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Protocols for High Risk Pregnancies 4th Edition John T.
Queenan Digital Instant Download
Author(s): John T. Queenan, John C. Hobbins, Cathe Y. Spong
ISBN(s): 9781405173209, 1405125799
Edition: 4
File Details: PDF, 5.53 MB
Year: 2005
Language: english
Protocols for High-Risk Pregnancies
To Barry, Juliana, Winston and my family for their dedication, support and
encouragement and to my coeditor (JQ) who through his mentoring and
friendship has inspired me to achieve more than I thought possible.
CYS

To Carrie and Susan who provided inspiration, guidance and support. For all
this and much more, we thank you.
JQ and JH

I dedicate this clinical text to Peter Grannum, the consummate clinician and
the ultimate class act. I am a better person for having known you.
JH
Protocols for
High-Risk
Pregnancies
EDITED BY

John T. Queenan
MD
Professor and Chairman Emeritus
Department of Obstetrics and Gynecology
Georgetown University School of Medicine
Washington, DC

John C. Hobbins
MD
Professor of Obstetrics
Department of Obstetrics and Gynecology
University of Colorado Health Sciences Center
Denver, CO

Catherine Y. Spong
MD
Chief, Pregnancy and Perinatology Branch
NICHD
National Institutes of Health
Bethesda, MD

FOURTH EDITION
© 1982 by Medical Economics Books
© 1987 by Medical Economics Books
© 1996 by Blackwell Science, Inc
© 2005 by Blackwell Publishing Ltd
Blackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia
The right of the Author to be identified as the Author of this Work has been asserted in accordance
with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the
prior permission of the publisher.
First published 1982
Second edition 1987
Third edition 1996
Fourth edition 2005
Library of Congress Cataloging-in-Publication Data
Protocols for high-risk pregnancies / edited by John T. Queenan, John C. Hobbins, Catherine Y.
Spong. — 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-2579-6
ISBN-10: 1-4051-2579-9 (alk. paper)
1. Pregnancy — Complications.
[DNLM: 1. Pregnancy Complications. 2. Pregnancy, High-Risk. WQ 240 P967 2005]
I. Queenan, John T. II. Hobbins, John C., 1936– III. Spong, Catherine Y.
RG571.P73 2005
618.3 — dc22
2005007102
ISBN-13: 978-1-4051-25796
ISBN-10: 1-4051-25799
A catalogue record for this title is available from the British Library
Set in 9/12 Photina MT by SNP Best-set Typesetter Ltd., Hong Kong
Printed and bound in India by Replika Press Pvt., Ltd.
Commissioning Editor: Stuart Taylor
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used have met acceptable environmental accreditation standards.
Contents

List of contributors, xi
Preface, xix

PART 1: HAZARDS TO PREGNANCY, 1

1 Alcohol, 3
Robert J. Sokol and Beth Nordstrom Bailey
2 Developmental toxicology and teratology, 9
James W. Hanson and Jan M. Friedman
3 Occupational hazards, 18
George R. Saade
4 Smoking, 26
Jorge E. Tolosa and Surasith Chaithongwongwatthana
5 Ionizing radiation, 31
Robert L. Brent
6 Microwaves and ultrasound, 39
Robert L. Brent
7 Exercise — risks and benefits, 45
James Clapp

PART 2: ANTENATAL TESTING, 55

8 Routine antenatal laboratory tests and specific screening tests, 57
Calvin J. Hobel
9 Assessment of gestational age, 64
Lawrence D. Platt
10 Second trimester biochemical screening for neural tube defects and
aneuploidy, 69
John C. Hobbins
11 Sonographic and first trimester detection of aneuploidy, 75
Fergal D. Malone

v
vi Contents

12 Indices of maturity, 89
Alessandro Ghidini and Anna Locatelli
13 Clinical use of Doppler, 96
Henry L. Galan
14 Fetal echocardiography, 106
Joshua A. Copel and Charles S. Kleinman
15 Fetal biophysical profile, 112
Michael P. Nageotte

PART 3: SPECIAL PROCEDURES, 117

16 Chorionic villus sampling, 119
Ronald J. Wapner
17 Genetic amniocentesis, 125
Katharine D. Wenstrom
18 Third trimester amniocentesis, 129
Nancy Chescheir
19 Fetal blood sampling, 134
Alessandro Ghidini and Anna Locatelli
20 Fetal reduction, 141
Mark I. Evans
21 Intrauterine transfusion, 145
Frederick U. Eruo and Ray O. Bahado-Singh
22 External cephalic version, 152
Monica Longo and Gary D.V. Hankins
23 Induction of labor, 157
Anna M. McKeown and Michael P. Nageotte
24 Amnioinfusion: indications and techniques, 164
Catherine Y. Spong

PART 4: MATERNAL DISEASE, 169

25 Sickle cell disease, 171
Chad K. Klauser and John C. Morrison
26 Isoimmune thrombocytopenia, 176
Jane Cleary-Goldman and Mary E. D’Alton
27 Autoimmune disease, 182
Charles J. Lockwood and Edmund F. Funai
28 Cardiac disease, 196
Katharine D. Wenstrom
29 Peripartum cardiomyopathy, 205
F. Gary Cunningham
30 Thromboembolism, 208
Alan Peaceman
 Contents vii

31 Renal disease, 214

Linda Fonseca, Larry C. Gilstrap III and Susan Ramin
32 Obesity, 221
Frank J. Zlatnik
33 Gestational diabetes, 224
Donald R. Coustan
34 Diabetes mellitus, 227
Steven G. Gabbe
35 Hypothyroidism, 235
Brian Casey
36 Hyperthyroidism, 239
George D. Wendel, Jr
37 Acute and chronic hepatitis, 244
Marshall W. Carpenter
38 Asthma, 251
Michael Schatz
39 Epilepsy, 259
Neil K. Kochenour
40 Chronic hypertension, 264
Baha M. Sibai
41 Immunizations, 273
Stanley A. Gall
42 Cytomegalovirus, 284
Hans M.L. Spiegel and John L. Sever
43 Herpes simplex, 288
Jeanne S. Sheffield
44 Influenza, 293
Jeanne S. Sheffield
45 West Nile virus, 297
Ronald Gibbs and Joel K. Schwartz
46 Human immune deficiency virus infection, 301
Howard Minkoff
47 Parvovirus B19 infection, 315
Maureen P. Malee
48 Syphilis, 320
Vanessa Laibl and George D. Wendel, Jr
49 Rubella, 326
Hans M.L. Spiegel and John L. Sever
50 Group B streptococcus, 329
Mara J. Dinsmoor
51 Toxoplasmosis, 334
Shad Deering
viii Contents

52 Varicella, 341
Hans M.L. Spiegel and John L. Sever
53 Tuberculosis, 348
Kim A. Boggess
54 Urinary tract infections, 356
F. Gary Cunningham
55 Acute abdominal pain resulting from non-obstetric causes, 359
Sara Sukalich and Fred M. Howard
56 Acute pancreatitis, 368
Sarah H. Poggi
57 Gallbladder, 373
Monica Longo and Gary D.V. Hankins
58 Mastitis, 376
Wendy F. Hansen, Deborah Hubbard, and Jennifer R. Niebyl

PART 5: OBSTETRIC PROBLEMS, 381

59 First trimester vaginal bleeding, 383
Marsha Wheeler
60 Cervical incompetence, 388
Wendy F. Hansen
61 Nausea and vomiting, 395
Gayle Olson
62 Syncope, 402
Gary D. Helmbrecht
63 Fetal wastage: genetic evaluation, 406
Joe Leigh Simpson
64 Recurrent pregnancy loss: non-genetic causes, 412
Uma M. Reddy
65 Missed abortion and antepartum fetal death, 420
Robert M. Silver
66 Oligohydramnios, 428
Maryam Tarsa and Thomas R. Moore
67 Polyhydramnios, 434
Shad H. Deering and John T. Queenan
68 Pre-eclampsia, 441
Baha M. Sibai
69 Intrauterine growth restriction, 450
Ursula F. Harkness and Ray O. Bahado-Singh
70 Rh and other blood group alloimmunizations, 458
Kenneth J. Moise, Jr
71 Early detection of preterm labor, 467
Jay D. Iams
 Contents ix

72 Preterm labor – tocolysis, 475

Sarah J. Kilpatrick and Jay D. Iams
73 Premature rupture of the membranes, 483
Brian Mercer
74 Amnionitis, 495
Sindhu K. Srinivas and George A. Macones
75 Third trimester bleeding, 500
Alan Peaceman
76 Amniotic fluid embolus, 506
Robert Resnik
77 Sepsis syndrome, 509
F. Gary Cunningham
78 Counseling for fetal anomalies, 513
Lorraine Dugoff

PART 6: LABOR AND DELIVERY, 519

79 Maternal transport, 521
Jerome Yankowitz
80 Medications in labor, 528
Gary S. Eglinton and Isaac P. Lowenwirt
81 Intrapartum fetal heart rate monitoring, 546
Roger K. Freeman
82 Abnormal labor, 551
Alan Peaceman
83 Breech delivery, 555
Martin L. Gimovsky
84 Vaginal birth after cesarean section, 559
James R. Scott
85 Shoulder dystocia, 565
Thomas J. Benedetti
86 Twins, triplets, and beyond, 570
Jacquelyn K. Chyu
87 Post-term pregnancy, 580
Manuel Porto
88 Primary postpartum hemorrhage, 583
Monica Longo and Gary D.V. Hankins
89 Postpartum endometritis, 589
Jonathan Hodor
90 Vaginal and vulvar hematoma, 596
Robert Resnik
x Contents

PART 7: CLINICAL REFERENCE TABLES, 599

Appendix A: Commonly used ultrasound measurements, 601

Antonio Barbera
Appendix B: Changes in laboratory values during pregnancy, 623
Shad H. Deering
Appendix C: Evaluation of fetal defects and maternal disease, 627
Lynn L. Simpson
Appendix D: The newborn: reference charts and tables, 637
Adam Rosenberg
Appendix E: Medications cited, 648
Catalin S. Buhimschi and Carl P. Weiner

Index, 717
List of contributors

Ray O. Bahado-Singh, MD Room 308, A/R Building

University of Cincinnati Wilmington, DE 19899
Department of Obstetrics and Gynecology
231 Albert Sabin Way
Catalin S. Buhimschi, MD
PO Box 670526 Yale University School of Medicine
Cincinnati, OH 45267-0526 Department of Obstetrics and Gynecology
550 First Avenue
Beth Nordstrom Bailey, PhD New Haven, CT 06520-8063

Department of Family Medicine Marshall W. Carpenter, MD

James H. Quillen College of Medicine
Women and Infants Hospital
East Tennessee State University
Department of Obstetrics and Gynecology
Johnson City, TN
101 Dudley Street
Providence, RI 02905
Antonio Barbera, MD
University of Colorado Brian Casey, MD
Department of Obstetrics and Gynecology University of Texas Southwestern Medical
71 South Grape Street Center at Dallas
Denver, CO 80246 Department of Obstetrics and Gynecology
5323 Harry Hines Blvd
Thomas J. Benedetti, MD Dallas, TX 75390-9032
University of Washington
Department of Obstetrics and Gynecology Surasith Chaithongwongwatthana,
Box 356460 MD
Seattle, WA 98195-6460 Department of Obstetrics and Gynecology
Faculty of Medicine, Chulalongkorn
Kim A. Boggess, MD University
University of North Carolina School of Rama IV Rd., Bangkok 10330
Medicine Thailand
Department of Obstetrics and Gynecology
CB 7570, 214 MacNider Building Nancy Chescheir, MD
Chapel Hill, NC 27599-7516 University of North Carolina School of
Medicine
Robert L. Brent, MD, PhD Department of Obstetrics and Gynecology
Alfred I. duPont Hospital for Children CB 7570, 214 MacNider Building
Department of Research Chapel Hill, NC 27599-7516
PO Box 269

xi
xii List of contributors

Jacquelyn K. Chyu, MD Mara J. Dinsmoor, MD

University of Colorado Health Sciences Evanston Northwestern Healthcare
Center Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology 2650 Ridge Avenue
4200 East 9th Avenue, B-198 Evanston, IL 60201
Denver, CO 80262
Lorraine Dugoff, MD
James Clapp, MD University of Colorado Health Sciences
Metro Health Medical Center Center
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
2500 Metro Health Drive 4200 East 9th Avenue, B-198
Cleveland, OH 44109-1998 Denver, CO 80262

Jane Cleary-Goldman, MD Gary S. Eglinton, MD

Columbia Presbyterian Medical Center New York Hospital Medical Center of
Department of Obstetrics and Gynecology Queens
622 West 168th Street, PH16 Department of Obstetrics and Gynecology
New York, NY 10032-3784 70A Davis Road
Flushing, NY 11355-5095
Joshua A. Copel, MD
Yale University School of Medicine Frederick U. Eruo, MD
Department of Obstetrics and Gynecology University of Cincinnati
PO Box 208063 Division of Maternal Fetal Medicine
333 Cedar Street 231 Albert Sabin Way
New Haven, CT 06520-8063 PO Box 670526
Cincinnati, OH 45267-0526
Donald R. Coustan, MD
Women and Infants Hospital of Rhode Mark I. Evans, MD
Island Institute for Genetics
101 Dudley Street 635 Madison Avenue
Providence, RI 02905-2401 10th Floor
New York, NY 10022
F. Gary Cunningham, MD
University of Texas Southwestern Medical Linda Fonseca, MD
Center at Dallas University of Texas Health Science Center at
Department of Obstetrics and Gynecology Houston
5323 Harry Hines Blvd Department of Obstetrics, Gynecology and
Dallas, TX 75390-9032 Reproductive Sciences
6431 Fannin Street, Room 3.262
Mary D’Alton, MD Houston, TX 77030
Columbia Presbyterian Hospital
Obstetrics and Gynecology Roger K. Freeman, MD
622 West 168th Street, PH 16-66 Long Beach Memorial Medical Center
New York, NY 10032 Department of Obstetrics and Gynecology
2801 Atlantic Avenue
Shad H. Deering, MD Long Beach, CA 90801
Department of Obstetrics and Gynecology
Madigan Army Medical Center Jan M. Friedman, MD, PhD
Tacoma University of British Columbia
Washington, DC 98431 Vancouver, Canada
 List of contributors xiii

Edmund F. Funai, MD Gary D.V. Hankins, MD

Yale University School of Medicine University of Texas Medical Branch at
Department of Obstetrics and Gynecology Galveston
550 First Avenue Department of Obstetrics and Gynecology
New Haven, CT 06520-8063 301 University Blvd, Route 0587
Galveston, TX 77555-1062
Steven G. Gabbe, MD
Vanderbilt University School of Medicine Wendy F. Hansen, MD
D-3300 Medical Center North University of Kentucky
Nashville, TN 37232-2104 Chandler Medical Center
800 Rose Street
Henry L. Galan, MD Department of Obstetrics and Gynecology
University of Colorado Health Sciences Room C-358
Center Lexington, KY 40536-0293
Department of Obstetrics and Gynecology
4200 East 9th Avenue, B-198 James W. Hanson, MD
Denver, CO 80262 Acting Director, CDBPM, NICHD
6100 Executive Blvd, 4th Floor
Stanley A. Gall, MD MSC 7510
University of Louisville Bethesda, MD 20892
Department of Obstetrics and Gynecology
550 South Jackson Street Ursula F. Harkness, MD, MPH
Louisville, KY 40202 Division of Maternal Fetal Medicine
Department of Obstetrics and Gynecology
Alessandro Ghidini, MD University of Cincinnati
Georgetown University Medical Center 231 Albert Sabin Way
Department of Obstetrics and Gynecology PO Box 670526
3800 Reservoir Road NW, 3 PHC Cincinnati, OH 45267-0526
Washington, DC 20007-2197
Gary D. Helmbrecht, MD
Ronald Gibbs, MD Martha Jefferson Hospital
University of Colorado Health Sciences Prenatal Diagnosis Center
Center 595 Peter Jefferson Parkway
4200 East 9th Avenue, B-198 Charlottesville, VA 22911
Denver, CO 80262
John C. Hobbins, MD
Larry C. Gilstrap, III, MD University of Colorado Health Sciences
University of Texas Health Science Center at Center
Houston Department of Obstetrics and Gynecology
Department of Obstetrics, Gynecology and 4200 East 9th Avenue, B-198
Reproductive Sciences Denver, CO 80262
6431 Fannin Street, Room 3.286
Houston, TX 77030 Calvin J. Hobel, MD
Cedars-Sinai Medical Center – UCLA
Martin L. Gimovsky, MD 8700 Beverly Blvd
Newark Beth Israel Medical Center Suite 160W
Department of Obstetrics and Gynecology Los Angeles, CA 90048
201 Lyons Avenue
Newark, NJ 07112 Jonathan Hodor, DO, MS
Georgetown University Hospital
Department of Obstetrics and Gynecology
3800 Reservoir Road NW, 3 PHC
Washington, DC 20007-2197
xiv List of contributors

Wolfgang Holzgreve, MD Vanessa Laibl, MD

University Women’s Hospital Basel University of Texas Southwestern Medical
Obstetrics and Gynecology Center at Dallas
Schanzenstrasse 46 Department of Obstetrics and Gynecology
CH-4031 Basel, Switzerland 5323 Harry Hines Blvd
Dallas, TX 75390-9032
Fred M. Howard, MD
University of Rochester School of Medicine Anna Locatelli, MD
and Dentistry Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology University of Milano-Bicocca
601 Elmwood Avenue, Box 668 Monza, Italy
Rochester, NY 14642
Charles J. Lockwood, MD
Deborah Hubbard Yale University School of Medicine
University of Iowa Hospitals and Clinics Department of Obstetrics and Gynecology
Department of Nursing PO Box 208063, 333 Cedar Street
200 Hawkins Drive New Haven, CT 06520-8063
Iowa City, IA 52242
Monica Longo, MD
Jay D. Iams, MD University of Texas Medical Branch at
The Ohio State University College of Galveston
Medicine Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology 301 University Blvd
1654 Upham Drive Galveston, TX 77555-1062
Columbus, OH 43210-1228
Isaac P. Lowenwirt, MD
Sarah J. Kilpatrick, MD New York Hospital Medical Center of
University of Illinois at Chicago Queens
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
820 South Wood Street 70A Davis Road
Chicago, IL 60612-7313 Flushing, NY 11355-5095

Chad K. Klauser, MD George A. Macones, MD

University of Mississippi Medical Center University of Pennsylvania
Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology
2500 North State Street 2000 Courtyard Building
Jackson, MS 39216 34th And Spruce Streets
Philadelphia, PA 19104-4283
Charles S. Kleinman, MD
Children’s Hospital of New York – Maureen P. Malee, MD
Presbyterian Hospital Jackson Memorial Hospital
Department of Cardiology Obstetrics and Gynecology
3959 Broadway 1611 North West 12th Avenue
New York, NY 10032 Miami, FL 33136-1094

Neil K. Kochenour, MD Fergal D. Malone, MD

University of Utah Health Sciences Center Royal College of Surgeons in Ireland
Department of Obstetrics and Gynecology Department of Obstetrics and Gynaecology
50 North Medical Drive The Rotunda Hospital
Salt Lake City, UT 84132 Parnell Square
Dublin 1
Ireland
 List of contributors xv

Anna M. McKeown, MD Gayle Olson, MD

Long Beach Memorial Medical Center University of Texas Medical Branch at
Department of Obstetrics and Gynecology Galveston
4242 Pacific Avenue Department of Obstetrics and Gynecology
Long Beach, CA 90801 301 University Blvd
Galveston, TX 77555-5302
Brian Mercer, MD
MetroHealth Medical Center Alan Peaceman, MD
Department of Obstetrics and Gynecology Northwestern University School of Medicine
2500 Metro Health Drive Department of Obstetrics and Gynecology
Cleveland, OH 44109-1998 333 East Superior Street, #410
Chicago, IL 60611
Howard Minkoff, MD
Maimonides Medical Center Lawrence D. Platt, MD
Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA
967 48th Street 6310 San Vicente Blvd, Suite 520
Brooklyn, NY 11219 Los Angeles, CA 90048

Kenneth J. Moise, Jr., MD Sarah H. Poggi, MD

University of North Carolina School of Georgetown University Hospital
Medicine Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology 3PHC
214 MacNider Building, CB#7516 3800 Reservoir Rd, NW
Chapel Hill, NC 27599-7516 Washington, DC 20007

Thomas R. Moore, MD Manuel Porto, MD

University of California, San Diego Medical 101 The City Drive
Center Building 25
Department of Reproductive Medicine Orange, CA 92868-3298
200 West Arbor Drive
San Diego, CA 92103-8433 John T. Queenan, MD
3257 N Street NW,
John C. Morrison, MD Washington, DC 20007
University of Mississippi Medical Center
Department of Obstetrics and Gynecology Susan Ramin, MD
2500 North State Street University of Texas at Houston
Jackson, MS 39216-4505 Department of Obstetrics and Gynecology
6431 Fannin, Suite 3604
Michael P. Nageotte, MD Houston, TX 77030
Long Beach Memorial Medical Center
Department of Obstetrics and Gynecology Uma M. Reddy, MD
4242 Pacific Avenue National Institute of Child Health and
Long Beach, CA 90801 Human Development
Center for Developmental Biology and
Jennifer R. Niebyl, MD Perinatal Medicine
University of Iowa Hospitals and Clinics Pregnancy and Perinatology Branch
Department of Obstetrics and Gynecology National Institutes of Health
200 Hawkins Drive 6100 Executive Blvd
Iowa City, IA 52242 Bethesda, MD 20892-7510
xvi List of contributors

Robert Resnik, MD Baha M. Sibai, MD

University of California, San Diego University of Cincinnati College of Medicine
Reproductive Medicine Department of Obstetrics and Gynecology
9500 Gilman Drive – Dept. 0621 231 Albert Sabin Way
La Jolla, CA 92093-0621 Cincinnati, OH 45267-0526

Adam Rosenberg, MD Robert M. Silver, MD

The Children’s Hospital University of Utah School of Medicine
University of Colorado Health Sciences Department of Obstetrics and Gynecology
Center 50 North Medical Drive
Pediatric Residency Program Room 2B200
1056 East 19th Avenue Salt Lake City, UT 84132
Denver, CO 80218
Joe Leigh Simpson, MD
George R. Saade, MD Baylor College of Medicine
University of Texas Medical Branch at Department of Obstetrics and Gynecology
Galveston and Molecular Human Genetics
Department of Obstetrics and Gynecology 6550 Fannin, Suite 901A
301 University Blvd Houston, TX 77030-3498
Galveston, TX 77555-1062
Lynn L. Simpson, MD
Michael Schatz, MD, MS Columbia Presbyterian Hospital
Kaiser-Permanente Medical Center Obstetrics and Gynecology
7060 Clairemont Mesa Blvd 622 West 128th Street
San Diego, CA 92111 New York, NY 10032

Joel K. Schwartz, MD Robert J. Sokol, MD

University of Colorado Health Sciences Wayne State University School of Medicine
Center Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology CS Mott Center for Human Growth and
4200 East 9th Avenue, B-198 Development
Denver, CO 80262 275 East Hancock Avenue
Detroit, MI 48201
James R. Scott, MD
Obstetrics and Gynecology Hans M.L. Spiegel, MD
423 Wakara Way, Suite 201 Children’s National Medical Center
Salt Lake City, UT 84108-1242 Department of Infectious Disease
111 Michigan Avenue, NW
John L. Sever, MD Washington, DC 20010-2979
Children’s National Medical Center
Department of Infectious Disease Catherine Y. Spong, MD
111 Michigan Avenue, NW National Institute of Child Health and
Washington, DC 20010-2979 Human Development
Center for Developmental Biology and
Jeanne S. Sheffield, MD Perinatal Medicine
University of Texas Southwestern Medical Pregnancy and Perinatology Branch
Center at Dallas National Institutes of Health
Department of Obstetrics and Gynecology 6100 Executive Bivd
5323 Harry Hines Blvd Bethesda, MD 20892-7510
Dallas, TX 75390-9032
 List of contributors xvii

Sindhu K. Srinivas, MD George D. Wendel, Jr, MD

University of Pennsylvania University of Texas Southwestern Medical
Department of Obstetrics and Gynecology Center at Dallas
2000 Courtyard Building Department of Obstetrics and Gynecology
34th And Spruce Streets 5323 Harry Hines Blvd
Philadelphia, PA 19104-4283 Dallas, TX 75390-9032

Sara Sukalich, MD Katharine D. Wenstrom, MD

University of Rochester School of Medicine University of Alabama at Birmingham
and Dentistry Hospital
Department of Obstetrics and Gynecology Obstetrics and Gynecology
601 Elmwood Avenue, Box 668 618 South 20th Street, UAB Station
Rochester, NY 14642 Birmingham, AL 35233

Maryam Tarsa, MD Marsha Wheeler, MD

University of California University of Colorado Health Sciences
Division of Perinatal Medicine Center
Department of Reproductive Medicine Department of Obstetrics and Gynecology
San Diego, CA 4200 East 9th Avenue, B-198
Denver, CO 80262
Jorge E. Tolosa, MD, MSCE
Oregon Health Sciences University Jerome Yankowitz, MD
Department of Obstetrics and Gynecology University of Iowa Hospitals and Clinics
Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology
3181 South West Sam Jackson Park Road 200 Hawkins Drive
L-458 Iowa City, IA 52242-1080
Portland, OR 97201-3098
Frank J. Zlatnik, MD
Ronald J. Wapner, MD University of Iowa Hospitals and Clinics
Columbia University Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology 200 Hawkins Drive
622 W. 168th Street PH 16–66 Iowa City, IA 52242-1080
New York, NY 10032-3795

Carl P. Weiner, MD
University of Maryland Medical Center
Department of Obstetrics, Gynecology and
Reproductive Sciences
22 South Greene Street
Baltimore, MD 21201
Preface

In light of the rapid advances in medicine and ready access to information, it

is critical for health-care providers to have up-to-date guidance for the workup
and management of high-risk pregnancies. Patients today are medically
sophisticated and expect an optimal outcome for their pregnancy. Given the
push by both managed care and the educated patient, the health-care provider
needs guidelines for practical patient management. Most importantly, physi-
cians want to do what is best for their patients.
Classifying pregnancies as “normal” or “high-risk” is an effective way to
provide additional attention to patients with the greatest need. All pregnancies
must be carefully evaluated to determine whether there are or will be risk
factors. Some patients have factors at the beginning of pregnancy, such as dia-
betes or history of a premature delivery that place them in a high-risk category.
Others start with normal pregnancies but subsequently develop risk factors,
such as ruptured membranes or pregnancy-induced hypertension, which may
develop suddenly; therefore, it is critical to be able to identify complications
quickly and have a protocol for management.
Since the third edition of this book was published, advances in medical tech-
nology and new clinical knowledge have dictated changes in the diagnosis and
therapy of “high-risk” patients. Thus, in this fourth edition, we have not only
updated the original protocols but have also added many new protocols on
topics such as vaginal birth after Cesarean delivery and West Nile virus. As with
the prior editions, we have identified what we believe are the most important
issues that confront the health care professional caring for high-risk patients
and selected outstanding authors to discuss each topic. We asked each con-
tributor to write a brief introduction and develop the protocol as if they were
working up the patient and following her through the various stages of man-
agement. We asked for each protocol to be evidence-based to the degree that
evidence is available, and where no data exists, we have asked the experts to
describe their recommendations. There is some intentional overlap, as medicine

xix
xx Preface

is an art as well as a science. All of these protocols represent the individual

thoughts of the experts.
This edition, as with the others, was kept true to being practical and cost
effective with a useful presentation: one that is easy to carry on rounds and
consults.
We wish to thank Michele Prince, our dedicated editorial and administrative
coordinator, and Stuart Taylor and Helen Harvey at Blackwell Publishing.
We realize that with the passage of time and continual updating of medical
advances, new editions will need to be published in a timely fashion, thus we
welcome your comments for future incorporation. We have designed this book
to help you in your practice, make it your own!

John T. Queenan
John C. Hobbins
Catherine Y. Spong
2005
PA R T 1

Hazards to
pregnancy
 CHAPTER 1

Alcohol
Robert J. Sokol and Beth Nordstrom Bailey

INTRODUCTION
For over three decades, many in the medical community have recognized the
negative consequences of maternal alcohol consumption for the developing
fetus. Despite this, rates of pregnancy drinking have remained relatively stable,
with 10% or more of women engaging in some level of alcohol consumption
during pregnancy. A myriad of negative pregnancy, newborn, and long-term
problems are associated with prenatal exposure to alcohol, and as many as 1
in 100 births are affected. Prenatal alcohol exposure is the most common cause
of mental retardation and the leading preventable cause of birth defects in
the USA. Armed with evidence-based clinical recommendations, healthcare
providers working with pregnant women are now in a position to alter these
statistics.

PATHOPHYSIOLOGY OF PRENATAL ALCOHOL EXPOSURE

Fetal alcohol spectrum disorder (FASD) is the latest term used to cover the range
of outcomes associated with all levels of prenatal alcohol exposure. Fetal
alcohol syndrome (FAS) represents the severe end of the spectrum and is char-
acterized by specific facial dysmorphology, growth restriction, and central
nervous system/neurodevelopmental abnormalities. However, even in the
absence of full FAS, effects of prenatal alcohol exposure are evident. Hundreds
of reports are now available, detailing outcomes associated with even low to
moderate levels of exposure to alcohol prenatally. Low birth weight, prematu-
rity, infant and childhood growth restriction, cognitive delay, hyperactivity and
impulsivity, inattention, aggression, poor reaction time, memory deficits, diffi-
culty with problem solving, and mood disorders have all been linked to expo-
sure to alcohol during gestation, even at what appear to be moderate drinking
levels.

DIAGNOSIS OF RISK DRINKING

How much drinking during pregnancy is too much? The short answers are that

3
4 Chapter 1

no safe threshold has been identified, binge drinking is particularly harmful,

and alcohol consumption during pregnancy should be avoided. Such are the
recommendations of the US Surgeon General, the American College of Obstet-
rics and Gynecology (ACOG), and the National Institutes on Alcohol Abuse and
Alcoholism. Drinking as little as twice weekly is associated with a 200-g
decrease in birth weight, and binge drinking as infrequently as twice monthly
has been demonstrated to double the likelihood of mental retardation, and to
increase by 2.5-fold the risk of clinically significant child behavior problems.
Thus, the threshold for risk drinking during pregnancy is much lower than
what is considered risk drinking for other segments of the population. Not sur-
prisingly, the developing embryo/fetus is more sensitive to the adverse effects of
alcohol than is the adult woman. Generally, normal non-risk drinking for
women is defined as not exceeding seven standard drinks per week, and never
exceeding three standard drinks per day. A standard drink is, for example, a 12-
ounce beer, a 5-ounce glass of wine, or a mixed drink containing an 80-proof
jigger (1.5 ounces) of liquor. Using these standards, approximately 70% of
American women do not engage in risky drinking patterns. However, risk
drinking during pregnancy, defined as alcohol consumption at a level that
could potentially damage the embryo/fetus, certainly involves a lower, but not
well-defined threshold. Due to this, as well as differing susceptibilites, at risk
drinking during pregnancy may include levels many clinicians would consider
social drinking.
Identifying women who drink during pregnancy is not always an easy task.
ACOG first recommended screening for alcohol use in pregnancy in 1977,
several years before the Surgeon General’s warning regarding pregnancy
alcohol consumption was issued. Most recently, the Committee on Ethics
in Obstetrics and Gynecology of ACOG released a policy statement informing
clinicians they have an ethical obligation to screen for alcohol use during preg-
nancy, and to intervene when use is identified. Unfortunately, this recommen-
dation is not yet universal policy. While a recent report reveals that 97% of
women are asked about alcohol use as part of their prenatal care, only 25% of
practitioners use standard screening tools, and only 20% know that abstinence
is the only known way to avoid any possibility of alcohol-related pregnancy,
delivery, and child outcome problems.
Because no reliable biomarker for alcohol use is available, clinicians must rely
on self-report of maternal alcohol use during pregnancy. Under-reporting is
common because of social desirability factors, so alcohol use histories must be
sensitively elicited to yield accurate information. Debate continues over the best
way to screen pregnant women for alcohol use in a clinical setting. An exam-
ination of the research literature, however, reveals some very specific evidence-
based recommendations. Traditional tools are either too long for practical
clinical use (MAST), or are not particularly reliable when used with women
 Alcohol 5

(CAGE). An adaptation of the CAGE, the T-ACE, was developed for and validated
with pregnant women, is simple to use, and is widely recommended. The T-ACE
consists of four questions that may be asked verbally as part of the history, or
included in the forms to be completed by the patient.
1 T — Tolerance. “How may drinks can you hold?” A positive answer, scored as
a 2, is at least a 6-pack of beer, a bottle of wine, or six mixed drinks. This
suggests a tolerance of alcohol and very likely a history of at least moderate
to heavy alcohol consumption.
2 A — Annoyed. “Have people annoyed you by criticizing your drinking?”
3 C — Cut down. “Have you felt you ought to cut down on your drinking?”
4 E — Eye opener. “Have you ever had a drink first thing in the morning to
steady your nerves or get rid of a hangover?”
These last three questions, if answered positively, are worth 1 point each. A
score on the entire scale of 2 or higher is considered positive for risk drinking,
and indicates that a woman is at risk to drink enough during pregnancy to
potentially damage her offspring.
The T-ACE typically identifies 90% or more of women engaging in risk drink-
ing during pregnancy. False-positives can be determined with follow-up ques-
tions. Since the development of the T-ACE, several other screening tools have
been suggested for use with pregnant women, including the TWEAK, the
Alcohol Use Disorders Test (AUDIT) and the Short Michigan Alcoholism Screen-
ing Test (SMAST). The AUDIT and the SMAST may not have not adequate sen-
sitivity (less than 20% in one recent validation study), and while the TWEAK
has been found to have a reasonably adequate sensitivity in identifying preg-
nancy risk drinking, it is not better than T-ACE and includes five, rather than
four questions. Thus, we recommend the T-ACE as the best tool to use to screen
pregnant women for alcohol use.
While the T-ACE identifies who is at risk by asking questions about the effect
of drinking on daily life, responses do not tell a clinician exactly how much
alcohol is being consumed. Thus, when a woman screens positive on the T-ACE,
follow-up should include questions about volume and frequency. A report of
more than three days per week, or a single episode involving more than three
standard drinks, should be considered an additional risk. Sensitively using a
combination of the T-ACE and frequency questions will identify over 90% of
pregnant women who are drinking at risk levels during pregnancy, typically
about 1 in 10 to 1 in 5 prenatal patients.

TREATMENT OF RISK DRINKING IN PREGNANCY

Once a prenatal patient is identified as an at-risk drinker, the clinician is in a
position to intervene. Brief physician advice has been shown unequivocally to
be powerful and feasible in the clinical setting. Brief behavioral counseling
interventions with follow-up aimed at problem drinkers identified in the clini-
6 Chapter 1

cal setting have been demonstrated to produce significant reductions in alcohol

consumption lasting 12 months or longer. Thus, the physician can make a
positive difference by engaging in a brief intervention. Some obstetricians and
an increasing number of primary care physicians have obtained training in
cognitive–behavioral therapy (CBT) or Motivational Interviewing. The basic
principle is that communication from the physician is a powerful motivator, and
can empower patients to make changes. In this empathic patient-centered
counseling approach, the physician points out the importance of reducing or
eliminating alcohol consumption, indicates that it may be difficult, but that the
woman can do it, and provides education about why it is important. Follow-up
is critical, and there is developing evidence that a series of such brief interven-
tions is more effective than a single mention of stopping drinking. For example,
a CDC-sponsored multicenter pilot study known as Project Choices identified
reproductive-age, sexually active, heavy drinking women and targeted them for
intervention. After a minimum of four motivational counseling sessions, nearly
70% were no longer at risk for an alcohol-exposed pregnancy 6 months later,
with the most reduced risk among the heaviest drinkers. It should be noted that
some patients chose not to decrease their drinking, but instead to use effective
contraception or sterilization.
Brief interventions for pregnancy risk drinking generally involve systematic
counseling sessions, approximately 5 min in length, which are tailored to the
severity of the identified alcohol problem. Ideally, such interventions should
occur preconceptionally, but it is never too late. The first time a brief interven-
tion is conducted, the physician should state his/her concern, give advice, and
negotiate abstinence or at a minimum a significant reduction in drinking by
helping to set a goal. Educational “carry away” materials should be provided.
Routine follow-up is essential and should involve encouragement, information,
and re-evaluation of goals. While these steps are usually effective in reducing
pregnancy drinking, lack of time in a busy clinical setting is often a major per-
ceived barrier to implementation. Time can be saved by including alcohol-
screening questions on intake forms, and by triaging patients. Those who do
not meet criteria for risk drinking during pregnancy can receive brief targeted
advice, while those with evidence of significant problems can receive more
intense intervention. Finally, women who are actually alcohol-dependent may
require additional assistance to reduce or eliminate consumption during preg-
nancy. For these women, referral for more intensive intervention and alcohol
treatment is usually warranted.
Brief interventions for reducing or eliminating pregnancy alcohol con-
sumption most often take the form of Motivational Interviewing. When imple-
menting a motivational brief intervention, it is important to express empathy,
manage resistance without confrontation, and support the self-efficacy of the
patient. Techniques such as open-ended questioning, reflective listening,
 Alcohol 7

summarizing, and affirming are most effective. Many women who may drink
enough to damage the embryo/fetus do not perceive themselves at risk. In this
common situation, Motivational Interviewing is particularly useful because it
guides the individual to explore and resolve ambivalence about changing,
increases the perceived discrepancy between current behavior and overall goals
and values, and minimizes patient resistance to the intervention. Many
resources are available to assist physicians with brief interventions and
Motivational Interviewing with childbearing age and pregnant women con-
suming alcohol at risk levels.
In addition to utilizing brief interventions with alcohol consuming precon-
ceptional and prenatal patients, we recommend that the following statements
should be shared with all pregnant women and those considering pregnancy.
• “If I were pregnant, knowing what I know today, I wouldn’t drink.” This infor-
mation is necessary to share based on the vast body of literature document-
ing adverse consequences of prenatal alcohol exposure.
• “There is no evidence that an occasional drink during pregnancy will harm your
baby” and “Do not worry about a few drinks earlier in pregnancy.” While
researchers and parents of affected children often cringe at such suggestions,
they are scientifically accurate. While a physician should in no way advocate
that pregnant women should have an occasional drink, it is reassuring to
many women who had a few drinks before knowing they were pregnant, or
who have consumed occasional drinks during pregnancy without realizing
the dangers. They do not need to have an induced abortion!
• “Certainly, don’t get drunk during pregnancy.” This statement is warranted by
evidence from animal studies of high circulating blood alcohol levels, and
human studies of binge drinking. This research clearly demonstrates that
alcohol consumed in quantity is much more likely to harm the fetus than the
same amount of alcohol consumed over time.
• “Even if you only drink socially, a few drinks in the evening throughout pregnancy
could interfere with your baby’s development.” Recent research has been docu-
menting that persistent frequent drinking, even at relatively limited levels, is
associated with FASD. A tiny minority of women in the USA drink daily
during pregnancy, and this practice should be discouraged — it is a risk.
• “You can help yourself have a healthier baby by cutting your drinking way down,
or better yet, by quitting drinking completely.” This is perhaps the key message
that every woman should be told in the periconceptional period, and again
during pregnancy.
• “To avoid any possibility of FASD, any drinking during pregnancy is too much.”
8 Chapter 1

CONCLUSIONS
Alcohol consumption during pregnancy can have significant negative conse-
quences for the fetus, with effects lasting throughout life. Exposure even at low
levels, and particularly exposure to binge drinking, can be harmful. Armed
with brief, well-validated screening tools and intervention approaches, the
clinician has an opportunity and an ethical obligation to diagnose and treat
pregnancy drinking.

SUGGESTED READING
Chang G, Goetz MA, Wilkins-Haug L, Berman S. A brief intervention for prenatal alcohol
use: an in depth look. J Subst Abuse Treat 2000;18:363–9.
Chang G, Wilkins-Haug L, Berman S. Alcohol use and pregnancy: improving identifica-
tion. Obstet Gynecol 1998;91:892–8.
Handmaker NS, Wilbourne P. Motivational interventions in prenatal clinics. Alcohol Res
Health 2001;25:219–29.
Nordstrom B, Delaney-Black V, Covington C, et al. Prenatal exposure to binge drinking
and cognitive and behavioral outcomes at age 7. Am J Obstet Gynecol 2004;191(3):
1037–43.
Sokol RJ, Delaney-Black V, Nordstrom B. Fetal alcohol spectrum disorder. JAMA
2003;290(22):2996–9.
Sokol RJ, Martier S, Ager J. The T-ACE questions: practical prenatal detection of risk-
drinking. Am J Obstet Gynecol 1989;160:863–70.
Sood B, Delaney-Black V, Covington C, et al. Prenatal alcohol exposure and childhood
behavior at age 6–7 years: threshold effect. Pediatrics 2001;108(2):e34.
 CHAPTER 2

Developmental
toxicology and teratology
James W. Hanson and Jan M. Friedman

INTRODUCTION
Exposures to potentially hazardous agents during pregnancy are common.
Such agents include drugs (both therapeutic agents and abused substances),
environmental chemicals, infectious agents, physical agents (radiation, heat,
and mechanical factors), and maternal health conditions. Many of these expo-
sures are not readily avoidable, as pregnancy is often not planned or recognized
for an extended period after conception, or because there is a continuing need
for maternal treatment for health conditions (e.g. epilepsy, infection, asthma,
chronic cardiovascular disorders). Exposure to various agents in the home or
workplace, or as a consequence of maternal lifestyles and self-medication is
almost universal, and preconception planning only rarely provides an oppor-
tunity to identify exposures of concern. As a consequence, questions about the
significance of such an exposure, whether stated or not, are often a source of
concern to pregnant women or their care provider.
It is important to screen systematically for such concerns as early as pos-
sible in pregnancy. Ideally, such screening should be a part of a comprehensive
risk factor analysis. This includes not only identification of risks related to
developmental toxicants and teratogens, but also consideration of genetic risk
factors (including maternal age), often identifiable through a careful family
history.
Likewise, it is prudent to utilize opportunities to anticipate and educate
non-pregnant women of reproductive age who are known to have, or are at
increased liability for significant risk factors whenever possible. This approach
can minimize maternal anxiety about adverse consequences of potentially haz-
ardous exposures and can help to avoid inappropriate alarm, especially should
abnormalities in the fetus or newborn be encountered. As the interaction of
more than single genetic characteristics with each other, or in combination
with environmental exposures, in the pathogenesis of adverse outcomes is
understood, the need for comprehensive evaluation and preconception coun-
seling and education will become increasingly imperative.

9
10 Chapter 2

OUTCOMES OF EXPOSURE TO TERATOGENS AND OTHER

DEVELOPMENTAL TOXICANTS
Not all developmental toxicants necessarily lead to permanent adverse out-
comes for the fetus or newborn. Some agents may have at least partially
reversible or transient effects if recognized early and appropriately managed.
Examples include fetal growth restriction from tobacco smoking, or other func-
tional disturbances in metabolism or physiology.
It is important to recognize that structural birth defects resulting from ex-
posure to human teratogens are not the only manifestations of exposure to
developmental toxicants. Fetal or postnatal growth disorders, functional devel-
opmental disorders including cognitive and behavioral deficits, abnormalities
of placental function putting the fetus at increased risk, and death (embryonic,
fetal, perinatal, or postnatal) are among potential manifestations of exposures.
Furthermore, some adverse outcomes may not become apparent until many
years later (e.g. reproductive consequences and cancer from exposure to
diethylstilbestrol).

PATHOGENETIC FACTORS IN EVALUATION OF RISK

FROM EXPOSURE TO TERATOGENS AND OTHER
DEVELOPMENTAL TOXICANTS
When evaluating the likely significance of exposure to potentially hazardous
agents, it is essential to consider the following issues in the context of the
known or likely pathogenetic mechanisms for adverse fetal outcomes.
1 Dose and duration of exposure. In general, the larger the dose, the more likely
an effect, and the more likely the effect will be significant. Likewise, the
longer the duration of exposure, the greater the chance is that susceptible
periods of organogenesis and development will be encountered.
2 Timing. Timing of exposure is a critical issue. Certain organ systems may
have only a limited period of susceptibility for damage. Although it is com-
monly thought that damage can only result during the period of organo-
genesis, that is during the first trimester, this is not correct. Some organ
systems (e.g. brain) still undergo important developmental processes later in
pregnancy or can be damaged throughout the prenatal period.
3 Pathogenetic mechanism(s). Teratogens and developmental toxicants produce
their adverse effect by specific mechanisms. As these mechanisms are often
important in multiple tissues and organs, it is not surprising that several
specific types of damage can result. Those agents that affect basic
morphogenetic processes are commonly related to first trimester exposures.
However, those agents that act through mechanical pressures are likely to
have the greatest impact during the third trimester, and those agents that
produce necrosis through inflammation and/or hemorrhage can potentially
destroy normally developing structures throughout pregnancy.
 Developmental toxicology and teratology 11

4 Host susceptibility. Variability in the genetic factors related to metabolism of

certain drugs and chemicals may result in differential susceptibility of the
host to adverse outcomes. However, it should be emphasized that these phar-
macogenetic factors must be expressed at a relevant time in the tissue
or organ system affected. It should also be emphasized that there are two
potentially relevant “hosts” to be considered. Mother and embro/fetus only
share 50% of the genome. Thus, depending on the pathogenesis of the
adverse outcome, maternal or fetal (or perhaps both) genotype may be more
important.
It should also be understood that exposures to human teratogens and other
developmental toxicants are commonly manifest across a wide spectrum
of effects based upon the above factors. At the severe end of this spectrum, a
clinically recognizable pattern of effects (a “syndrome”) may be identified.
However, variability of manifestations within the scope of specific adverse out-
comes comprising a syndrome is the rule. Among the population of exposed
and affected infants, less severe and less pervasive manifestations are often
more frequent. Thus, infants exposed to alcohol prenatally may have outcomes
ranging from mild effects on cognition and behavior from smaller amounts con-
sumed on a few occasions, to the full-blown fetal alcohol syndrome in infants
of severe chronic alcoholics.

IMPORTANT HUMAN TERATOGENS

Information about the teratogenic or developmental toxicities of various agents
is commonly woefully inadequate, especially for chemical agents in the envi-
ronment where exposures are often of low intensity and multiple. Table 2.1
presents a list of agents, including therapeutic agents, for which substantial
human data are available, establishing a risk for humans.

SOURCES OF INFORMATION
The list above is not comprehensive. It continues to grow as new research
reveals more details about the magnitude and nature of risks associated with
many of these and other newly recognized agents. Thus, it is important to
check the current literature before counseling an exposed family. A variety of
information resources, ranging from Internet-based computerized databases
and commercially available information resources, to standard reference
resources for further reading is listed in the suggested reading below.
For the clinician whose practice only rarely encounters these questions, or
for those who encounter a question for which current data are limited or diffi-
cult to access, consultation with a specialist may be an appropriate option.
Many states or academic centers have established “Teratogen Information
Services” to help meet this need. Table 2.2 presents a current listing of these
resources.
Table 2.1 Important human teratogens.

Agent Dose Susceptible period

Medications

Acitretin Usual therapeutic 1st trimester

Aminopterin Usual therapeutic 1st trimester

Amiodarone Usual therapeutic 12 weeks–term

Androgens (including danazol) Usual therapeutic Unknown

Angiotensin II receptor inhibitors Usual therapeutic 2nd and 3rd trimesters
(candesartan, eprosartan, irbesartan,
losartan, olmesartan, tasosartan,
telmisartan, valsartan)

Angiotensin-converting enzyme Usual therapeutic 2nd and 3rd trimesters

inhibitors (benazepril, captopril,
cilazapril, enalapril, enalaprilat,
fosinopril, lisinopril, moexipril,
perindopril, quinapril, ramipril,
trandolapril)

Carbamazepine Usual therapeutic 1st trimester

Clonazepam Usual therapeutic 1st trimester

Coumarin anticoagulants Usual therapeutic 1st trimester

Cyclophosphamide Usual therapeutic 1st trimester

Diethylstilbestrol 1.5–150 mg/day 1st and 2nd trimesters

Ethosuximide Usual therapeutic 1st trimester

Etretinate Usual therapeutic 1st trimester

Fluconazole Chronic, parenteral, 1st trimester

400–800 mg/day

Indomethacin Usual therapeutic 2nd and 3rd trimesters

Isotretinoin Usual therapeutic 1st trimester

(oral)

Lithium Usual therapeutic 1st trimester

Methimazole Usual therapeutic 1st trimester (malformations)

12 weeks–term (hypothyroidism,
goitre)

Methotrexate ≥12.5 mg/week 1st trimester

Methythioninium chloride Intra-amniotic 2nd trimester

injection

Continued
Table 2.1 Continued.

Agent Dose Susceptible period

Misoprostol Usual therapeutic 1st and 2nd trimesters

Penicillamine Usual therapeutic Unknown

Phenobarbital Usual therapeutic 1st trimester

Phenytoin Usual therapeutic 1st trimester

Primidone Usual therapeutic 1st trimester

Quinine ≥2 g/day Entire pregnancy

Tetracyclines (chlortetracycline, Usual therapeutic 1st trimester

demeclocycline, doxycycline,
methacycline, minocycline,
oxytetracycline, tetracycline)

Thalidomide Usual therapeutic 41–54 days

Trimethadione, paramethadione Usual therapeutic 1st trimester

Trimethoprim Usual therapeutic 1st trimester

Valproic acid Usual therapeutic 1st trimester

Agents of abuse

Alcohol Abuse Unknown

Cigarette smoking Risks greater with Entire pregnancy

heavy smoking

Cocaine Abuse Entire pregnancy

Toluene Abuse (inhalation) Unknown

Environmental exposures

Methylmercury Associated with Unknown

maternal
methylmercury
concentration
≥0.1 µg/mL

PCBs Toxic exposure Unknown

Infections

Varicella Primary infection Entire pregnancy

(much smaller risk (but higher in 2nd trimester)
with recurrent
infection)

Continued on p. 14
Table 2.1 Continued.

Agent Dose Susceptible period

Parvovirus B19 Primary infection Entire pregnancy

(but higher in 2nd
trimester)

Cytomegalovirus Primary infection Entire pregnancy

(much smaller risk (but much higher in first half)
with recurrent
infection)

Syphilis 2nd and 3rd trimester

HIV 3rd trimester, especially during

labor

LMCV Unknown

Toxoplasmosis Primary infection Entire pregnancy

Rubella Primary infection 1st and 2nd trimester

(rarely secondary (but much higher in 1st
infection) trimester)

Maternal illnesses and conditions

Maternal diabetes mellitus 1st trimester

Maternal autoantibodies 2nd and 3rd trimester

(Rh, SLE, platelet)

Maternal endocrinopathies Unknown

Maternal phenylketonuria Untreated Unknown

Maternal obesity Risk greater with 1st trimester

severe obesity
than with mild
obesity

Physical agents

Chorionic villus sampling <10 weeks

Early amniocentesis <14 weeks

Ionizing radiation >10–20 cGy Entire pregnancy

(but highest in 1st trimester)

Radioactive iodine Therapeutic 12 weeks–term

HIV, human immunodeficiency virus; LMCV, LCM virus; PCBs, polychlorinated biphenyls; SLE,
systemic lupus erythematosus.
 Developmental toxicology and teratology 15

Table 2.2 Teratogen information services in North America.

Alabama Birth Defects Surveillance

(800) 423-8324 or (334) 460-7691

Arizona Teratogen Information Program

(888) 285-3410 or (520) 626-3410 (in Tucson)

Arkansas Teratogen Information Service

(800) 358-7229 or (501) 296-1700

CTIS Pregnancy Risk Information

(800) 532-3749 (CA only)

IMAGE: Info-Medicaments en Allaitement et Grossesse

Province of Quebec, Canada
(514) 345-2333

Motherisk Program
(416) 813-6780
Ontario, Canada

Connecticut Pregnancy Exposure Information Service

(800) 325-5391 (CT only) or (860) 679-8850

Reproductive Toxicology Center

District Of Columbia (MD)
(301) 620-8690 or (301) 657-5984

Illinois Teratogen Information Service

(800) 252-4847 (IL only) or (312) 981-4354

Indiana Teratogen Information Service

(317) 274-1071

Massachusetts Teratogen Information Service (MaTIS)

(800) 322-5014 (MA only) or (781) 466-8474

Genetics & Teratology Unit, Pediatric Service

Massachusetts General Hospital
(617) 726-1742

Missouri Teratogen Information Service (MOTIS)

(800) 645-6164 or (573) 884-1345

Nebraska Teratogen Project

(402) 559-5071

Pregnancy Healthline
Southern New Jersey Perinatal Cooperative
(888) 722-2903 (NJ) or (856) 665-6000
Continued on p. 16
16 Chapter 2

Table 2.2 Continued.

Pregnancy Risk Network

(800) 724-2454 (then press 1) (NY only) or (716) 882-6791 (then press 1)

PEDECS
Rochester, NY
(716) 275-3638

NCTIS Pregnancy Exposure Riskline

1-800-532-6302 (NC)

North Dakota Teratogen Information Service

(701) 777-4277

Texas Teratogen Information Service

(800) 733-4727 or (940) 565-3892

Pregnancy RiskLine
Salt Lake City, UT
(801) 328-2229 or (800) 822-2229

Pregnancy Risk Information Service

800-531-9800 (VT only) and 800-932-4609

CARE Northwest
Seattle, WA
(888) 616-8484

West Virginia University Hospitals

(304) 293-1572

Wisconsin Teratogen Information Service

(800) 442-6692

Workplace Hazards to Reproductive Health

Madison, WI
(608) 266-2074

For information regarding the Teratology Information Service in your area, contact the
Organization of Teratology Information Services (OTIS) at:
(866) 626-6847 or http://www.otispregnancy.org
 Developmental toxicology and teratology 17

SUGGESTED READING
Bennett PN. Drugs and Human Lactation. Amsterdam: Elsevier, 1988.
Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 6th edn. Baltimore:
Williams & Wilkins, 2001.
Friedman JM, Hanson JW. Clinical teratology. In: Rimoin DL, Connnor JM, Pyeritz R, Korf
B, eds. Principles and Practice of Medical Genetics, 4th edn. London: Churchill Living-
stone, 2002.
Paul M. Occupational and Environmental Reproductive Hazards. Baltimore: Williams &
Wilkins, 1993.
Schardein JL. Chemically Induced Birth Defects, 3rd edn. New York: Marcel Dekker, 2001.
Scialli AR. A Clinical Guide to Reproductive and Developmental Toxicology. Boca Raton: CRC,
1992.
Shepard TH. Catalog of Teratogenic Agents, 10th edn. Baltimore: Johns Hopkins, 2001.

Computerized databases
REPROTOX (202) 687-5137.
TERIS (206) 543-2465.
 CHAPTER 3

Occupational hazards
George R. Saade

INTRODUCTION
In 1970, the Occupational Safety and Health Act was implemented and occu-
pational medicine has been a growing science ever since. At the same time,
there has been a surge of interest in the reproductive effects of working and the
workplace. While an adult worker with an occupational exposure is best served
by referral to an occupational medicine specialist, workplace exposures of preg-
nant women tend to be avoided by occupational physicians and the responsi-
bility for these issues thus falls to the obstetrician. In their Guidelines for
Perinatal Care, the American Academy of Pediatrics (AAP) and the American
College of Obstetricians and Gynecologists (ACOG) include environmental and
occupational exposures among the components of the preconceptional and
antepartum maternal assessment and counseling. Help is available in the form
of Teratogen Information Services, accessed through local health departments,
and via the databases, such as REPROTOX (http://reprotox.org/) and TERIS
(http://depts.washington.edu/~terisweb/teris/), which were set up to provide
information to physicians and the Teratogen Information Services on potential
teratogens from any source, including the workplace.

ERGONOMIC STRESSORS
The AAP/ACOG Guidelines for Perinatal Care state that a woman with an
uncomplicated pregnancy usually can continue to work until the onset of labor,
and that women with medical or obstetric complications of pregnancy may
need to make adjustments based on the nature of their activities, occupation,
and specific complaints. In its most recent update, the American Medical Asso-
ciation (AMA) did not include the recommendation made in the 1983 report
that set a gestational age limit at which certain activities must be discontinued.
The AMA’s updated report concludes that the potential benefits and risks of
occupational activities and exposures should be considered on an individual
basis, and that physicians should work with patients and employers to define
a healthy working environment. These include modifications in the work

18
 Occupational hazards 19

schedule to accommodate breaks every few hours, with a longer “meal” break
every 4 h; encouraging adequate hydration; regularly varying work positions;
and minimizing heavy lifting, especially if associated with bending. All guide-
lines have been marred by the paucity of conclusive scientific evidence on which
to base them. A multitude of studies have been carried out attempting to show
an association between standing work, lifting, strenuous work, and length of
work on preterm delivery rates and low birth weight infants. The greatest diffi-
culty in evaluating the effect of work on reproduction is the vast range of activ-
ities that fall into the category of “work,” and the difficulty in controlling for
confounding variables such as the work environment, socioeconomic stresses,
and psychosocial factors (Table 3.1).
It is important to elicit a detailed account of the patient’s work activity.
Although the studies on independent risk factors are reassuring, it is suspected
that the heterogeneous nature of work may obscure important effects in
women with particularly rigorous jobs. Clearly, a salesperson and a construc-
tion worker both stand for most of the working day, but other aspects of their
jobs are markedly different. Studies that examine the additive effects of multi-
ple risk factors (posture, machinery, exertion, stress, and environment) show
an increase in prematurity and a slight decrease in birth weight. These same
studies also demonstrate that defined rest periods during the working day, and
each month, decrease the incidence of preterm birth in women with manual
labor jobs. It is important to keep in mind that pregnancy affects the ability to
lift a load safely. Compared with the woman’s ability before pregnancy, the
maximum load should be reduced by 20–25% during late pregnancy.
There is a general consensus that some limitation of activity is indicated in
women at risk for adverse pregnancy outcomes, such as women with repeated
preterm birth or pregnancy loss, uterine or cervical anomalies, cardiac or pul-
monary anomalies that may be exacerbated by activity or may limit activity,
oligohydramnios, fetal growth restriction, multiple gestations, or preterm labor
in the current pregnancy. However, there is no clear agreement as to the spe-
cific risk factors or the degree of activity restriction. It is of note that the most

Table 3.1 Impact of work on pregnancy.

Activity Risks

Standing more than 5 h Most studies show an increase in prematurity and no effect on
birthweight

Lifting more than 12 kg No studies show any effect on birthweight or prematurity

Strenuous work Most studies show no effect on birthweight or prematurity

20 Chapter 3

recent reviews in the Cochrane Library (http://www.Cochrane.org) concluded

that there is not enough evidence to support a policy of routine hospitalization
for bed rest in multiple pregnancy (most recent update November 2000), no
evidence either supporting or refuting the use of bed rest at home or in the hos-
pital to prevent preterm birth in singleton pregnancies (most recent update
November 2003), and not enough evidence to evaluate the use of bed rest in
the hospital for women with suspected impaired fetal growth (most recent
update November 2002). Protocols for evaluating bed rest with or without hos-
pitalization for hypertension during pregnancy and for evaluating bed rest for
preventing miscarriage are still pending (most recent updates November 2001
and February 2002, respectively).
When discussing work in pregnancy, it is essential not to overlook work at
home, which is often more strenuous and stressful than work away from home,
and may actually increase if the patient is on leave from her job without ade-
quate household help.

PHYSICAL AGENTS
Heat
The metabolic rate increases during pregnancy, and the fetus’ temperature is
approximately 1°C above the mother’s. Because pregnant women have to elim-
inate the physiologic excess heat, they may be less tolerant of high environ-
mental temperatures. Exposure to heat and hot environments can occur in
many occupations and industries. Few studies specifically address the hazards
of occupational heat stress in pregnancy. Data from animal studies and fever
during pregnancy indicate that core temperature elevations of 38.9°C or more
may increase the rate of spontaneous abortion or birth defects, most notably
neural tube defects.
The National Institute of Occupational Safety and Health guidelines include
ambient air monitoring, heat acclimation, medical surveillance, workload
limits, hydration, and rest periods in cooler areas, heat shielding, ventilation,
and worker education. If a question arises concerning heat or a pregnant
worker complains of discomfort, worksite evaluation may be warranted and
can be arranged through the local Occupational Safety and Health Adminis-
tration office. It may also be necessary to consult with an occupational medi-
cine specialist. Women with early pregnancy hyperthermic episodes should be
counseled about possible effects and offered alpha-fetoprotein screening and
directed sonogram studies.

Ionizing radiation
The effects of prenatal irradiation depend on the exposure dose and the timing
of exposure during pregnancy as well as the repair capabilities of the develop-
ing organism. Information on the reproductive and developmental effects of
Exploring the Variety of Random
Documents with Different Content
lead a regular life. I lead the deuce of a life, simply tearing myself to
pieces. Look here, you and I, we're made for one another ... hand
and glove. Why don't we marry? Do you see any reason why we
shouldn't?"
Connie looked at him amazed: and yet she felt nothing. These men,
they were all alike, they left everything out. They just went off from
the top of their heads as if they were squibs, and expected you to be
carried heavenwards along with their own thin sticks.
"But I am married already," she said. "I can't leave Clifford, you
know."
"Why not? but why not?" he cried. "He'll hardly know you've gone,
after six months. He doesn't know that anybody exists, except
himself. Why the man has no use for you at all, as far as I can see;
he's entirely wrapped up in himself."
Connie felt there was truth in this. But she also felt that Mick was
hardly making a display of selflessness.
"Aren't all men wrapped up in themselves?" she asked.
"Oh, more or less, I allow. A man's got to be, to get through. But
that's not the point. The point is, what sort of a time can a man give a
woman? Can he give her a damn good time, or can't he? If he can't
he's no right to the woman...." He paused and gazed at her with his
full, hazel eyes, almost hypnotic. "Now I consider," he added, "I can
give a woman the darndest good time she can ask for. I think I can
guarantee myself."
"And what sort of a good time?" asked Connie, gazing on him still
with a sort of amazement, that looked like thrill; and underneath
feeling nothing at all.
"Every sort of a good time, damn it, every sort! Dress, jewels up to a
point, any night-club you like, know anybody you want to know, live
the pace ... travel and be somebody wherever you go.... Darn it,
every sort of good time."
He spoke it almost in a brilliancy of triumph, and Connie looked at
him as if dazzled, and really feeling nothing at all. Hardly even the
surface of her mind was tickled at the glowing prospects he offered
her. Hardly even her most outside self responded, that at any other
time would have been thrilled. She just got no feeling from it all, she
couldn't "go off." She just sat and stared and looked dazzled, and felt
nothing, only somewhere she smelt the extraordinarily unpleasant
smell of the bitch-goddess.
Mick sat on tenterhooks, leaning forward in his chair, glaring at her
almost hysterically: and whether he was more anxious out of vanity
for her to say Yes! or whether he was more panic-stricken for fear
she should say Yes!—who can tell?
"I should have to think about it," she said. "I couldn't say now. It may
seem to you Clifford doesn't count, but he does. When you think how
disabled he is...."
"Oh damn it all! if a fellow's going to trade on his disabilities, I might
begin to say how lonely I am, and always have been, and all the rest
of the my-eye-Betty-Martin sob-stuff! Damn it all, if a fellow's got
nothing but disabilities to recommend him...."
He turned aside, working his hands furiously in his trousers pockets.
That evening he said to her:
"You're coming round to my room tonight, aren't you? I don't darned
know where your room is."
"All right!" she said.
He was a more excited lover that night, with his strange, small boy's
frail nakedness. Connie found it impossible to come to her crisis
before he had really finished his. And he roused a certain craving
passion in her, with his little boy's nakedness and softness; she had
to go on after he had finished, in the wild tumult and heaving of her
loins, while he heroically kept himself up, and present in her, with all
his will and self-offering, till she brought about her own crisis, with
weird little cries.
When at last he drew away from her, he said, in a bitter, almost
sneering little voice:
"You couldn't go off at the same time as a man, could you? You'd
have to bring yourself off! You'd have to run the show!"
This little speech, at the moment, was one of the shocks of her life.
Because that passive sort of giving himself was so obviously his only
real mode of intercourse.
"What do you mean?" she said.
"You know what I mean. You keep on for hours after I've gone off ...
and I have to hang on with my teeth till you bring yourself off by your
own exertions."
She was stunned by this unexpected piece of brutality, at the
moment when she was glowing with a sort of pleasure beyond
words, and a sort of love for him. Because after all, like so many
modern men, he was finished almost before he had begun. And that
forced the woman to be active.
"But you want me to go on, to get my own satisfaction?" she said.
He laughed grimly: "I want it!" he said. "That's good! I want to hang
on with my teeth clenched, while you go for me!"
"But don't you?" she insisted.
He avoided the question. "All the darned women are like that," he
said. "Either they don't go off at all, as if they were dead in there ... or
else they wait till a chap's really done, and then they start in to bring
themselves off, and a chap's got to hang on. I never had a woman
yet who went off just at the same moment as I did."
Connie only half heard this piece of novel, masculine information.
She was only stunned by his feeling against her ... his
incomprehensible brutality. She felt so innocent.
"But you want me to have my satisfaction too, don't you?" she
repeated.
"Oh, all right! I'm quite willing. But I'm darned if hanging on waiting
for a woman to go off is much of a game for a man...."
This speech was one of the crucial blows of Connie's life. It killed
something in her. She had not been so very keen on Michaelis; till he
started it, she did not want him. It was as if she never positively
wanted him. But once he had started her, it seemed only natural for
her to come to her own crisis with him. Almost she had loved him for
it ... almost that night she loved him, and wanted to marry him.
Perhaps instinctively he knew it, and that was why he had to bring
down the whole show with a smash; the house of cards. Her whole
sexual feeling for him, or for any man, collapsed that night. Her life
fell apart from his as completely as if he had never existed.
And she went through the days drearily. There was nothing now but
this empty treadmill of what Clifford called the integrated life, the long
living together of two people, who are in the habit of being in the
same house with one another.
Nothingness! To accept the great nothingness of life seemed to be
the one end of living. All the many busy and important little things
that make up the grand sum-total of nothingness!

CHAPTER VI
"Why don't men and women really like one another nowadays?"
Connie asked Tommy Dukes, who was more or less her oracle.
"Oh, but they do! I don't think since the human species was invented,
there has ever been a time when men and women have liked one
another as much as they do today. Genuine liking! Take myself ... I
really like women better than men; they are braver, one can be more
frank with them."
Connie pondered this.
"Ah, yes, but you never have anything to do with them!" she said.
"I? What am I doing but talking perfectly sincerely to a woman at this
moment?"
"Yes, talking...."
"And what more could I do if you were a man, than talk perfectly
sincerely to you?"
"Nothing perhaps. But a woman...."
"A woman wants you to like her and talk to her, and at the same time
love her and desire her; and it seems to me the two things are
mutually exclusive."
"But they shouldn't be!"
"No doubt water ought not to be so wet as it is; it overdoes it in
wetness. But there it is! I like women and talk to them, and therefore
I don't love them and desire them. The two things don't happen at
the same time in me."
"I think they ought to."
"All right. The fact that things ought to be something else than what
they are, is not my department."
Connie considered this. "It isn't true," she said. "Men can love
women and talk to them. I don't see how they can love them without
talking, and being friendly and intimate. How can they?"
"Well," he said, "I don't know. What's the use of my generalising? I
only know my own case. I like women, but I don't desire them. I like
talking to them; but talking to them, though it makes me intimate in
one direction, sets me poles apart from them as far as kissing is
concerned. So there you are! But don't take me as a general
example, probably I'm just a special case: one of the men who like
women, but don't love women, and even hate them if they force me
into a pretence of love, or an entangled appearance."
"But doesn't it make you sad?"
"Why should it? Not a bit! I look at Charlie May, and the rest of the
men who have affairs.... No, I don't envy them a bit! If fate sent me a
woman I wanted, well and good. Since I don't know any woman I
want, and never see one ... why, I presume I'm cold, and I really like
some women very much."
"Do you like me?"
"Very much! And you see there's no question of kissing between us,
is there?"
"None at all!" said Connie. "But oughtn't there to be?"
"Why, in God's name? I like Clifford, but what would you say if I went
and kissed him?"
"But isn't there a difference?"
"Where does it lie, as far as we're concerned? We're all intelligent
human beings, and the male and female business is in abeyance.
Just in abeyance. How would you like me to start acting up like a
continental male at this moment, and parading the sex thing?"
"I should hate it."
"Well then! I tell you, if I'm really a male thing at all, I never run
across the female of my species. And I don't miss her, I just like
women. Who's going to force me into loving, or pretending to love
them, working up the sex game?"
"No, I'm not. But isn't something wrong?"
"You may feel it, I don't."
"Yes, I feel something is wrong between men and women. A woman
has no glamour for a man any more."
"Has a man for a woman?"
She pondered the other side of the question.
"Not much," she said truthfully.
"Then let's leave it all alone, and just be decent and simple, like
proper human beings with one another. Be damned to the artificial
sex-compulsion! I refuse it!"
Connie knew he was right, really. Yet it left her feeling so forlorn, so
forlorn and stray. Like a chip on a dreary pond, she felt. What was
the point, of her or anything?
It was her youth which rebelled. These men seemed so old and cold.
Everything seemed old and cold. And Michaelis let one down so; he
was no good. The men didn't want one; they just didn't really want a
woman, even Michaelis didn't.
And the bounders who pretended they did, and started working the
sex game, they were worse than ever.
It was just dismal, and one had to put up with it. It was quite true,
men had no real glamour for a woman: if you could fool yourself into
thinking they had, even as she had fooled herself over Michaelis,
that was the best you could do. Meanwhile you just lived on and
there was nothing to it. She understood perfectly well why people
had cocktail parties, and jazzed, and Charlestoned till they were
ready to drop. You had to take it out some way or other, your youth,
or it ate you up. But what a ghastly thing, this youth! you felt as old
as Methuselah, and yet the thing fizzed somehow, and didn't let you
be comfortable. A mean sort of life! And no prospect! She almost
wished she had gone off with Mick, and made her life one long
cocktail party, and jazz evening. Anyhow that was better than just
mooning yourself into the grave.
On one of her bad days she went out alone to walk in the wood,
ponderously, heeding nothing, not even noticing where she was. The
report of a gun not far off startled and angered her.
Then, as she went, she heard voices, and recoiled. People! She
didn't want people. But her quick ear caught another sound, and she
roused; it was a child sobbing. At once she attended; someone was
ill-treating a child. She strode swinging down the wet drive, her
sullen resentment uppermost. She felt just prepared to make a
scene.
Turning the corner, she saw two figures in the drive beyond her: the
keeper, and a little girl in a purple coat and moleskin cap, crying.
"Ah, shut it up, tha false little bitch!" came the man's angry voice, and
the child sobbed louder.
Constance strode nearer, with blazing eyes. The man turned and
looked at her, saluting coolly, but he was pale with anger.
"What's the matter? Why is she crying?" demanded Constance,
peremptory but a little breathless.
A faint smile like a sneer came on the man's face. "Nay, yo' mun ax
'er," he replied callously, in broad vernacular.
Connie felt as if he had hit her in the face, and she changed colour.
Then she gathered her defiance, and looked at him, her dark-blue
eyes blazing rather vaguely.
"I asked you," she panted.
He gave a queer little bow, lifting his hat. "You did, your Ladyship,"
he said; then, with a return to the vernacular: "but I canna tell yer."
And he became a soldier, inscrutable, only pale with annoyance.
Connie turned to the child, a ruddy, black-haired thing of nine or ten.
"What is it, dear? Tell me why you're crying!" she said, with the
conventionalised sweetness suitable. More violent sobs, self-
conscious. Still more sweetness on Connie's part.
"There, there, don't you cry! Tell me what they've done to you!" ...
and intense tenderness of tone. At the same time she felt in the
pocket of her knitted jacket, and luckily found a sixpence.
"Don't you cry then!" she said, bending in front of the child. "See
what I've got for you!"
Sobs, snuffles, a fist taken from a blubbered face, and a black
shrewd eye cast for a second on the sixpence. Then more sobs, but
subduing. "There, tell me what's the matter, tell me!" said Connie,
putting the coin into the child's chubby hand, which closed over it.
"It's the ... it's the ... pussy!"
Shudders of subsiding sobs.
"What pussy, dear?"
After a silence the shy fist, clenching on sixpence, pointed into the
bramble brake.
"There!"
Connie looked, and there, sure enough, was a big black cat,
stretched out grimly, with a bit of blood on it.
"Oh!" she said in repulsion.
"A poacher, your Ladyship," said the man satirically.
She glanced at him angrily. "No wonder the child cried," she said, "if
you shot it when she was there. No wonder she cried!"
He looked into Connie's eyes, laconic, contemptuous, not hiding his
feelings. And again Connie flushed; she felt she had been making a
scene, the man did not respect her.
"What is your name?" she said playfully to the child. "Won't you tell
me your name?"
Sniffs; then very affectedly in a piping voice; "Connie Mellors!"
"Connie Mellors! Well, that's a nice name! And did you come out with
your Daddy, and he shot a pussy? But it was a bad pussy!"
The child looked at her, with bold, dark eyes of scrutiny, sizing her
up, and her condolence.
"I wanted to stop with my Gran," said the little girl.
"Did you? But where is your Gran?"
The child lifted an arm, pointing down the drive. "At th' cottidge."
"At the cottage! And would you like to go back to her?"
Sudden, shuddering quivers of reminiscent sobs. "Yes!"
"Come then, shall I take you? Shall I take you to your Gran? Then
your Daddy can do what he has to do." She turned to the man. "It is
your little girl, isn't it?"
He saluted, and made a slight movement of the head in affirmation.
"I suppose I can take her to the cottage?" asked Connie.
"If your Ladyship wishes."
Again he looked into her eyes, with that calm, searching detached
glance. A man very much alone, and on his own.
"Would you like to come with me to the cottage, to your Gran, dear?"
The child peeped up again. "Yes!" she simpered.
Connie disliked her; the spoilt, false little female. Nevertheless she
wiped her face, and took her hand. The keeper saluted in silence.
"Good morning!" said Connie.
It was nearly a mile to the cottage, and Connie senior was well bored
by Connie junior by the time the gamekeeper's picturesque little
home was in sight. The child was already as full to the brim with
tricks as a little monkey, and so self-assured.
At the cottage the door stood open, and there was a rattling heard
inside. Connie lingered, the child slipped her hand, and ran indoors.
"Gran! Gran!"
"Why, are yer back a'ready!"
The grandmother had been blackleading the stove, it was Saturday
morning. She came to the door in her sacking apron, a blacklead-
brush in her hand, and a black smudge on her nose. She was a little,
rather dry woman.
"Why, whatever?" she said, hastily wiping her arm across her face as
she saw Connie standing outside.
"Good morning!" said Connie. "She was crying, so I just brought her
home."
The grandmother looked round swiftly at the child:
"Why, wheer was yer Dad?"
The little girl clung to her grandmother's skirts and simpered.
"He was there," said Connie, "but he'd shot a poaching cat, and the
child was upset."
"Oh, you'd no right t'ave bothered, Lady Chatterley, I'm sure! I'm sure
it was very good of you, but you shouldn't 'ave bothered. Why, did
ever you see!"—and the old woman turned to the child: "Fancy Lady
Chatterley takin' all that trouble over yer! Why, she shouldn't 'ave
bothered!"
"It was no bother, just a walk," said Connie smiling.
"Why, I'm sure t'was very kind of you, I must say! So she was crying!
I knew there'd be something afore they got far. She's frightened of
'im, that's wheer it is. Seems 'e's almost a stranger to 'er, fair a
stranger, and I don't think they're two as'd hit it off very easy. He's got
funny ways."
Connie didn't know what to say.
"Look, Gran!" simpered the child.
The old woman looked down at the sixpence in the little girl's hand.
"An' sixpence an' all! Oh, your Ladyship, you shouldn't, you
shouldn't. Why, isn't Lady Chatterley good to yer! My word, you're a
lucky girl this morning!"
She pronounced the name, as all the people did: Chat'ley.—"Isn't
Lady Chat'ley good to you!"—Connie couldn't help looking at the old
woman's nose, and the latter again vaguely wiped her face with the
back of her wrist, but missed the smudge.
Connie was moving away.... "Well, thank you ever so much, Lady
Chat'ley, I'm sure. Say thank you to Lady Chat'ley!"—this last to the
child.
"Thank you," piped the child.
"There's a dear!" laughed Connie, and she moved away, saying
"Good morning," heartily relieved to get away from the contact.
Curious, she thought, that that thin, proud man should have that
little, sharp woman for a mother!
And the old woman, as soon as Connie was gone, rushed to the bit
of mirror in the scullery, and looked at her face. Seeing it, she
stamped her foot with impatience. "Of course she had to catch me in
my coarse apron, and a dirty face! Nice idea she'd get of me!"
Connie went slowly home to Wragby. "Home!" ... it was a warm word
to use for that great, weary warren. But then it was a word that had
had its day. It was somehow cancelled. All the great words, it
seemed to Connie, were cancelled for her generation: love, joy,
happiness, home, mother, father, husband, all these great, dynamic
words were half dead now, and dying from day to day. Home was a
place you lived in, love was a thing you didn't fool yourself about, joy
was a word you applied to a good Charleston, happiness was a term
of hypocrisy used to bluff other people, a father was an individual
who enjoyed his own existence, a husband was a man you lived with
and kept going in spirits. As for sex, the last of the great words, it
was just a cocktail term for an excitement that bucked you up for a
while, then left you more raggy than ever. Frayed! It was as if the
very material you were made of was cheap stuff, and was fraying out
to nothing.
All that really remained was a stubborn stoicism: and in that there
was a certain pleasure. In the very experience of the nothingness of
life, phase after phase, étape after étape, there was a certain grisly
satisfaction. So that's that! Always this was the last utterance: home,
love, marriage, Michaelis: So that's that!—And when one died, the
last words to life would be: So that's that!—
Money? Perhaps one couldn't say the same there. Money one
always wanted. Money, success, the bitch-goddess, as Tommy
Dukes persisted in calling it, after Henry James, that was a
permanent necessity. You couldn't spend your last sou, and say
finally: So that's that!—No, if you lived even another ten minutes, you
wanted a few more sous for something or other. Just to keep the
business mechanically going, you needed money. You had to have it.
Money you have to have. You needn't really have anything else. So
that's that!—
Since, of course, it's not your own fault you are alive. Once you are
alive, money is a necessity, and the only absolute necessity. All the
rest you can get along without, at a pinch. But not money.
Emphatically, that's that!—
She thought of Michaelis, and the money she might have had with
him; and even that she didn't want. She preferred the lesser amount
which she helped Clifford to make by his writing. That she actually
helped to make.—"Clifford and I together, we make twelve hundred a
year out of writing;" so she put it to herself. Make money! Make it!
Out of nowhere! Wring it out of the thin air! The last feat to be
humanly proud of! The rest all-my-eye-Betty-Martin.
So she plodded home to Clifford, to join forces with him again, to
make another story out of nothingness: and a story meant money.
Clifford seemed to care very much whether his stories were
considered first class literature or not. Strictly, she didn't care.
Nothing in it! said her father. Twelve hundred pounds last year! was
the retort simple and final.
If you were young, you just set your teeth, and bit on and held on, till
the money began to flow from the invisible; it was a question of
power. It was a question of will; a subtle, subtle, powerful emanation
of will out of yourself brought back to you the mysterious
nothingness of money: a word on a bit of paper. It was a sort of
magic, certainly it was triumph. The bitch-goddess! Well, if one had
to prostitute oneself, let it be to a bitch-goddess! One could always
despise her even while one prostituted oneself to her, which was
good.
Clifford, of course, had still many childish taboos and fetishes. He
wanted to be thought "really good," which was all cock-a-hoopy
nonsense. What was really good was what actually caught on. It was
no good being really good and getting left with it. It seemed as if
most of the "really good" men just missed the bus. After all you only
lived one life, and if you missed the bus, you were just left on the
pavement, along with the rest of the failures.
Connie was contemplating a winter in London with Clifford, next
winter. He and she had caught the bus all right, so they might as well
ride on top for a bit, and show it.
The worst of it was, Clifford tended to become vague, absent, and to
fall into fits of vacant depression. It was the wound to his psyche
coming out. But it made Connie want to scream. Oh God, if the
mechanism of the consciousness itself was going to go wrong, then
what was one to do? Hang it all, one did one's bit! Was one to be let
down absolutely?
Sometimes she wept bitterly, but even as she wept she was saying
to herself: Silly fool, wetting hankies! As if that would get you
anywhere!
Since Michaelis, she had made up her mind she wanted nothing.
That seemed the simplest solution of the otherwise insoluble. She
wanted nothing more than what she'd got; only she wanted to get
ahead with what she'd got: Clifford, the stories, Wragby, the Lady-
Chatterley business, money, and fame, such as it was ... she wanted
to go ahead with it all. Love, sex, all that sort of stuff, just water-ices!
Lick it up and forget it. If you don't hang on to it in your mind, it's
nothing. Sex especially ... nothing! Make up your mind to it, and
you've solved the problem. Sex and a cocktail: they both lasted
about as long, had the same effect, and amounted to about the
same thing.
But a child, a baby! that was still one of the sensations. She would
venture very gingerly on that experiment. There was the man to
consider, and it was curious, there wasn't a man in the world whose
children you wanted. Mick's children! Repulsive thought! As lief have
a child to a rabbit! Tommy Dukes?... he was very nice, but somehow
you couldn't associate him with a baby, another generation. He
ended in himself. And out of all the rest of Clifford's pretty wide
acquaintance, there was not a man who did not rouse her contempt,
when she thought of having a child by him. There were several who
would have been quite possible as lovers, even Mick. But to let them
breed a child on you! Ugh! Humiliation and abomination.
So that was that!
Nevertheless, Connie had the child at the back of her mind. Wait!
wait! She would sift the generations of men through her sieve, and
see if she couldn't find one who would do.—"Go ye into the streets
and byways of Jerusalem, and see if ye can find a man." It had been
impossible to find a man in the Jerusalem of the prophet, though
there were thousands of male humans. But a man! C'est une autre
chose!
She had an idea that he would have to be a foreigner: not an
Englishman, still less an Irishman. A real foreigner.
But wait! wait! Next winter she would get Clifford to London; the
following winter she would get him abroad to the South of France,
Italy. Wait! She was in no hurry about the child. That was her own
private affair, and the one point on which, in her own queer, female
way, she was serious to the bottom of her soul. She was not going to
risk any chance comer, not she! One might take a lover almost at
any moment, but a man who should beget a child on one ... wait!
wait! it's a very different matter.—"Go ye into the streets and byways
of Jerusalem...." It was not a question of love; it was a question of a
man. Why, one might even rather hate him, personally. Yet if he was
the man, what would one's personal hate matter? This business
concerned another part of oneself.
It had rained as usual, and the paths were too sodden for Clifford's
chair, but Connie would go out. She went out alone every day now,
mostly in the wood, where she was really alone. She saw nobody
there.
This day, however, Clifford wanted to send a message to the keeper,
and as the boy was laid up with influenza,—somebody always
seemed to have influenza at Wragby,—Connie said she would call at
the cottage.
The air was soft and dead, as if all the world were slowly dying. Grey
and clammy and silent, even from the shuffling of the collieries, for
the pits were working short time, and today they were stopped
altogether. The end of all things!
In the wood all was utterly inert and motionless, only great drops fell
from the bare boughs, with a hollow little crash. For the rest, among
the old trees was depth within depth of grey, hopeless, inertia,
silence, nothingness.
Connie walked dimly on. From the old wood came an ancient
melancholy, somehow soothing to her, better than the harsh
insentience of the outer world. She liked the inwardness of the
remnant of forest, the unspeaking reticence of the old trees. They
seemed a very power of silence, and yet a vital presence. They, too,
were waiting: obstinately, stoically waiting, and giving off a potency of
silence. Perhaps they were only waiting for the end; to be cut down,
cleared away, the end of the forest, for them the end of all things. But
perhaps their strong and aristocratic silence, the silence of strong
trees, meant something else.
As she came out of the wood on the north side, the keeper's cottage,
a rather dark, brown stone cottage, with gables and a handsome
chimney, looked uninhabited, it was so silent and alone. But a thread
of smoke rose from the chimney, and the little railed-in garden in the
front of the house was dug and kept very tidy. The door was shut.
Now she was here she felt a little shy of the man, with his curious
far-seeing eyes. She did not like bringing him orders, and felt like
going away again. She knocked softly, no one came. She knocked
again, but still not loudly. There was no answer. She peeped through
the window, and saw the dark little room, with its almost sinister
privacy, not wanting to be invaded.
She stood and listened, and it seemed to her she heard sounds from
the back of the cottage. Having failed to make herself heard, her
mettle was roused, she would not be defeated.
So she went round the side of the house. At the back of the cottage
the land rose steeply, so the backyard was sunken, and enclosed by
a low stone wall. She turned the corner of the house and stopped. In
the little yard two paces beyond her, the man was washing himself,
utterly unaware. He was naked to the hips, his velveteen breeches
slipping down over his slender loins. And his white slim back was
curved over a big bowl of soapy water, in which he ducked his head,
shaking his head with a queer, quick little motion, lifting his slender
white arms, and pressing the soapy water from his ears, quick,
subtle as a weasel playing with water, and utterly alone. Connie
backed away round the corner of the house, and hurried away to the
wood. In spite of herself, she had had a shock. After all, merely a
man washing himself; common-place enough, Heaven knows!
Yet in some curious way it was a visionary experience: it had hit her
in the middle of the body. She saw the clumsy breeches slipping
down over the pure, delicate, white loins, the bones showing a little,
and the sense of aloneness, of a creature purely alone,
overwhelmed her. Perfect, white, solitary nudity of a creature that
lives alone, and inwardly alone. And beyond that, a certain beauty of
a pure creature. Not the stuff of beauty, not even the body of beauty,
but a lambency, the warm, white flame of a single life, revealing itself
in contours that one might touch: a body!
Connie had received the shock of vision in her womb, and she knew
it; it lay inside her. But with her mind she was inclined to ridicule. A
man washing himself in a backyard! No doubt with evil-smelling
yellow soap!—She was rather annoyed; why should she be made to
stumble on these vulgar privacies?
So she walked away from herself, but after a while she sat down on
a stump. She was too confused to think. But in the coil of her
confusion, she was determined to deliver her message to the fellow.
She would not be balked. She must give him time to dress himself,
but not time to go out. He was probably preparing to go out
somewhere.
So she sauntered slowly back, listening. As she came near, the
cottage looked just the same. A dog barked, and she knocked at the
door, her heart beating in spite of herself.
She heard the man coming lightly downstairs. He opened the door
quickly, and startled her. He looked uneasy himself, but instantly a
laugh came on his face.
"Lady Chatterley!" he said. "Will you come in?"
His manner was so perfectly easy and good, she stepped over the
threshold into the rather dreary little room.
"I only called with a message from Sir Clifford," she said in her soft,
rather breathless voice.
The man was looking at her with those blue, all-seeing eyes of his,
which made her turn her face aside a little. He thought her comely,
almost beautiful, in her shyness, and he took command of the
situation himself at once.
"Would you care to sit down?" he asked, presuming she would not.
The door stood open.
"No thanks! Sir Clifford wondered if you would ..." and she delivered
her message, looking unconsciously into his eyes again. And now
his eyes looked warm and kind, particularly to a woman, wonderfully
warm, and kind, and at ease.
"Very good, your Ladyship. I will see to it at once."
Taking an order, his whole self had changed, glazed over with a sort
of hardness and distance. Connie hesitated, she ought to go. But
she looked round the clean, tidy, rather dreary little sitting-room with
something like dismay.
"Do you live here quite alone?" she asked.
"Quite alone, your Ladyship."
"But your mother...?"
"She lives in her own cottage in the village."
"With the child?" asked Connie.
"With the child!"
And his plain, rather worn face took on an indefinable look of
derision. It was a face that changed all the time, baffling.
"No," he said, seeing Connie stand at a loss, "my mother comes and
cleans up for me on Saturdays; I do the rest myself."
Again Connie looked at him. His eyes were smiling again, a little
mockingly, but warm and blue, and somehow kind. She wondered at
him. He was in trousers and flannel shirt and a grey tie, his hair soft
and damp, his face rather pale and worn-looking. When the eyes
ceased to laugh they looked as if they had suffered a great deal, still
without losing their warmth. But a pallor of isolation came over him,
she was not really there for him.
She wanted to say so many things, and she said nothing. Only she
looked up at him again, and remarked:
"I hope I didn't disturb you?"
The faint smile of mockery narrowed his eyes.
"Only combing my hair, if you don't mind. I'm sorry I hadn't a coat on,
but then I had no idea who was knocking. Nobody knocks here, and
the unexpected sounds ominous."
He went in front of her down the garden path to hold the gate. In his
shirt, without the clumsy velveteen coat, she saw again how slender
he was, thin, stooping a little. Yet, as she passed him, there was
something young and bright in his fair hair, and his quick eyes. He
would be a man about thirty-seven or eight.
She plodded on into the wood, knowing he was looking after her; he
upset her so much, in spite of herself.
And he, as he went indoors, was thinking: "She's nice, she's real!
she's nicer than she knows."
She wondered very much about him; he seemed so unlike a
gamekeeper, so unlike a working-man anyhow; although he had
something in common with the local people. But also something very
uncommon.
"The gamekeeper, Mellors, is a curious kind of person," she said to
Clifford; "he might almost be a gentleman."
"Might he?" said Clifford. "I hadn't noticed."
"But isn't there something special about him?" Connie insisted.
"I think he's quite a nice fellow, but I know very little about him. He
only came out of the army last year, less than a year ago. From
India, I rather think. He may have picked up certain tricks out there,
perhaps he was an officer's servant, and improved on his position.
Some of the men were like that. But it does them no good, they have
to fall back into their old place when they get home again."
Connie gazed at Clifford contemplatively. She saw in him the
peculiar tight rebuff against anyone of the lower classes who might
be really climbing up, which she knew was characteristic of his
breed.
"But don't you think there is something special about him?" she
asked.
"Frankly, no! Nothing I had noticed."
He looked at her curiously, uneasily, half-suspiciously. And she felt
he wasn't telling her the real truth; he wasn't telling himself the real
truth, that was it. He disliked any suggestion of a really exceptional
human being. People must be more or less at his level, or below it.
Connie felt again the tightness, niggardliness of the men of her
generation. They were so tight, so scared of life!

CHAPTER VII
When Connie went up to her bedroom she did what she had not
done for a long time: took off all her clothes, and looked at herself
naked in the huge mirror. She did not know what she was looking for,
or at, very definitely, yet she moved the lamp till it shone full on her.
And she thought, as she had thought so often ... what a frail, easily
hurt, rather pathetic thing a human body is, naked; somehow a little
unfinished, incomplete!
She had been supposed to have rather a good figure, but now she
was out of fashion: a little too female, not enough like an adolescent
boy. She was not very tall, a bit Scottish and short; but she had a
certain fluent, down-slipping grace that might have been beauty. Her
skin was faintly tawny, her limbs had a certain stillness, her body
should have had a full, down-slipping richness; but it lacked
something.
Instead of ripening its firm, down-running curves, her body was
flattening and going a little harsh. It was as if it had not had enough
sun and warmth; it was a little greyish and sapless.
Disappointed of its real womanhood, it had not succeeded in
becoming boyish, and unsubstantial, and transparent; instead it had
gone opaque.
Her breasts were rather small, and dropping pear-shaped. But they
were unripe, a little bitter, without meaning hanging there. And her
belly had lost the fresh, round gleam it had had when she was
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