-blind study. Am J Obstet
OHP-C Gynecol 2003; 188: 419-24.
. OBrien JM, Adair CD, Lewis DF, Hall DR, Defranco
EA, Fusey S, et al. Progesterone vaginal gel for
the reduction of recurrent preterm birth: primary

results from a randomized, double-blind, placebo
()
controlled trial. Ultrasound Obstet Gynecol 2007;
conflict of interest 30: 687-96.
.Haas DM, Ramsey PS. Progestogen for preventing
miscarriage. Cochrane Database Syst Rev 2013;
. Di Renzo GC, Giardina I, Clerici G, CD003511.
Mattei A, Alajmi AH, Gerli S. The role .Walch KT, Huber JC. Progesterone for recurrent
of progesterone in maternal and fetal miscarriage: truth and deceptions. Best Pract Res
medicine. Gynecol Endocrinol 2012; 28: Clin Obstet Gynaecol 2008; 22: 375-89.
925-32.

15412

. El-Zibdeh MY. Dydrogesterone in the
reduction of recurrent spontaneous
abortion. J Steroid Biochem Mol Biol
2005; 97: 431-4.
. Meis PJ, Klebanoff M, Thom E, et al.
Prevention of recurrent preterm delivery
by 17 alpha-hydroxyprogesterone
caproate. N Engl J Med 2003; 348:
2379-85.
. Rai P, Rajaram S, Goel N, Ayalur
Gopalakrishnan R, Agarwal R, Mehta
S. Oral micronized
. progesterone for prevention of preterm
birth. Int J Gynaecol Obstet 2009;
104: 40-3.
. Fonseca EB, Celik E, Parra M, Singh
M, Nicolaides KH. Progesterone and
the risk of preterm birth among women
with a short cervix. N Engl J Med
2007; 357: 462-9.
. Hassan SS, Romero R, Vidyadhari
D, Fusey S, Baxter JK, Khandelwal
M, et al. Vaginal progesterone
reduces the rate of preterm birth in
women with a sonographic short
cervix: a multicenter, randomized,
double-blind, placebo- controlled trial.
Ultrasound Obstet Gynecol 2011; 38:
18-31.
. Rouse DJ, Caritis SN, Peaceman AM,
Sciscione A, Thom EA, Spong CY,
et al. A trial of 17 alpha-hydroxy
progesterone caproate to prevent
prematurity in twins. N Engl J Med
2007; 357: 454-61.
. Berghella V. Society for Maternal- Fetal
Medicine (SMFM). Progesterone and
preterm birth prevention: translating
clinical trials data into clinical practice.
SMFM clinical guideline. Am J Obstet
Gynecol 2012; 206: 376-86.
. Di Renzo GC, Roura LC, Facchinetti F, Antsaklis
A, Breborowicz G, Gratacos E, et al. Guidelines
for the management of spontaneous preterm
labor: identification of spontaneous preterm
labor, diagnosis of preterm premature rupture of
membranes, and preventive tools for preterm
birth. J Matern Fetal Neonatal Med 2011; 24:
659-67.
. Briery CM, Veillon EW, Klauser CK, Martin RW,
Magann EF, Chauhan SP, et al. Women with
preterm premature rupture of the membranes do
not benefit from weekly progesterone. Am J Obstet
Gynecol 2011; 204: 54.e1-5.
. Noblot G, Audra P, Dargent D, Faguer B, Mellier
G. The use of micronized progesterone
. In the treatment of menace of preterm delivery.
Eur J Obstet Gynecol Reprod Biol 1991; 40:
. 203-9.
. Facchinetti F, Paganelli S, Comitini G, Dante G,
Volpe A. Cervical length changes during preterm
cervical ripening: effects of 17- -
hydroxyprogesterone caproate. Am J Obstet
Gynecol
. 2007; 196: 453.e1-4.
. Borna S, Sahabi N. Progesterone for mainte-
nance tocolytic therapy after threatened preterm
. labor: a randomized controlled trial. Aust N Z J
Obstet Gynaecol 2008; 48:58-63.
. Romero R, Stanczyk FZ. Progesterone is not
the same as 17?-hydroxyprogesterone caproate:
implications for obstetrical practice. Am J Obstet
Gynecol 2013; 208: 421-6.
. Northen AT, Norman GS, Anderson K, Moseley
L, Divito M, Cotroneo M, et al, for the National
Institute of Child Health and Human Development
(NICHD) Maternal-Fetal Medicine Units
. (MFMU) Network. Follow-up of children exposed
in utero to 17 ?-hydroxyprogesterone caproate
compared with placebo. Obstet Gynecol 2007;
110: 865-72.
13 155

-
-

..-

-()
..
. ,
, ()

156 8

 (preeclampsia)






systolic diastolic
()
cuff
.
diastolic Korotkoff phase V
Korotkoff phase IV (-)

Proteinuria .
+ ( .)
(,) protein:creatinine
. ()
Classification
(,)

. Gestational hypertension
. Preeclampsia eclampsia syndrome
. Preeclampsia syndrome superimposed on chronic hypertension
. Chronic hypertension
()
. Gestational hypertension
() systolic .. diastolic ..

() proteinuria
()
()
()
. Preeclampsia

() systolic .. diastolic ..

9 157

 () Proteinuria . +


() systolic .. diastolic ..

() Proteinuria +

() serum creatinine . . ()
() ,
() lactate dehydrogenase (LDH)
() serum alanine aminotransferase (ALT) aspartate aminotransferase (AST)
()
()
. Eclampsia
. Superimposed preeclampsia on chronic hypertension
() Proteinuria .
proteinuria
() Proteinuria ,
proteinuria
. Chronic hypertension
() / ..
gestational trophoblastic disease
()

preeclampsia mild severe preec-
lampsia severe preeclampsia ()
systolic .. diastolic ..

Proteinuria +

Serum creatinine

Serum transaminase

Pulmonary edema

severe preeclampsia severe preeclampsia
antiphospholipid syndrome mild preeclampsia

158 10

 mild preeclampsia ()
systolic .. / diastolic ..
Proteinuria
Serum transaminase





proteinuria

(NST BPP )
serum transaminase
SPE
severe preeclampsia()


.
. (eclampsia)
. rales pulse oximetry
pulmonary edema
. AST ALT
.
. . Cr . .
. ,
. /

. ( )
. (Amniotic fluid index )
. late variable deceleration
. biophysical profile
. Doppler umbilical artery reverse diastolic blood flow
.

eclampsia

11 159

 mild preeclampsia (MPE)

160 12

 severe preeclampsia (SPE)

13 161

 eclampsia

162 14

 severe preeclampsia/ eclampsia

. MgSO4 ()
. IM regimen
- Initial dose: % MgSO4 -
% MgSO4
- Maintenance dose: % MgSO4

. IV regimen infusion pump MgSO4
. % MgSO4
. systolic .. diastolic
..
. LRS .
.
.

. endotracheal tube, ambu bag,
calcium gluconate

(Anticonvulsant drugs)(,-)

15 163


patellar reflex .
. dose . . .

creatinine > . . maintenance dose
Mg+
maintenance dose MgSO4 phenytoin .
( . - ) diazepam .
Mg+
Mg+
: . - . ./
Patellar reflex : - ./
: - ./
: - ./
: - ./

. Hydralazine (Apresoline)
: . .
Test dose : . (to avoid
idiosyncratic hypotensive effect)
Treatment dose : - -
- . - ()
: .
. Labetalol (Avexa)
: . .
: -
: -
: -
IV bolus: ampoules ( ./ .)
. . ./. .
- .
. . () -
. - total dose .()
IV drip: ampoules ( ./ .)
. . ./. drip . .
. . total dose . .
0.9%NSS, 5%D/NSS, 5%D/N/2, 5%D/RLS, RLS
: heart block first degree, sick
sinus syndrome, Prinzmetals angina, severe peripheral arterial disease,
cardiogenic shock

164 16

 . Nifedipine (Adalat)
: , .
Treatment dose : . ()
.
: MgSO4
. Nicardipine (Cardipine)
: . . , . .
: IV - -
: -
: -

IV push : nicardipine ( . .) ampoule + NSS . .
. . . IV - . (.- . .)

IV drip: nicardipine ( ./ .) ampoule + NSS .
. . . . IV - . (.- .
) titrate . . .

: Cardiogenic shock, recent MI or acute unstable angina, severe aortic stenosis

1. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Stong CY. Pregnancy
hypertension. In: Williams Obstetrics. 23rd ed. New York: McGraw - Hill, 2010; 706-56.
2. .. 2548-2552

3. Report of the National High Blood Pressure Education Program Working Group on High Blood
Pressure in Pregnancy. Am J Obstet Gynecol 2000;183:S1-S22.
4. ACOG Committee on Practice Bulletins--Obstetrics. ACOG practice bulletin. Diagnosis and management
of preeclampsia and eclampsia. Number 33, January 2002. Obstet Gynecol 2002;99(1):159-67.
5. Magee LA, Helewa M, Moutquin JM, von Dadelszen P; Hypertension Guideline Committee; Strategic
Training Initiative in Research in the Reproductive Health Sciences (STIRRHS) Scholars. Diagnosis,
evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can
2008;30(3 Suppl):S1-48.
6. Royal College of Obstetricians and Gynaecologists (2010). NICE clinical guideline 107 - Hypertension
in pregnancy: the management of hypertensive disorders during pregnancy. Available from
www.nice.org.uk/guidance/CG107.
7. Sibai BM. Master class: Management algorithms for mild gestational hypertension-preeclampsia.
September 4, 2008.
8. Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term: patient
selection, treatment, and delivery indications.Am J Obstet Gynecol 2007;196:514. e1-514.e9.
9. Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet
Gynecol 2003;102:181-92.

17 165


National Institutes of Health (NIH) Working Group on Hypertension in
Pregnancy ) chronic hypertension ) preeclampsia
eclampsia ) preeclampsia superimposed on chronic hypertension ) gestational
hypertension()

(,)
(,) preeclampsia chronic hypertension with superim-
posed preeclampsia

(-)
( > / .)
()
(fetal distress)
systolic blood pressure (SBP) diastolic blood pressure (DBP) - . - .
() hypertensive encephalopathy, hemorrhage, eclampsia
mean arterial pressure /
. (,)
severe preeclampsia, severe gestational hypertension

166 14

 ()
(FDA risk) ()
Labetalol (C) - . IV - . - hydralazine
.
- ./ asthma
congestive heart failure
neonatal
bradycardia ()
Hydralazine (C) . IV IM - . - NHBEP

.- .
. IV . IM

Nifedipine (C) - . FDA ()
. (intermediate-release tablets)
()
.
Diazoxide (C) - . IV -

DBP . -
.
FDA: Food and Drug Administration
NHBPEP: National High Blood Pressure Education Program Report on High Blood Pressure in Pregnancy

sympathetic
Meta-analysis (, )
() meta-analysis
(, ) hydralazine
hydralazine
labetalol nifedipine hydralazine
()
JOGC () MgSO4 nifedipine MgSO4

preeclampsia
diuretic preeclampsia ()
(Management of hypertension postpartum)


( ) severe
preeclampsia pulmonary peripheral edema furosemide

15 167

 ()
Captopril Labetalol Oxprenolol
Diltiazem Methyldopa Propanolol
Enalapril Minoxidil Spironolactone
Hydralazine Nadolol Timolol
Hydrochlorothiazide Nifedipine Verapamil

plasma protein binding

oral bioavailability

/ .
SBP DBP - . - .
labetalol, nifedipine, hydralazine
preeclampsia


References
. Roberts JM, Funai EF. Pregnancy-related hypertension. In: Creasy RK, Resnik R, Iams JD, Lockwood CJ, Moore TR,
editors. Creasy & Resniks maternal-fetal medicine: principles and practice. 6th ed. Philadelphia: Saunders Elsevier;
2009. p. 651-88.
. Sibai BM, Mabie WC, Shamsa F, Vilnar MA, Anderson GD. A comparison of no medication versus methyldopa or
labetalol in chronic hypertension during pregnancy. Am J Obstet Gynecol. 1990; 162: 960-7.
. Gruppo di Studio Ipertensione in Gravidanza. Nifedipine versus expectant management in mild to moderate hyperten-
sion in pregnancy. Br J Obstet Gynaecol. 1998; 105: 718-22.
. De Swiet M. Maternal blood pressure and birthweight. Lancet. 2000; 355: 81-2.
. von Dadelszen P, Ornstein MP, Bull SB, Logan AG, Koren G, Magee LA. Fall in mean arterial pressure and fetal growth
restriction in pregnancy hypertension: a meta-analysis. Lancet. 2000; 355: 87-92.
. Abalos E, Duley L, Steyn D, Henderson-Smart D. Antihypertensive drug therapy for mild to moderate hypertension
during pregnancy. Cochrane Database Syst Rev. 2007; CD002252.
. von Dadelszen P, Magee LA. Antihypertensive medications in management of gestational hypertension-preeclampsia.
Clin Obstet Gynecol. 2005; 48: 441-59.
. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy.
Am J Obstet Gynecol. 2000; 183: S1-S22.
. The Society of Obstetricians and Gynaecologists of Canada (SOGC). Diagnosis, evaluation, and management of the
hypertensive disorders of pregnancy. JOGC. 2008; 30 (3): S 1.
. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008; 51; 960-9.
. Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane
Database Syst Rev. 2006; 3: CD001449.
. Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in
pregnancy: meta-analysis. BMJ. 2003; 327; 955-60.
. The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the
European Society of Cardiology (ESC). 2007 Guidelines for the management of arterial hypertension. Journal of

hypertension. 2007; 25: 1105-87.

168 16

 (jaundice, icterus)

1 ./. (17 mol/L)

3 ./. (51 mol/L) tetrapyrrole pigment
heme 200-300
70-80
erythroid
turnover hemoprotein myoglobin cytochrome
0.2-0.9 mg/dL (3.4-15.4 mol/L)(1)

2
1. (pregnancy- specific)
2. (coincidentally in pregnancy)
hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of
hemolysis, elevated liver tests, and low platelets (HELLP), acute fatty liver of pregnancy (AFLP), intrahepatic
cholestasis of pregnancy (ICP)
(viral hepatitis, VH) intrahe-
patic cholestasis, hemolytic disorders (pyelonephritis)
tetracycline
Intrahepatic cholestasis of pregnancy (ICP)
(pruritus)
bile acid (BA)
1:500 1:1,000
BA
chronic placental insufficiency fetal distress

heterogeneous
bile canalicular membrane phospholipid translocator

2553 13 169

 [ATP-cassette transporter B4 (ABCB4) or multidrug resistant protein-3 (MDR3)]
sulfated progesterone metabolites BA (2)
( 6 . %) transaminase
( 250 U/L) BA 10-100 BA myometrial
contractility chorion fetal distress
BA 40 mol/L(3)

4 48
10-25 ursodeoxycholic acid (UDCA) antihista-
mine topical emollients malabsorption K fat-soluble vitamin

Acute fatty liver of pregnancy (AFLP)
acute metamorphosis acute yellow atrophy of liver


(recessively inherited abnormalities) mitochondrial fatty
acid oxidation G1528C (E474Q) code long-chain-3-
hydroxyacyl-CoA-dehydrogenase (LCHAD) fetal-maternal interaction
1 5 AFLP LCHAD long-chain fatty acid


microvesicular histology hepatocyte central nuclei cytoplasm with microvesicular
fat, periportal sparing minimal hepatocellular necrosis

37.5 (
31-42 ) malaise, anorexia, nausea, vomiting,
epigastric pain progressive jaundice 1-2
50 proteinuria
preeclampsia ascites
hypofibrinogenemia, hypoalbuminemia, hypocholesterolemia,
prolonged clotting times elevated serum transaminase 10 mg/dL
endothelial cell activation capillary leakage hemoconcentration, hepatorenal syndrome, ascites
hemolysis impaired cholesterol synthesis erythrocyte membranes
hepatic encephalopathy 60, severe coagulopathy
55 50 7-10
transient diabetes insipidus vasopressinase
acute pancreatitis
coagulopathy procoagulant consump-
tion fibrin split product D-dimers profound thrombocytopenia
(hepatic encephalopathy) lethargy, agitation, confusion

(coma)
170 14

 metabolic acidosis impaired clearance of serum
lactate (hepatocytes) -

preeclampsia
imaging
echogenicity computed tomography (CT) decrease or diffuse attenu-
ation 2 AFLP
(gold standard) (liver biopsy)

preeclampsia
acute fulminant viral hepatitis
VH ascites (4)

intensive


1. -
2. coagulopathy international normalized ratio 1.5
50,000

24

general anesthesia epidural analgesia mid-
line Pfannenstiel midline

Viral hepatitis (VH) in pregnancy

5 A (HAV), B (HBV), D (HDV) hepatitis B-associated delta agent, C (HCV) E (HEV)
Hepatitis B C hepatotoxic
hepatocellular 0.1
fulminant hepatic necrosis AFLP


(preexposure and postexposure at risk of infection)(5)
subclinical
malaise 1-2 A
transaminase 400 - 4,000 U/L

2553 15 171

 5-20 mg/dL transaminase
1-2 prolonged prothrombin time

Hepatitis B B DNA hepadnavirus
(hepatocellular carcinoma) hepatitis B
5-10
70-90 50 hepatitis B fulminant hepatitis
hepatic encephalopathy 80 (3)
50 immunological serum marker
acute chronic hepatitis hepatitis B virus (Dane particle), hepatitis B core antigen (HBcAg),
hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg) marker
HBsAg HBeAg early acute hepatitis marker
90 10 HBeAg
B

vertical transmission hepatitis B surface e antigen
anti-HBe antibody hepatitis B
85
hepatitis B immune globulin (HBIG,
0.5 .) 12 hepatitis B recombinant
recombinant 2 1-2 3 6 85-95(6)

1. Pratt DS, Kaplan MM. Jaundice. In: Fauci AS, Braunwald E, Kasper DL , Hauser SL, Longo DL, Jameson JL,
Loscalzo J, editors. Harrisons Principle of Internal Medicine. 17th ed. New York: McGraw-Hill; 2008; 261-6.
2. Jacquemin E, Cresteil D, Manouvrier S, Boute O, Hadchouel M. Heterozygous non-sense mutation of the
MDR3 gene in familial intrahepatic cholestasis of pregnancy. Lancet 1999; 353: 210-1.
3. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Williams Obstetrics 23rd ed. New
York: McGraw-Hill; 2010; 1063-65, 1067-71.
4. Devarbhavi H, Kremers WK, Dierkhising R, Padmanabhan L. Pregnancy-associated acute liver disease and
acute viral hepatitis: Differentiation, course and outcome. J Hepatol 2008; 49: 9305.
5. Hay JE. Liver Disease in Pregnancy. Hepatology 2008; 4: 1067-76.
6. Lee NM, Brady CW. Liver disease in pregnancy. World J Gastroenterol 2009; 15: 897- 906.



172 16


:, :,

-
(Preeclampsia) Eclampsia
HELLP (HELLP syndrome)

-

(necrosis)

portal (periportal necrosis) fibrin
portal

16
173



HELLP ,/..,

(liver imaging)

, - (ultra-
sonography) (computerized tomography) (magnetic
resonance imaging) (angiography)
(contrast)

(selective arterial embolization)

HELLP , , -

(hepatocellular carcinoma) (hepatic adenoma), acute fatty liver of pregnancy

,
(randomized trial)

. , ,

.
pack red cells, fresh frozen plasma

.
,
.
,

. (unstable hemodynamic status)

(conservative treatment)

174 17

 (laparotomy sponges packing)
(perihepatic drains) , , porta hepatis
gelfoam collagen impregnated materials
(hepatic artery ligation),
(hepatic resection or lobectomy)
(liver transplantation) (acute
liver failure) (severe hepatic necrosis) ,
activated
factor VII , Argon (Argon
beam electrocoagulation) spray
electrocautery (eschar) Argon beam coagulator

.
(stable hemodynamic status)




, ,
, , ,



(ischemic necrosis)
(sepsis) ,

-
,
,

18
175

2


HELLP

. Wicke C, Pereira PL, Neeser E, Flesh I, Rodegerdts EA, Becker HD. Subcapsular liver hematoma in
HELLP syndrome: evaluation of diagnostic and therapeutic options-a unicenter study. Am J
Obstet Gynecol 2004; 190: 106-112.
. Poo JL, G?ngora J. Hepatic hematoma and hepatic rupture in pregnancy. Ann Hepatol 2006;
5: 224-6.
. Rinehart BK, Terrone DA, Magann EF, Martin RW, May WL, Martin JN Jr. Preeclampsia-associated
hepatic hemorrhage and rupture: mode of management related to maternal and perinatal
outcome. Obstet Gynecol Surv 1999; 54: 196-202.
. Reck T, Bussenius-Kammerer M, Ott R, M?ller V, Beinder E, Hohenberger W. Surgical treatment
of HELLP syndrome-associated liver rupture-an update. Eur J Obstet Gynecol Reprod Biol 2001;
99: 57-65.
. Marsh FA, Kaufmann SJ, Bhabra K. Surviving hepatic rupture in pregnancy-a literature review
with an illustrative case report. J Obstet Gynaecol 2003; 23: 109-13.
. Sibai BM. The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): Much ado
about nothing? Am J Obstet Gynecol 1990; 162: 311-6.
. Sheikh RA, Yasmeen S, Pauly MP, Riegler JL. Spontaneous intrahepatic hemorrhage and hepatic
rupture in the HELLP syndrome: four cases and a review. J Clin Gastroenterol 1999; 28: 323-8.
. Knox TA, Olans LB. Liver disease in pregnancy. N Engl J Med 1996; 335: 569-76.
. Loevinger VH, Vujic I, Lee WM, Anderson MC. Hepatic rupture associated with pregnancy:
treatment with transcatheter embolotherapy. Obstet Gynecol 1985; 65: 281-4.
. Araujo AC, Leao MD, Nobrega MH, Bezerra PF, Pereira FV, Dantas EM, et al. Characteristics and
treatment of hepatic rupture caused by HELLP syndrome. Am J Obstet Gynecol 2006; 195: 129-
33.
. Hibbard LT. Spontaneous rupture of the liver in pregnancy: a report of 8 cases. Am J Obstet
Gynecol 1976; 126: 334-8.

176 19

 . Henny CP, Lim TE, Brummelkamp WH, B?ller HR, ten Cate JW. Spontaneous rupture of the
Glissons capsule during pregnancy: an acute surgical emergency. Neth J Surg 1982; 34: 72-5.
. Barton JR, Sibai BM. Hepatic imaging in HELLP syndrome (hemolysis, elevated liver enzymes, and
low platelet count). Am J Obstet Gynecol 1996; 174: 1820-5.
. Paley MR, Ros PR. MR imaging of the liver: a practical approach. Magn Reson Imaging Clin North
Am 1997; 5: 415-29.
. Sommer DG, Greenway GD, Brookstein JJ, Orloff MJ. Hepatic rupture with toxemia of pregnancy:
angiographic diagnosis. Am J Roentgenol 1979; 132: 455-6.
. Yotsumoto G, Tanaka K, Ishzaki N, Ikoma A, Kawashima S, Taira A. Spontaneous subcapsular
hepatic hemorrhage associated with pregnancy: report of a case. Surg Today 1997; 27: 657-60.
. Stevenson JT, Graham DJ. Hepatic hemorrhage and the HELLP syndrome: a surgeons perspective.
Am Surg 1995; 61: 756-60.
. Miguelote RF, Costa V, Vivas J, Gonzaga L, Menezes CA. Postpartum spontaneous rupture of a liver
hematoma associated with preeclampsia and HELLP syndrome. Arch Gynecol Obstet 2009; 279:
923-6.
. Barton JR, Sibai BM. Care of the pregnancy complicated by HELLP syndrome. Gastroenterol Clin
North Am 1992, 4: 937-50.
. Heller TD, Goldfarb JP. Spontaneous rupture of the liver during pregnancy, a case report and review
of the literature. N Y State J Med 1986; 86: 314-6.
. Abercrombie J. Hemorrhage of the liver. Lon Med Gaz 1844; 34: 792-4.
. Geary M. The HELLP syndrome. Br J Obstet Gynaecol 1997; 104: 887-91.
. Hunter SK, Martin M, Benda JA, Zlatnik FJ. Liver transplant after massive spontaneous hepatic
rupture in pregnancy complicated by preeclampsia. Obstet Gynecol 1995; 85(5 Pt 2): 819-22.
. Merchant SH, Mathew P, Vanderjagt TJ, Howdieshell TR, Crookston KP. Recombinant factor VIIa in
management of spontaneous subcapsular liver hematoma associated with pregnancy. Obstet Gynecol
2004; 103: 1055-8.
. Dart BW 4th, Cockerham WT, Torres C, Kipikasa JH, Maxwell RA. A novel use of recombinant
factor VIIa in HELLP syndrome associated with spontaneous hepatic rupture and abdominal com-
partment syndrome. J Trauma 2004; 57: 171-4.
. Shrivastava VK, Imagawa D, Wing DA. Argon beam coagulator for treatment of hepatic rupture
with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Obstet Gynecol 2006; 107:
525-6.
. Terasaki KK, Quinn MF, Lundell CJ, Finck EJ, Pentecost MJ. Spontaneous hepatic hemorrhage in
preeclampsia: treatment with hepatic artery embolization. Radiology 1990; 174: 1039-41.
. Wust MD, Bolte AC, de Vries JI, Dekker GA, Cuesta MA, van Geijn HP. Pregnancy outcome after
previous pregnancy complicated by hepatic rupture. Hypertens Pregnancy 2004; 23: 1-7.


20 177

 ...

RTCOG Guideline : Management of Labor and Vaginal
Delivery

.. -

..-

178 11





.

(
.
)

.
.
.

. ()
partograph ( )
. ( ) labor record ( )







.

/ (
) partograph (
) labor record (
)
.


.
(
)
. ()


.
( )

()

. (
()
)
partograph ( )
12 labor record ( )
179

 .


partograph (

) labor record ( )

.

( )

.

( ) /





/


()

.


( )

.
.
/
.
(

)


.

( ) .



. .

.
.
.
/ progress note .

180 13


..................................................... ............... HN...........................
..................................................................................

....................................................................................

................................................... ...................................................
(................................................................) (................................................................)
.........................................................................
(................................................................)
.........................................................................
(................................................................)

......................................................................

/ ()..........................................

......................................................................
.................................................. ........................................................

14 181


Ward -
Assessment Form AN...........................HN........................... Attend Staff........................................
(Obstetric) .............................................................. Resident...............................................
.................. ............................... Diagnosis.............................................
- .........................................................
.................................................................
............................................... ............................ - ..................................................
Refer .............................................................................. - .........................................
............................................................ - .....................................
- ....................................................
........................................................ - ............................................
- .............................................................................................
(Basic conditioning factors) / ......................................
/..........................................................................
....................................................................................... Lab ........................
................................................................................. Hct 1................... vol% ..........................
. (Health State) . 2................... vol% ..........................
VDRL 1................... ..........................
............................................................................................... . 2................... ..........................
............................................................................................... Anti HIV 1................... ..........................
............................................................................................... . 2................... ..........................
............................................................................................... HBsAg................... .................................
MCV................... OF................... DCIP...................
G.................P.................LMP.................EDC....................
ANC.............. ................................. .................................................
Clinic...................... ...................................... ................................................
................... ...............
V/S BT..........................C PR........................./min
...................................................................................... RR........................./min BP..................../mmHg
............................................................................................... FHR....................................../
............................................................................................... PV ................................................................................
.....................................................................................................

Blood group..................................Rh.................................. Hb Typing.................................. HBeAg..................................
Lab .......................................................
Bl.gr..................................Rh.................................. Hct..................................vol% Hb..................................gm%
VDRL.................................. TPHA.................................. Anti HIV..................................HbsAg..................................
HbeAg.................................. MCV.................................. Hb Typing.................................. ........................................................
.
182 15



Partograph

Labor Record

16 183



184 17


................................................. .......................................................... ............... HN.....................................
............................................................................................................
/
...........................................................................
............................................................ ..........................................
/ .......................................................
//.......................................................

..................................................................................

-

...................................................
(................................................................)
......................................................................
...................................................
(................................................................)
.........................................................................
(................................................................)
.........................................................................
(................................................................)

/ ()..........................................

......................................................................
.................................................. ........................................................

18 185






. 41 1,450
120,000 - 200,000 41










Ob - Gyn
-


3



16

186 7 2552


1. 70

2. 24

fetal distress
30
3. 3 - 5

4. 20

acidosis
5.

6. cesarean section
45 - 60
amniotic fluid embolism
7.
cesarean
8. active phase ruptured membranes


9. fetal monitoring


10.

.....

8 2552 187

 (Induction of labour)

20
(1)

(Indications & contraindications of
induction of labour)

(placental abruption)
(chorioamnionitis)

(postterm pregnancy)
(premature rupture of membranes)


(2)
41
(premature rupture of membranes) 41
(meconium aspiration syndrome)
(perinatal death)
(chorioamnionitis)




188

15 2552
 (contraindications)

(previous myomectomy)
classical inverted T



vasa previa
(umbilical cord prolapse)






1.
2.
3.
4. (cervical status) (membrane status)
Bishop (Bishop pelvic scoring system)(3) 1
8
6
unfavourable cervix
5.

1. Bishop (Bishop pelvic scoring system)

( Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964; 24:267.)

189

16 2552


oxytoci
n






4
misoprostol 6 12


(Methods of induction of labour) dinoprostone
30 60
(Cervical dinop
rostone
ripening)

Bishop 6 (unfavourable
cervix)
(cervical ripening)
1. (mechanical methods)
Foley (Foley catheter) ,
double balloon Laminaria japonicum

oxytocin
(uterine tachysystole)(4, 5)
2. (administration of synthetic prostaglandins)
2 misoprostol
prostaglandin E1 (PGE1) dinoprostone prostaglandin E2 (PGE2)
misoprostol PGE1 (cervical
ripening)
..2002 misoprostol 100 200

25 3 6
25 (6)
misoprostol
misoprostol (uterine tachysystole)
5 10 50
deceleration
(7-10) misoprostol 3
(11)

190

17 2552
 dinoprostone PGE2
2

2.5 0.5
10
oxytocin
chysystole),
(uterine ta

dinoprostone



w a te r intoxication 0.5
6
1.5 24

30 2 (12)

dinoprostone PGE2 0.3

(uterine tachysystole) 1
dinoprostone 5 dinoprostone (13-15)
1 (14-16) dinoprostone PGE2
(glaucoma), (asthma) (severe hepatic
or renal dysfunction)

1. nipple stimulation unilateral breast stimulation


(perinatal death)
(17)
2. membrane stripping
membrane stripping PGF2
48
membrane stripping (18)
3. (amniotomy)
(19)
oxytocin (20)
(umbilical cord prolapse)
(chorioamnionitis) (umbilical cord compression)

18 2552191

 vasa previa
vasa previa
HIV(19)
4. oxytocin
oxytocin 3 5
40

oxytocin 2 (low-dose regimen)
(high-dose regimen) 2

(chorioamnionitis) (dystocia)

2. oxytocin

* hyperstimulation 3 1
recurrent hyperstimulation
( Satin AJ, Leveno KJ, Sherman ML, Brewster DS, Cunningham FG. High- versus low-dose oxytocin for
labor stimulation. Obstet Gynecol 1992;80:111-6.)

oxytocin
4 misoprostol 6 12 dinoprostone
30 60 dinoprostone
oxytocin (uterine tachysystole),
water intoxication

intrauterine resuscitation (21)

(premature rupture of membranes) oxytocin

(chorioamnionitis) (22)
oxytocin (premature rupture of
membranes)

192

19 2552

-
..

..

.-. -
.-

9 193


(brachial plexus injury)











,,

(suspected fetal macrosomia)
-
, ,



.

.
. episiotomy
.
.

.
. Suprapubic pressure
adduction
. McRoberts maneuver stirrups

194 10
suprapubic pressure

Suprapubic pressure Suprapubic pressure

. . McRobert maneuver
. Wood corkscrew maneuver
corkscrew
. Rubin maneuver
adduction bisacromial diameter

adduction bisacromial diameter

Wood corkscrew maneuver Rubin maneuver

. Delivery of posterior shoulder (tocolytic

drugs)



. All-fours position or Gaskin maneuver
2 2
promontory sacrum
Woods corkscrew maneuver delivery
of posterior arm
11 195

 Delivery of posterior shoulder All-fours position or Gaskin maneuver

. Fracture of clavicle clavicle clavicle distal part

pubic rami clavicle





clavicle (brachial plexus injury)











augmentation
active

196 12







fundal pressure

1. Baskett TF, Allen AC. Perinatal implications of shoulder dystocia. Obstet Gynecol 1995;86:14-7.
2. McFarland M, Hod M, Piper JM, Xenakin EMJ, Langer O. Are labor abnormalities more common in
shoulder dystocia?. Am J Obstet Gynecol 1995;173:1221-4.
3. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia : an analysis of risks and
obstetric maneuvers. Am J Obstet Gynecol 1993;168:1732-7.
4. Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the
unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol
2006;195:657-72.
5. American College of Obstetricians and Gynecologists. Shoulder dystocia. ACOG practice bulletin
clinical management guidelines for obstetrician-gynecologists. Number 40, November 2002. Obstet
Gynecol 2002;100:1045-50.
6. Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk. Am J Obstet
Gynecol 1987;156:1408-18.
7. Bahar AM. Risk factors and fetal outcome in cases of shoulder dystocia compared with normal
deliveries of a similar birthweight. Br J Obstet Gynaecol 1996;103:868-72.
8. Sanchez-Ramos L, Bernstein S, Kaunitz AM. Expectant management versus labor induction for
suspected fetal macrosomia: a systematic review. Obstet Gynecol 2002;100:997-1002.

13 197



9. Irion O, Boulvain M. Induction of labour

for suspected fetal macrosomia. Cochrane
Review. The Cochrane Library, Issue
2,2002.
10. Gonen O, Rosen DJ, Dolfin Z, Tepper R,
Markov S, Fejgin MD. Induction of labor
versus expectant management in macroso-
mia: a randomized study. Obstet Gynecol
Episiotomy
1997;89:913-7.
11. Gonen R, Bader D, Ajami M. Effects of a
policy of elective cesarean delivery in cases
of suspected fetal macrosomia on the in-
cidence of brachial plexus injury and the
Suprapubic pressure rate of cesarean delivery. Am J Obstet
McRobert maneuver Gynecol 2000;183:1296-300.
12. Rouse DJ, Owen J. Prophylactic caesar-
ean delivery for fetal macrosomia diagnosed
by means of ultrasonography-A Faustian
Wood corkscrew maneuver bargain? Am J Obstet Gynecol
Gaskin maneuver
or Rubin maneuver 1999;181:332-8.
13. Bennett BB. Shoulder dystocia: an
obstetric emergency. Obstet Gynecol Clin
Delivery of posterior arm North Am 1999;26:445-58.
14. Cunningham FG, Gant NF, Leveno KJ,
Gilstrap III LC, Hauth JC, Wenstrom KD.
Fracture clavicle Williams Obstetrics. 21st ed. New York:
McGraw-Hill, 2001:462-4.
15. Bruner JP, Drummond SB, Meenan AL, et

al. All-fours maneuver for reducing shoul-
der dystocia during labor. J Reprod Med
1998;43:439-43.
16. Acker DB. A shoulder dystocia interven-
tion form. Obstet Gynecol 1991;78:150-1.

198 14



........................................................
.......................................................................HN..................................................

1.
[ ] [ ] [ ]
2. .............................................................................
3. [ ] [ ]
4. [ ] [ ]
5. [ ] [ ]
6. Episiotomy [ ] median [ ] mediolateral [ ]
7. [ ] [ ] pudendal nerve block [ ]
8.

8.1 Suprapubic pressure [ ] [ ] .......................................
8.2 McRobert maneuver [ ] [ ] .......................................
8.3 Wood corkscrew maneuver [ ] [ ] .......................................
8.4 Rubin maneuver [ ] [ ] .......................................
8.5 Gaskin maneuver [ ] [ ] .......................................
8.6 Delivery of posterior arm [ ] [ ] .......................................
8.7 Fracture clavicle [ ] [ ] .......................................
8.8 .............................. [ ] [ ] .......................................
9. ........................ .................... .
10. .........................
11. .............................
12. Apgar score 1 = ......... 5 = ......... 10 = .........
13. [ ] [ ] ..............................................

................................................................................

15 199




RTCOG Guideline
Management of atonic postpartum hemorrhage

-
..

..

(postpartumhemorrhage, PPH)
, ()
. ..-()

() . ()

200 8

 ..
.()
(uterine atony)
(genital tract laceration) (retained placental tissue)
(maternal bleeding disorders)
()
grandmultiparity
(polyhydramnios) oxytocin

()
active management of the third stage of labor

Active management of the third stage of labor ()
.
. Clamp
. controlled cord traction


(bimanual compression) intrauterine balloon/condom
tamponade

9 201

 .
.
. crystalloid
.
.

.
. complete blood count hematocrit
(coagulogram venous clotting time)

. (Medical interventions)
. First -line treatment
oxytocin
ergometrine, fixed-dose of ergometrine and oxytocin, carbetocin
prostaglandins (Quality of evidence: very low-low, Strength of recommendation:
strong)()
. Second-line treatment
oxytocin oxytocin
ergometrine, fixed- dose of ergometrine and oxytocin second-line treatments
(Quality of evidence: very low-low, Strength of recommendation: strong)()
. Third-line treatment
second-line second-line
treatment prostaglandins third-line treatment (Quality of
evidence: very low-low, Strength of recommendation: strong)()
. Tranexamic acid (Transamine)
Tranexamic acid PPH third-line treatment
trauma (Quality of evidence: very low,
Strength of recommendation: weak)()


isotonic crystalloid colloids (Quality of evidence: low,
Strength of recommendation: strong)()

202 10



First-line treatment:
Oxytocin (Syntocinon) Initial treatment:
oxytocin -
/ oxytocin
Continuous treatment:
oxytocin (
/)
Second-line treatment:
oxytocin

oxytocin
Ergometrine (Methergin, ergometrine . .
Ergotyl) . .
doses . .

Fixed- dose of ergometrine Syntometrine .
and oxytocin (Syntometrine) .
Third-line treatment:
oxytocin
ergometrine
oxytocin
ergometrine
Misoprostol (Cytotec) misoprostol -

Sulprostone (Nalador) Initial treatment
sulprostone .
- /
Continuous treatment
sulprostone
/ . .

11 203

 .
(Non-medical interventions for management of PPH)

. (Uterine massage)

(Quality of evidence:very
low, Strength of recommendation: strong)()
. (Bimanual uterine compression)




() (Quality of evidence:
very low, Strength of recommendation: weak)()
(Bimanual uterine compression)()

. Intrauterine balloon/condom tamponade

intrauterine balloon/condom tamponade

(Quality of evidence: low, Strength of recommendation: weak)()
uterine
packing (Quality of evidence: very low, Strength of recommendation: weak)()
. Uterine artery embolization
uterine artery embolization

(Quality of evidence:very low, Strength of recommendation: weak)()
.
(Surgical interventions in the treatment of PPH)
surgical interventions
compression sutures uterine,
utero-ovarian internal iliac (subtotal total hysterectomy)
(abdominal packing) raw surface
disseminated intravascular coagulation (DIC)
( ) pack
and go-back() umbrella packing()

204 12



(conservative approaches)
invasive compression suture (uterine,
utero-ovarian internal iliac vessels)
(subtotal or supracervical total hysterectomy) (Quality of
evidence: no formal scientific evidence of benefit or harm, Strength of recommendation: strong)()

multidisciplinary interventions

/




. Oxytocin (Syntocinon)
Initial treatment oxytocin - /
oxytocin
Continuous treatment oxytocin (
/)
. Ergometrine (Methergin, Ergotyl)
. . . (
doses) . .
. Fixed-dose of ergometrine and oxytocin (Syntometrine)
. oxytocin ergometrine maleate . . .
. .- .

13 205

 . Misoprostol (Cytotec)
misoprostol -
(con-
sciousness) ()
. Sulprostone (Nalador)
Initial treatment sulprostone .
- /
Continuous treatment sulprostone /
. .
. Tranexamic acid (Transamine) tranexamic acid -
() high dose loading tranexamic
acid . maintenance
/ ()

Intrauterine balloon/condom tamponade

tamponade ()
Sengstaken-Blakemore tube, SOS Bakri tamponade balloon condom balloon ()

tamponade test uterine
tamponade test positive
test negative embolization

intrauterine tamponade
. Sengstaken-Blakemore tube sponge
forceps anterior lip
catheter
esophageal balloon gastric
balloon - .
.

central lumen
pack
balloon
Tamponade balloon ()
oxytocin (- . % sodium chloride , .) -

206 14

 balloon
oxytocin balloon


. SOS Bakri tamponade balloon - .
. Condom balloon sterile rubber catheter -
.

Compression sutures
Compression sutures B-Lynch()
lithotomy (hysterotomy)
peritoneum
Monocryl .
. . .
cornue .

()
vertical
()

B-Lynch()
(Selective artery ligation)
.()
. Uterine artery/ utero-ovarian vessels ligation
uterine
uterine lower segment (
- . ) atraumatic

15 207


uterine - .
broad ligament

- .
utero-ovarian
(high ligation) ()
. Internal iliac artery ligation
internal iliac

Uterine utero-ovarian() internal iliac
internal iliac
-()
. (Subtotal total hysterectomy)

tissue hypoxia
subtotal total hysterectomy
stump double ligation()
. (Abdominal packing)
raw
surface DIC

(
) pack and
go-back() umbrella packing()

Umbrella packing()
pelvic floor
()

. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-
Gynecologists Number 76, October 2006: Postpartum hemorrhage. Obstet Gynecol
2006;108:1039-47.
. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC. Williams obstetrics. 23rd ed.
New York: McGraw-Hill, 2010:758.

208 16

 . Abou Zahr C. Global burden of maternal death and disability. Br Med Bull 2003;67: 1-11.
. Khan KS, Wojdyla D, Say L, G?ulmezoglu AM, von Look PFA. WHO analysis of
causes of maternal death: a systematic review. Lancet 2006;367:1066-74.
. 2547-2549. .
Available: http://hp.anamai.moph.go.th/ewt_dl_link.php?nid=199&filename=situation
. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage
with vaginal birth. Obstet Gynecol 1991;77:69-76.
. Breathnach F, Geary M. Uterine Atony: definition, prevention, nonsurgical
management, and uterine tamponade. Semin Perinatol 2009;33:82-7.
. WHO recommendations for the prevention of postpartum haemorrhage. Geneva,
World Health Organization, 2007.
. WHO guidelines for the management of postpartum haemorrhage and retained
placenta. Geneva, World Health Organization, 2009.
. Perel P, Roberts IG. Colloids versus crystalloids for fluid resuscitation in critically ill
patients. Cochrane Database of Systematic Reviews, 2007, Issue 4. Art. No.: CD000567.
. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC. Williams obstetrics. 23rd ed. New
York: McGraw-Hill, 2010:775.
. Finan MA, Fiorica JV, Hoffman MS, Barton DP, Gleeson N, Roberts WS, et al.
Massive pelvic hemorrhage during gynecologic cancer surgery: pack and go back.
Gynecol Oncol 1996;62:390-5.
. Dildy GA III. Postpartum hemorrhage: new management options. Clin Obstet Gynecol
2002;45:330-44.
. WHO Statement regarding the use of misoprostol for postpartum haemorrhage
prevention and treatment. Geneva, World Health Organization, 2007 (WHO/RHR/09.18).
. Ferrer P, Roberts I, Sydenham E, Blackhall K, Shakur H. Anti-fibrinolytic agents in
postpartum haemorrhage: a systematic review. BMC Pregnancy Childbirth 2009;9:29-34.
. Ducloy-Bouthors AS, Jude B, Duhamel A, Broisin F, Huissoud C, Keita-Meyer H,
et al. The EXADELI Study Group. High-dose tranexamic acid reduces blood loss
in postpartum haemorrhage. Crit Care 2011;15:R117.
. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a
review. BJOG 2009;116:748-57.
. Allam MS,B-Lynch C.The B-Lynch and other uterine compression suture techniques.
Int J Gynaecol Obstet 2005;89:236-41.
. Porreco RP, Stettler RW. Surgical remedies for postpartum hemorrhage. Clin Obstet
Gynecol 2010;53:182-95.
. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of
conservative management of postpartum hemorrhage: what to do when medical
treatment fails. Obstet Gynecol Surv 2007;62:540-7.

17 209


Uterine atony

. .
Complete blood count hematocrit

. (Coagulogram

. venous clotting time, PT, PTT)

. crystalloid
. / (Blood grouping & cross

. matching
.

(Uterine massage)

(Uterotonic drugs)

- Oxytocin - Ergometrine
- Prostaglandins (Misoprostol, Sulprostone)
Tranexamic acid

Nonsurgical uterine compression

- Bimanual uterine compress

- Balloon or condom tamponade
Uterine artery embolization

Compression sutures : B-Lynch

Artery ligation (uterine, utero-ovarian, internal iliac)

- Hysterectomy
- If intra-abdominal bleeding occurs after hysterectomy,
consider abdomininal packing

210 18

 ...

RTCOG Guideline
Postpartum management after vaginal delivery

..-
..
..-

7 211



- -
-
( )
. ()
( )

-
-
-
-


-

()

(Ferrous sulfate Ferrous fumarate

212 8



()

-
-

- ()

-
-
-
-
-
-

. The Puerperium. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY, editors.
Williams Obstetrics. 23 ed. New York: Mc Graw-Hill; 2010. p.654-8.
. Chiarelli P, Cockburn J. Promoting urinary continence in women after delivery: randomised controlled
trial. BMJ. 2002;324(7348):1241-4.
. Intrapartum and Postpartum Care of the Mother. Guidelines for Perinatal Care. 6 ed: American Acad-
emy of Pediatrics and the American College of Obstetricians and Gynecologists 2007. p. 162-74.
. Standards for Maternity Care. In: Moody J, editor. London: The Royal College of Obstetricians and
Gynaecologists 2008. p. 36-8.

 9 213



RTCOG Guideline: Management of Retained Placenta

-
..

..

(Retained placenta)
(
)
(,)
(placenta adherens)

-

uterine atony, cervical cramp,
()

.
()

214 13

 ) placenta accreta (
)
) placenta increta ( .
) .()
) placenta percreta (
. active management of third stage of

labor oxytocin controlled cord
)
traction (Quality of evidence: no formal specific evidence of
benefit or harm; Strength of recommendation: weak) ()

ergometrine

tetanic uterine contraction
(, )
(Quality of evidence: very

low; Strength of recommendation: weak) ()

prostaglandin E2 (dinoprostone

() sulprostone) (Quality of evidence: very
low; Strength of recommendation: strong) ()
. oxytocin -
saline . intraumbilical vein (Quality of
evidence: moderate; Strength of recommendation : weak) (,)
.

. .
(No formal assessment of quality of
evidence. Strength of recommendation: strong) ()
. .
()
()
.
.

general anesthesia ()
. normal saline Ringer-lactate
.

. .
. . (lithotomy)
.

14 215

 . curett
.
.
.
.


.



accoucheurs hand
.
oxytocin
oxytocin
.
, .

.

. (ulnar side)
.
. -

spongiosa decidua .

placenta increta placenta . oxytocin
percreta
. . (hematocrit)
-
.


. (single dose of

ampicillin gram first-generation cephalosporin: cefazolin

gram, Quality of evidence: very low ; Strength of recommen-
. dation :strong ) ()


(digital curettage)

216 15



( )

Oxytocin Controlled cord traction

oxytocin saline intraumbilical vein

(digital curettage)

Gentle curettage

oxytocin

. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse
DJ, Spong CY. Williams obstetrics. 23rd ed. New York,
McGraw-Hill;2010:774.
. Managing complications in pregnancy and childbirth: a
guide for midwives and doctors. Geneva, World Health
Organization, 2007.
. . . : , World Health Organization, 2009.
, . . 1.: . Carroli G, Bergel E. Umbilical vein injection for manage-
; 2546:189-92.
. Anderson JM. Prevention and management of postpartum
hemorrhage. Am Fam Physician 2007;75:875-82.
. Publications Committee, Society for Maternal-Fetal Medi-
cine, Belfort MA. Placenta accrete. Am J Obstet Gynecol
2010;203:430-9.
16
. Throp JMJ, Councell RB, Sandridge DA, Wiest HH.
Antepartum diagnosis of placenta previa percreta by
magnetic resonance imaging. Obstet Gynecol
1992;80:506-8.
. WHO recommendations for the management of post-
partum haemorrhage and retained placenta. Geneva,
ment of retained placenta. Cochrane Database of
Systematic Reviews,2001, Issue 4. Art. No.: CD001337.
. . . :
, , .
. 1.:
..; 2543: 449-50.
217


RTCOG Guideline
Management of Pregnancy after Female sterilization

.. -
.. -

..

..

. -

.

218 8

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(cesarean section)

. (counseling)


.
-

.
,



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.
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(gestational sac)
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intrauterine extrauterine
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(embryo) (fetus)
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(embryonic or fetal cardiac activity)
present absent
(number of embryo / fetus)
(crown-rump length, CRL)



.
.
(fetal cardiac activity)
present absent
(number of fetus)
(fetal presentation)
fetal biometry parameter

biparietal diameter (BPD)
head circumference (HC)
abdominal circumference (AC)
femur length (FL)

parameter

(estimated gestational age)
(estimated fetal weight)
(placental location)
(estimated amniotic fluid volume)
normal abnormal
amniotic fluid index (AFI) deepest
vertical pocket

222 16

.


.

.
()


(last menstrual period, LMP)
(gravida) (parity)
.
chorionicity amnionicity



cul-de-sac
nuchal translucency (NT)


.


()
fetal anatomical survey


cranium 4-chamber heart
cerebral ventricles stomach
posterior fossa kidneys
face bladder
lips abdominal cord insertion
spine 3-vessel cord
chest arms and hands
diaphragm legs and feet

17 223

 (Ultrasound)

224 10


(gel)

e-mail: pr_rtcog@rtcog.or.th
http://www.rtcog.or.th



2553 11 225

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226 12





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. :
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.
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.
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9 227

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(opened spina bifida)

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/ )
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236

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14
237

 Guideline for Injury Prevention in Well Child Care

1.

1.
2539
1-14 4153 1 ( 1)
(drowning)
1404 (33.8)
(transport injuries) 680 ( 16)
(land transport) 387 ( 9.3) (pedestrian injuries)
228 (5.5) (water transport)
492 169
4000 1
50 750
200,000
3,000,000
2528-2536

238

 1 (/100,000)
Males Females
2539
1-4 5-9 10-14 1-4 5-9 10-14

Total injuries 32.1 33.5 37.2 21.0 16.7 19.6

Drowning 14.2 15.7 5.2 8.0 6.9 5.4
Land transport 3.2 4.3 9.6 2.8 2.2 3.5
Pedestrian 1.9 2.9 4.8 1.7 1.6 1.7
Water transport 1.8 2.5 1.2 1.0 1.3 1.0
Electric current 0.8 0.6 1.1 0.4 0.2 0.5
Fire 0.6 0.2 0.3 0.8 0.2 0.1
Suffocation 0.4 0.1 0.1 0.2 0.1 0.1
Fall 0.3 0.1 0.2 0.3 0.1 0.0
Inanimate force 0.3 0.2 0.2 0.2 0.1 0.0
Venomous animal 0.1 0.1 0.2 0.2 0.2 0.1
Self harm 0.0 0.0 1.6 0.0 0.1 1.7
Assault 0.4 0.7 1.2 0.4 0.4 0.5

2.

1 6
13 1

1. 3

239

 2.
150
3. (water safety) 18
4. (water recovery) 2
2 5

5.

1. 5
2.


3.

3.
3.1
(unprotected road user)
10-50
6-7 3
2538 19,482 7,064
20,448 2,390 33.8
4 2543
74 4

240

3.2
5-14
94


3.2.1
7
(recreation area)











3.2.2 (traffic calming) (Neighbourhood)





30./ 24
458-9 :
1.

241

 2. (traffic
calming)
5 ./
28
(road hump) road strip
1 ./ 1 . 40
Gateway 23
3.2.3
- (retro-
reflective clothing) (reflective patches)
(retro-reflective tag)
145 259 10
- (facing traffic)
11
-


-- 11

3.3

3.3.1 (child restraint system)
(child seat)



National Highway Traffic Safety Administration (NHTSA), Department of Transportation

242

 69
1-4 47 5 45
5012
NHTSA American Academy of Pediatrics child
restraint system (National Transportation Safety Board, 1996) 13
1 10 . (infant seat) (
1.1) (convertible seat) ( 1.2) 1-5

1-5 10-18 . (convertible seat)
( 1.2)
5-10 18-28 . (booster seat)
( 1.3) (abdominal shield) ( 2)

(safety belt syndrome)

10 28 .

3.3.2
Center
for Disease Control 3 - 9 26
4 10 14


3.3.3
129 0-11

5
15

243

 FARS 1988-95
12 : 16
35
31
46
12

3.3.4



17-18

1980 (horizontal splitting of
the spine) 36 19
seat belt syndrome (SBS)
3 2-2.7 20
2
Kendall21
206 4

441 3
16 11
23 9 22

1.1 1 = infant seat 1.3 5-10 = booster seat

244

3.4
2
(bicycle spoke injuries) 75
23 24-25( 1)

30
1.2 1-5 = convertible seat
greenstick fractures spiral fractures tibia epiphyseal injuries distal
fibula 10 full thickness26-28
Bicycle spoke injuries (rigid plastic net)
(special child seat with foot support) 1

245

 4.

2

1. 3 3.17 .
5.71 . ( 1 )

2.
3.
Heimlich CPR

31.7 mm.

1 25.4
mm. 57.1
mm.

246

 5.

paracetamol, iron, antidiabetic, antihypertensive drug
3
5.1
5 (childproof cap)
Poisoning Prevention Packaging Act 1970
childproof cap aspirin tablet salicylate poisoning
leading cause of poison deaths 29
5 5.7 1000 3.4
0.9 1000 0.5 5 30
5.2 Poison Control Center
poison control center 24
84 1994 Miller TR, Lestina DC31
poison control center

Poison Control Center 24
2011083 2468282
5.3 syrup ipecac
Syrup of ipecac
Poison Control Center Poison Control
Center syrup of ipecac
25 admission 5532

247

 6.

30
7

(infant
walker)
1.

( )
2. (fall injury from
playground equipment)
2.1 (energy absorbing surfacing
materials) 9-12
2.1
1.7 6.2 (wood
chips) 33-4
2.2 6
6 2 33-4
2.3
3.

30-40
35



36

248


1. Plitponkarnpim A, Andersson R, Horte L, Svanstrom L. Trend and Current Status of Child Injury
Fatalities in Thailand Compared with Sweden and Japan. Journal of Safety Research
1999;30:163-171.
2. Asher KN, Rivara FP, Felix D, Vance L, Dunne R. Water safety training as a potential means of
reducing risk of young childrens drowning. Injury Prevention 1995;1:228-33.
3. . . ; :2533
4. . . 2540
5. , , , ,
. 8
6. National highway traffic safety administration. Prevention of Brain Injury. CODES Report to
Congress - 29 - February 1996.
7. Dowswell, T., Towner, E. M. L., Simpson, G., & Jarvis S. N. (1996). Preventing childhood
unintentional injuries-what works? A literature review. Injury Prevention, 2, 140-9.
8. Engel U, Thomsen LK. Safety effects of speed reducing measures in Danish residential areas.
Accident Analysis and Prevention, 1992; 24: 17-28.
9. Vis AA, Dijkstra A, Slop M. Safety effects of 30Km/H zones in the Netherlands. Accident
Analysis and Prevention, 1992; 24: 75-86.
10. Shinar D. The effects of expectancy, clothing reflectance, and detection criterion on Nighttime
pedestrian visibility. Human Factors, 1985; 27: 327-33.
11. National highway traffic safety administration, American college of emergency physicians.
Walking in traffic. http://www.nhtsa.dot.gov/people/injury/pedbimot/RxFlyer/Rxflyer2.html.
12. U.S. Department of Transportation, National Highway Traffic Safety Administration. Fatality
and Injury Statistics on Children Ages 0-15, 1994. Conference Participant Manual, Conference
on Moving Kids Safely. Washington, DC,1996.
13. Selecting the Appropriate Type of Child Restraint System: Guidelines of the American Academy
of Pediatrics, NHTSA,FMVSS 213, and a Child Restraint System Manufacturer. In: Safety
Study: The Performance and Use of Child Restraint Systems, Seatbelts, and Air Bags for
Children in Passenger Vehicles. National Transportation Safety Board, 1996.
14. U.S. Accidents Involving Air Bag Deployment at the Passenger-Side Seat Occupied by a
Child,1993 Through Mid-September 1996. In: Safety Study: The Performance and Use of Child
Restraint Systems, Seatbelts, and Air Bags for Children in Passenger Vehicles. National
Transportation Safety Board, 1996.
15. Petridou E, Skalkidou A, Lescohier I, Trichopoulos D. Car restraints and seating position for
prevention of motor vehicle injuries in Greece. Arch Dis Child 1998;78:335-9.
16. The Fatal Accident Reporting System (FARS) is maintained by the U.S. Department of
Transportation, National Highway Traffic Safety Administration. FARS contains data on fatal
traffic accidents.
17. National Transportation Safety Board. Performance of Lap/Shoulder Belts in 167 Motor Vehicle
Crashes (Volume 1). Safety Study NTSB/SS-88/02. Washington, DC., 1988.
18. National Transportation Safety Board. Performance of Lap Belts in 26 Frontal Crashes. Safety
Study NTSB/SS-86/03. Washington, DC, 1986.
19. Voss L, Cole PA, D'Amato C. Pediatric chance fractures from lapbelts: unique case report of
three in one accident. J Orthop Trauma 1996;10:421-8.
20. Lane JC. The seat belt syndrome in children. Accid Annual Prev 1994;26:813-20.

249

 21. Kendall IG, Bodiwala GG. The effect of legislation on injuries sustained by rear seat car
passengers. J Accid Emerg Med 1994;11:49-51.
22. Christian MS, Bullimore DW. Reduction in accident injury severity in rear seat passengers using
restraints. injury 1989;20:262-4.
23. Cross KD, Fisher G. A study of bicycle/motor-vehicle accidents: Identification of problem types
and countermeasure approaches (Technical Report DOT-HS-803 315). Washington, DC:
National Highway Traffic Safety Administration; 1977.
24. Dorsch MM, Woodward AJ, Somers RL. Do bicycle safety helmets reduce severity of head
injury in real crashes? Accident Analysis and Prevention 1987; 19: 183-190.
25. Thompson RS, Rivara FP, Thompson DC. A case control study of the effectiveness of bicycle
safety helmets. The New England Journal of Medicine 1989; 320: 1361-67.
26. Segers MJ, Wink D, Clevers GJ. Bicycle-spoke injuries: a prospective study. Injury 1997;28:267-
9.
27. Griffiths DM, MacKellar A. Bicycle-spoke and "doubling" injuries. Med J Aust 1988;149:618-9
28. Felman AH. Bicycle spoke fractures. J Pediatr 1973; 82:302-3 Fazen LE, Felizberto PI. Baby
walker injuries. Pediatrics 1982;70:106-109.
29. Clarke A, Walton WW. Effect of safety packaging on aspirin ingestion by children. Pediatrics
1979;63:687.
30. Wester TB. Project ipecac: an accident prevention program of the Robeson County Department
of Health. North Carolina Medical Journal 1985;46: 425-6.
31. Miller TR, Lestina DC. Costs of poisoning in the United States and savings from poison control
centers: a benefit-cost analysis. Ann of Emerg Med, 1997; 29: 239-45.
32. Walton WW. An evaluation of the Poison Prevention Packaging Act. Pediatrics 1982;69:363-
370.
33. Sacks JJ, Holt KW, Holmgreen P, Colwell LS, Brown JM. Playground hazards in Atlanta child
care centers. American Journal of Public Health 1990;80:986-8.
34. Sosin DM, Keller P, Sacks JJ, Kresnow M, van Dyck PC. Surface specific fall injury rates on
Utah school playgrounds. American Journal of Public Health, 1993;83:733-5.
35. Morrison CD, Stanwick RS, Tenenbein M. Infant walker injuries persist in Canada after sales
have ceased. Pediatr Emerg Care 1996;12:180-2.
36. Thein MM, Lee J, Tay V, Ling SL. Infant walker use, injuries, and motor development. Inj Prev
1997;3:63-6.

250

 251

252

 253


1
1-2 2557
.

1 2557
8.30-9.00 .
9.00-9.30 . .
1
9.30-12.00 . 2553-2557
1. MMR 2. LBW 3. Birth asphyxia
4. Teenage pregnancy 5. Perinatal mortality 6. Delay development

20 MCH Board
1
12.00-13.00
13.00-16.30 . () CPG.
1. teenage pregnancy MCH board.
2. preterm IUGR MCH board
3. Delay development
MCH board 10
4. Birth asphyxia MCH board
5. ( MMR) MCH board
6. ( perinatal mortality) MCH board
7. anemia MCH board.
8. APH: Placenta previa Abruptio placenta
MCH board
9. vacuum extraction
MCH board.
10. CPG anemia in children 10
10.00-10.30 14.30-15.00 .

2 2557
8.30-12.00 () CPG. ()
1. teenage pregnancy MCH board.
2. preterm IUGR MCH board
3. Delay development
MCH board 10

254

 4. Birth asphyxia MCH board
5. ( MMR) MCH board
6. ( perinatal mortality)
MCH board
7. anemia MCH board.
8. APH: Placenta previa Abruptio placenta
MCH board
9. vacuum extraction
MCH board.
10. CPG anemia in children 10
12.00-13.00
13.00-16.30 () CPG. ()
1. teenage pregnancy MCH board.
2. preterm IUGR MCH board
3. Delay development
MCH board 10
4. Birth asphyxia MCH board
5. ( MMR) MCH board
6. ( perinatal mortality) MCH board
7. anemia MCH board.
8. APH: Placenta previa Abruptio placenta
MCH board
9. vacuum extraction
MCH board.
10. CPG anemia in children 10

10.00-10.30 14.30-15.00 .

MCH board () word.

255


1
1-2 2557
.

1. 2. 3. 4.
5. 6. 7. 8.
9. 10.

1.. 2.. 3. 4.
5. 6. 7. 8..
9.. 10. 11.. 12.
13.. 14.. 15. 16.
17.. 18.. 19. 20..
21.. 22. 23.

10
1.. 2.. 3. . 4..
5. 6. 7.

1.. 2.. 3.. 4..
5. 6. 7. 8.
9. 10.

1. . 2. . 3. . 4.
5. 6. 7. 8.
9. . 10. 11. 12.
13. .

1.. 2.. 3.. 4. .
5. 6. 7. 8.
9. 10. . 11. 12. ..

256


1.. 2.. 3.. 4..
5.. 6.. 7.. 8.
9. 10. 11. 12.
13. 14. . 15. . 16. .

1.. 2.. 3.. 4..
5.. 6.. 7.. 8..
9. 10. 11. . 12.
13. 14. 15. . 16. .
17. . 18.. 19. . 20. .
21. .

1. .. 2. .. 3. 4.
5. 6. .. 7. .. 8. ..
9. 10. 11. 12. ..

1. . 2. . 3.. 4..
5. 6. 7. 8.
9.

257

 (
)


.

-




.

(
)

258


1
1-2 2557
.

259

260


1

2

7 24

10 261

262