SASGOG's Pearls of Exxcellence

Blood Transfusion in Obstetric Patients

Most blood transfusions in pregnancy and the postpartum period are performed to address acute blood loss. In the first and second trimesters, this mostly results from ruptured ectopic pregnancies or...

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Evaluation and Management of Listeria Monocytogenes Exposure and Diagnosis in Pregnancy

Listeriosis is primarily caused by eating food contaminated with the bacterium Listeria monocytogenes. Most affected persons present with a self-limiting flulike illness or gastroenteritis. In the most severe cases, individuals...

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Cesarean Delivery with Deeply Impacted Fetal Head

While various definitions have been proposed for impacted fetal head (IFH), all include the fetal head becoming deeply engaged within the maternal pelvis resulting in a difficult extraction. IFH complicates...

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Vaccination During Pregnancy for Prevention of Severe RSV Disease in Newborns

Respiratory Syncytial Virus (RSV) is the leading cause of hospitalization among U.S. infants; 2% to 3% of young infants will be hospitalized for RSV disease. RSV-associated hospitalization rates are highest...

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Management of Depression in Pregnancy

Depression in pregnancy and the postpartum period is common and affects up to 1 in 7 women. The risk for a major depressive episode is about 12% during pregnancy and...

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Recurrent Pregnancy Loss

Pregnancy loss occurs in 15% to 25% of pregnancies, while recurrent pregnancy loss affects up to 2% of pregnancies. One common definition of recurrent pregnancy loss is the loss of...

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Acute Cardiovascular Disease in Pregnancy

Cardiovascular disease is the leading cause of mortality during pregnancy and the postpartum period, accounting for 35% of maternal deaths worldwide. Nearly 4% of pregnancies in the United States are...

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Ultrasound Markers for Down Syndrome

Down Syndrome (trisomy 21) is the most common chromosomal disorder in live born infants. About 6,000 babies are born with Down Syndrome each year in the United States, or about...

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Stillbirth Evaluation

Stillbirth is one of the more challenging physical, emotional, mental, and spiritual events a patient and their family may ever face. Stillbirth is one of the most adverse pregnancy outcomes...

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Persistent Postpartum Endometritis

Postpartum endometritis complicates up to 3% of vaginal deliveries and up to 27% of cesarean deliveries. Initial broad-spectrum antibiotic therapy, most commonly with intravenous (IV) gentamicin and clindamycin, is usually...

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Management of Active Phase Arrest

In order to manage active phase arrest, the active phase must be correctly defined, and arrest properly diagnosed. The active phase begins when there is an acceleration in the rate...

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Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy-specific liver disease. While the incidence of ICP varies greatly among ethnic groups, in the United States incidence ranges from...

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Management of Prolonged Latent Phase

Labor is divided into three stages. The first stage of labor is divided into two phases – the latent phase and the active phase. In the latent phase,...

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Management of Late Term Pregnancy

Late term pregnancy refers to pregnancies from 41 0/7 through 41 6/7 weeks gestation. Compared to full term pregnancy (39 0/7 - 40 6/7 weeks), late term and post-term...

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Management of Preeclampsia at Term

Management of preeclampsia at term (≥ 37 0/7 weeks) involves assessing the maternal-fetal status, preparing for delivery, and monitoring for disease severity and progression. Delivery is indicated when...

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Management of Brow, Face, and Compound Malpresentations

Fetal malpresentations - including brow, face, or compound presentations - complicate 3-4% of term births. Because brow, face, and compound presentations are cephalic, many cases result in vaginal deliveries, yet...

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Evaluation and Management of Ruptured Membranes with Amnionitis at Term

Intraamniotic infection (IAI), or chorioamnionitis, is an inflammatory or infectious disorder involving any combination of amniotic fluid, placenta, fetus, fetal membranes, or decidua. IAI complicates approximately 2-5% of...

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Evaluation of Preeclampsia at Term

Gravidas at term (≥37 weeks) with new onset/worsening hypertension or symptoms suggesting end organ effects, such as persistent headache, visual changes, right upper quadrant or epigastric pain, should be evaluated...

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Pertussis Prophylaxis in Pregnancy

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. Infection causes paroxysms of coughing which can lead to dyspnea, hypoxia, and...

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Management of Placenta Accreta at Delivery

Placenta accreta spectrum (PAS) describes the pathologic adherence of the placentaand includes placenta increta, percreta, and accreta. The PAS incidence has increased in parallel with increasing cesarean...

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Postpartum Hemorrhage from Atony Unresponsive to First Line Uterotonics

Primary postpartum hemorrhage (PPH), a leading cause of severe maternal morbidity in the US, is defined as cumulative blood loss of ≥1000 ml and signs of hypovolemia during the 24...

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Trial of Labor after Cesarean (TOLAC)

Options following a cesarean delivery include elective repeat cesarean delivery and trial of labor after cesarean (TOLAC). Successful TOLAC results in vaginal birth after cesarean (VBAC), and is estimated...

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Management of Polyhydramnios

Polyhydramnios is an excessive amount of amniotic fluid relative to gestational age. It is thought to result from either increased production or decreased clearance of amniotic fluid and is often...

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Minor Red Cell Antigens and Fetal Hemolytic Anemia

There are more than 300 recognized blood-group antigens, of which the Rhesus (Rh) blood-group system is the most common cause of maternal alloimmunization. It is comprised of the c, C,...

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Cytomegalovirus Infection in Pregnancy

Cytomegalovirus (CMV) is the most common congenital viral infection, occurring in 0.2 – 2.2% of neonates with up to 4% of pregnant patients having a primary CMV infection. CMV remains...

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Monochorionic Twins

The risk for fetal and neonatal mortality and long-term morbidity in monochorionic twins is higher than dichorionic twins, with a 3- fold to 4-fold increase in intrauterine demise. Placental vascular...

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Hyperthyroidism in Pregnancy

During pregnancy, physiological adaptations of the thyroid include increased thyroid volume (up to 30%) and a 40-100% increase in thyroid hormone production. Cross-reactivity between human chorionic gonadotropin and thyroid-stimulating...

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Antepartum Management of Dichorionic/Diamniotic Twins

Chorionicity in twins is determined by ultrasonography in the late first or early second trimester, with sensitivity of 90% or better. The twin peak sign (lambda or delta sign)...

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Management of the Breech Presenting at the Introitus

Breech presentation occurs in 2-3% of pregnancies at term. Frank breech accounts for over 50% of breech presentations. Risk factors vary by gestational age, with at term include advanced maternal...

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Management of Twin Delivery

Factors that determine the route of delivery for a twin gestation can include chorionicity, fetal presentations, gestational age, and estimated fetal weights and discordance, as well as the availability of...

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Management of Second Trimester Fetal Loss

Second trimester fetal loss complicates 1% to 2% of pregnancies and occurs between 14 and 27 weeks gestation and may encompass spontaneous abortion, stillbirth, and early preterm labor. Risk factors...

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Management of Fetal Demise caused by Abruption at Term

Placental abruption complicates 0.5 to 1% of pregnancies, but very rarely results in fetal demise. Fetuses that survive are at increased risk of significant morbidity. Management must address maternal...

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Sepsis

Sepsis is a systemic, dysregulated, inflammatory response with an identified source of infection. Septic shock and multiorgan dysfunction are subtypes of severe sepsis and are associated with increased mortality. Many...

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Trichomonas, Gonorrhea, and Chlamydia in Pregnancy

Chlamydia Trachomatis Most infections are asymptomatic, but may manifest with urethritis, Bartholin gland infection, or mucopurulent cervicitis. Upper tract infection is uncommon. All pregnant patients < 25 years of...

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Postpartum Eclampsia

Eclampsia is defined as preeclampsia related new onset generalized tonic-clonic seizures and can result in significant morbidity and death. Postpartum eclampsia accounts for 10 to 44% of all cases of...

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Management of Adnexal Masses in Pregnancy

The overall prevalence of adnexal pathology in pregnancy is up to 3%, depending on the gestational age at presentation. The most common pathologic diagnoses include mature cystic teratomas, periovarian cysts...

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Neonatal Encephalopathy and Cerebral Palsy

Neonatal encephalopathy is a clinical syndrome of neurologic dysfunction diagnosed in the first days of life of a neonate born at or beyond 35 weeks gestation. This syndrome is characterized...

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Evaluation and Management of Obstetric Anal Sphincter Injuries (OASIS)

All women having vaginal delivery should be closely examined for vaginal and perineal injuries and those with perineal laceration should have rectal examination to determine the extent of their injury...

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Management of Wound Complications of Cesarean Delivery

Preoperative measures that reduce wound infection include weight-based prophylactic antibiotics given within one hour before the incision, the addition of azithromycin when indicated, hair removal with clippers rather than shaving,...

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Management of Broad Ligament Extension and Hematoma during a Cesarean Delivery

The broad ligaments consist of anterior and posterior leaflets of peritoneum which cover the lateral uterine corpus and upper cervix and extend from the lateral walls of the uterus to...

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Amniotic Fluid Embolism

Amniotic Fluid Embolism (AFE) is an uncommon, catastrophic obstetric emergency. The frequency of AFE is 2-7 cases per 100,000 births with a mortality rate as high as 60%. It is...

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Hematoma after Delivery

Puerperal hematomas occur in 1:300 to 1:1,500 deliveries and may pose life-threatening morbidity. A puerperal hematoma is an accumulation of blood in a pelvic avascular potential space. Injury...

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Management of Breakdown of Obstetrical Anal Sphincter Repairs

Obstetric anal sphincter injuries (OASIS) include 3rd and 4th degree lacerations. Risk factors include forceps or vacuum delivery, midline episiotomy, first vaginal delivery, higher infant birth weight (> 3500gms), vertex...

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Complications of Varicella Infection in the Third Trimester

Varicella, a herpes virus, is highly contagious and associated with significant maternal and neonatal morbidity during pregnancy. Clinical features of maternal infection include a prodrome of fever, headache, and malaise,...

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Singleton Breech Presentation

Approximately 3-4% of pregnancies at term are breech presentations. All pregnancies should undergo assessment of presentation beginning at 36 weeks, and confirmatory ultrasound should occur for all suspected breech presentations....

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Antepartum Management of Vasa Previa

Vasa previa occurs when fetal blood vessels that are unprotected by the umbilical cord or placenta run through the amniotic membranes and traverse the cervical os. Two types of...

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Management of Pregnancy with ABO Incompatibility

ABO incompatibility is the most common maternal-fetal blood group incompatibility and the most common cause of hemolytic disease of the newborn (HDN) with an occurrence of 0.5-1% of newborns. Generally,...

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Management of Placenta Accreta Spectrum Diagnosed Antenatally

Placenta accreta spectrum (PAS) encompasses a number of diagnoses describing the failure of the placenta to detach from the myometrium at the time of delivery. Historically, the degree of invasion...

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Elevated Maternal Serum AFP (MSAFP) During the Second Trimester

Alpha-fetoprotein (AFP) is produced by the fetal yolk sac and liver. Levels rise during the second trimester. Values are expressed as MoMs (multiples of the median) for each specific week...

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Anemia in Pregnancy

The two most common causes of anemia in pregnancy and the puerperium are iron deficiency and acute blood loss. Pregnancy results in a physiologic anemia due to expanded plasma volume....

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Postpartum Perineal Pain

The diagnosis and management of postpartum perineal pain depends on history and physical examination. Because pain is rarely an isolated symptom, additional symptoms by history may also include bleeding,...

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Fetal Ventral Abdominal Wall Defects

Gastroschisis and omphalocele are the most common fetal ventral abdominal wall defects. Omphalocele is a midline ventral abdominal wall defect through which abdominal contents herniate. The defect generally...

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Nonimmune Hydrops Fetalis

Nonimmune hydrops fetalis (NHF) is the presence of excessive fluid in two or more fetal compartments (skin edema, pleural effusion, pericardial effusion, or ascites), in the absence of red cell...

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Toxoplasmosis in Pregnancy

Toxoplasma gondii is an intracelluar protozoan parasite which is the causitive agent of the infection Toxoplasmosis. Transmission occurs via fecal-oral exposure of uncooked meat, contaminated soil or water, contaminated fruits...

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Parvovirus in Pregnancy

Parvovirus B19 is a single stranded DNA virus which causes erythema infectiosum, also known as fifth disease. Clinical manifestations include flu-like signs and symptoms, low-grade fever, malaise, arthralgia, and a...

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