Hot topics in perinatal medicine

Palacios-Jaraquemada, José Miguel

Placental Adhesive Disorders. Vol. 1, De Gruyter, Berlin/Munich/Boston 2012, e-ISBN 978-3-11-028238-2

Chervenak, Frank A./McCullough, Laurence B.

The Professional Responsibility Model of Perinatal Ethics. Vol. 2, De Gruyter, Berlin/Munich/Boston 2014, e-ISBN 978-3-11-031672-8

Farine, Dan

New Technologies for Managing Labor. Vol. 3, De Gruyter, Berlin/Munich/Boston 2015, e-ISBN 978-3-11-031670-4

Saling, Erich/Dräger, Monika/Stupin, Jens H.

In collab. with International Academy of Perinatal Medicine: The Beginnings of Perinatal Medicine. Vol. 4, De Gruyter, Berlin/Munich/Boston 2014, e-ISBN 978-3-11-031795-4

Perinatology is the discipline that deals with medical conditions during birth and in the peripartum period. In other words, perinatology combines collaborative efforts from obstetrics, neonatology and anesthesiology/intensive care therapy for caring about the life and health of the mother and the fetus/neonate. Therefore, clinicians of these three disciplines who care for pregnant women, fetal patients, and neonates are perinatologists. Perinatology emerged in the second half of the twentieth century, when the examination, care and treatment of the fetus as a patient became possible before and during birth with various biophysical and biochemical methods, and the life functions of preterm neonates could be maintained with intensive care therapy. Concomitantly, there have been extensive developments in adult intensive care therapy by this time, and the life expectancy of severely ill pregnant and post-partum women has also improved considerably.

For pregnant women the discipline of obstetrics starts with the conception and lasts until the sixth week of the post-partum period. Neonatology takes over the care of the neonate until the post-partum sixth week. The perinatal period starts at the 24^th week when the fetus/neonate already has a real chance to survive in the extrauterine life; thus, perinatology or perinatal medicine is the discipline for the perinatal period for both the mother and her fetus/neonate. Neonatal intensive care units (NICUs) are frequently called perinatal intensive care centers although this label can only be given to those obstetrical wards that have a NICU. Some, predominantly American obstetricians consider only the care of high-risk pregnancies/fetuses/neonates within the category of perinatology. This is unfortunate since there are multiple overlaps, and pregnancies considered as low-risk can turn into high-risk at any moment. Therefore, there is a need for the awareness of low-risk pregnancies and their preventive care in order to achieve the timely detection and treatment of high-risk cases in perinatology. Due to the significant increase in the information on the intrauterine status of the fetus, we also used to talk about fetal medicine from the period between conception and birth.

The old concept took the cutting of the umbilical cord as the meeting point of obstetrics and neonatology. On the contrary, the new, perinatologist concept involves the common thinking and collaboration of obstetricians, neonatologists and anesthesiologists throughout the perinatal period. For example, the decision on performing a cesarean delivery, and the planning and timing of the surgery requires not only an obstetrical but rather a multidisciplinary, perinatologist approach. Thus, for obstetrics to completely fulfill its mission, it needs the collaborative support from closely related disciplines. The health and the life of pregnant and then post-partum women as well as her fetus/neonate can dominantly be supported by these three disciplines; however, in many cases clinicians from other disciplines also need to be involved in these concerted efforts, as well.

Berlin was one of the birthplaces of perinatology at the end of the 1950s, with Professor Erich Saling considered the father of perinatal medicine. His distinguished successor Professor Joachim Dudenhausen has launched the handbook series “Hot Topics in Perinatal Medicine” with the publisher De Gruyter. I recommend the first four excellent volumes of this series for all who care for pregnant women, fetal patients, and neonates.

Volume 1 was written by José Miguel Palacios-Jaraquemada under the title of “Placental Adhesive Disorders”, aiming to provide an overview on all aspects of placenta accreta, increta and percreta including the etiology, diagnosis, treatment and the author’s personal experience in more than 500 cases. Not only is the current knowledge summarized on these severe clinical conditions with massive hemorrhage and high maternal morbidity and mortality, but the book also provides pathways for the accurate diagnosis and clinical management, including vascular control, urology, anesthesia and hemodynamic management of abnormal placentation disorders. The book contains 125 figures, five tables and 26 links to online videos, and thus, provides colorful, visually engaging and strong insights into this clinically important issue.

Indeed, the significance of the topic is growing, since the incidence of these disorders is rising due to the elevation in the number of repeat cesarean sections, which constitute the main risk factor that result in myometrial damage and scar formation. This damage may lead to abnormal placentation in subsequent pregnancies due to a complex process that also includes endometrial damage, defective decidualization and abnormal trophoblast invasion.

First, the book describes the risk factors, epidemiology, etiology and anatomical aspects of placental adhesive disorders, as well as their histological and clinical classifications. Then it illustrates the presurgical techniques that may provide a high confidence diagnosis and support for optimal clinical management including various surgical techniques such as hysterectomy or conservative surgery. This is important, since the topography of the invaded area is in direct contact with highly vascularized tissues, and placental invasion has to be carefully mapped to know which type of proximal vascular control may be the most successful.

Volume 2 was written by the founder of perinatal ethics, Frank A. Chervenak, and his collaborator of more than three decades in this newly emerging field, Laurence B. McCullough. This book aimed at providing a comprehensive overview on the most important clinical and research challenges in ethics that perinatologists have to face in a daily basis in today’s practice. In accord, the title “The Professional Responsibility Model of Perinatal Ethics” reflects the essential role of ethics in elucidating professional responsibility in the practice of perinatologists.

The authors first introduce the professional responsibility model that was rooted in the medical ethics of Scottish and English Enlightenments two centuries ago. The two core concepts of this secular model are nicely described, namely the ethical concepts of medicine as a profession, and the ethical concepts of pregnant women, their fetus and neonate as a patient including the principles of beneficence and respect for autonomy. The preventive approach of this ethics model to the challenges of perinatal medicine is also emphasized.

Then the book addresses a wide range of ethical challenges that we have to face in clinical practice, innovation and research, and it also provides a practical guidance for responsible clinical judgment, decision making and management. The interesting and important topics also include ethics issues related to feticide, home birth, neonatal care as a trial management, patient-choice cesarean delivery, periviability, and research for fetal benefit. Importantly, the advocacy for the health and healthcare of women and children is addressed as a critical constituent of professional responsibility in perinatal medicine.

Volume 3 was edited by Dan Farine, and Isis Amer-Wåhlin, Diogo Ayres-de-Campos, Brianne Bimson, Sergio Carmona, Simon S. Cohen, Rohan D’Souza, Gian Carlo Di Renzo, Anna Maria Dückelmann, Darine El-Chaar, Drorith Hochner-Celnikier, Richard Horgan, Karim D. Kalache, Hugo Krupitzki, Inês Nunes, Yoav Paltieli, Hadar Rosen, Barak Rosenn, Rami Sammour, Javier Schvartzman, Tim van Mieghem and Yariv Yogev also contributed besides the editor. This book was published under the title of “New Technologies for Managing Labor” and aimed at reviewing the novel methodologies and equipment, which have helped clinicians in improving the management and the outcomes of labor.

As it is introduced in the historical overview, due to the fetal and maternal anatomical features of humans, women cannot deliver alone as compared to primates. Moreover, the benefits of brain development and locomotion changes during evolution are counterbalanced by the complications that can affect human birth. Therefore, there is a mandatory need for assistance in human labor and delivery. This book gives an elegant overview how labor assistance has developed from its roots in the activities of labor attending women in primitive societies and lay midwifes, through the establishment of labor floors in hospitals, until the introduction of key instruments and technologies including forceps, vacuum, cesarean surgery, analgesia and various maternal and fetal monitoring devices to improve birth outcomes.

Among the promising novel methodologies that are currently being developed or introduced into the clinical use, two are particularly interesting. The LaborPro system is an ultrasound-based equipment that supports the accurate and non-invasive assessment as well as 3D display of labor progress. Therefore, it promotes better decision making and management during labor and the reduction in the risks and costs associated with childbirth. The Odón device, which represents a completely novel approach to instrumental delivery, has recently been developed and is currently in test phase by a multi-center study. Due to its unique technical characteristics, it may assist vaginal deliveries by avoiding the two great limitations that forceps and vacuum have, namely maternal and fetal injuries and the high degree of training required for their use.

Volume 4 was published in collaboration with the International Academy of Perinatal Medicine (IAPM) under the title of “The Beginnings of Perinatal Medicine”. This book was edited by Erich Saling, Monika Dräger and Jens H. Stupin, and Mary E. D’Alton, José Maria Carrera, Jack Bennebroek Gravenhorst, Anne Greenough, Amos Grünebaum, Asim Kurjak, Anthony D. Milner and Noelia Zork also contributed besides the editors.

The book of these highly qualified specialists and experts aimed at elucidating from a historical perspective how perinatal medicine was born in the middle of the twentieth century, and also to show how the methods used in the everyday work of obstetricians have been innovated. This is of importance, since it is the first collection of publications which present the history of this young and interdisciplinary field of medicine in an integrative way. Although the book mainly focuses on the early stages of perinatal medicine, some of the scientific foundations and later progresses in the field are also described briefly.

It is nicely elucidated by Professor Erich Saling, also called as “The Father of Perinatal Medicine”, and his co-authors how the predominantly mother-oriented obstetrics has become also embryo- and fetal-oriented from the 60’s, and the fetus has become a patient. Pioneers of this period whose instrumental contributions to the birth of perinatal medicine were emphasized in this book also included Apgar, Bevis, Caldeyro-Barcia, Donald, Hammacher, Hon, James, Kratochwil, Liggins, Liley, Maeda and others. Their most important scientific and medical breakthroughs have led to the introduction of fetal blood analysis, monitoring of fetal heart and labor activities, examination of amniotic fluid by amniocentesis and amnioscopy, prevention of Rh-immunization, assessment of the state of the newborn immediately after delivery, and the use of ultrasonography. These milestone innovations have made it possible for human medicine to enter into the intrauterine space and to reform the character of obstetrics in technical, methodical and structural ways. This was also the time when the first national and international societies, including the European Association of Perinatal Medicine, and the World Association of Perinatal Medicine have been established to promote the activities in modern obstetrics and perinatology.