Book Review

The High-Risk Fetus: Pathophysiology, Diagnosis, Management

N Engl J Med 1993; 329:513-514August 12, 1993

Article

The High-Risk Fetus: Pathophysiology, Diagnosis, Management
Edited by Chin-Chu Lin, Marion S. Verp, and Rudy E. Sabbagha. 708 pp., illustrated. New York, Springer-Verlag, 1993. $99. ISBN: 0-387-97836-4

The relatively new concept that the fetus should be viewed as a patient reflects the development of high-resolution ultrasonography and ultrasound-guided techniques of prenatal diagnosis and treatment. Remarkable advances in molecular genetics have also allowed us to diagnose an ever-growing list of inherited diseases and even to consider treatments for them. Fetal medicine is changing so rapidly that it is difficult for the practicing obstetrician to stay informed. This book is an ambitious and thoughtful attempt to provide guidelines for the diagnosis and treatment in fetuses considered to be at high risk. My assessment of the work is mixed.

The overall organization of the book and selection of topics are excellent. The first section concentrates on fetal physiology and early fetal pathophysiology; the second, on prenatal fetal evaluation; and the third, on specific fetal conditions, fetal therapy, and intrapartum fetal evaluation and resuscitation. Unfortunately, the quality and depth of the chapters vary greatly. This unevenness was so evident that after finishing the book I felt compelled to rate the chapters in order to assess the book as a whole. Sixteen I rated excellent, seven adequate, and seven poor. Overall, readers will find this work both informative and enjoyable.

The chapters written primarily by Dr. Chin-Chu Lin are superb. Two of them, “Biophysical Evaluation of the Fetus” and “Fetal Growth Retardation” are particularly meritorious. Dr. Lin also provides a splendid review of the literature in the chapter on breech presentation, presenting this confusing and controversial subject with unusual clarity and balance. In contrast, the chapter “Multifetal Gestation,” coauthored by Dr. Lin, is disappointing. It concentrates on basic definitions and statistics available in any standard obstetrical textbook, whereas the discussions of more current or controversial subjects -- such as the diagnosis and treatment of twin-to-twin transfusion, death of a twin, reduction in the number of fetuses in a multifetal pregnancy, selective termination, and pregnancies with more than two fetuses -- are superficial and already outdated. The chapter on maternal-fetal infections contains almost no information on prenatal diagnosis or the effects on the fetus of various infections, concentrating instead on adult and neonatal symptoms. It would have been more useful to provide a discussion of the prenatal diagnosis of fetal infections, such as cytomegalovirus, rubella, parvovirus, and toxoplasmosis, rather than cover rare diseases such as trypanosomiasis and leishmaniasis. Furthermore, the section on the human immunodeficiency virus (HIV) is outdated and does not cover aspects such as the prevalence of HIV infection during pregnancy and the factors influencing vertical transmission. Subjects such as the effect of mode of delivery and breast-feeding on perinatal transmission of HIV deserve a more detailed review, since these are still controversial. Statements such as “the mode of delivery does not alter the transmission rate of the infection” (with only one 1987 reference) are unwarranted.

Some of the chapters on ultrasonography are also disappointing. For example, the chapter on externally visible body defects presents long lists of skeletal abnormalities but no ultrasound pictures of any of them. Similarly, the chapter on cardiac ultrasonography does not include any ultrasound pictures, although it refers to pictures in the preceding chapter. The chapter “Fetal Anomalies Involving Cardiac, Pulmonary, Gastrointestinal, and Urinary Systems” states that the standard ultrasound examination includes measurements of nuchal-fold thickness and orbital diameters, which are not included in the guidelines of the American College of Obstetrics and Gynecology and not generally evaluated. The chapter on vaginal ultrasonography, by contrast, is full of data, excellent pictures, and useful technical pointers.

The chapter “Immunogenetics of Fetal Growth and Development” is comprehensive, current, and easy to read despite the complexity of the subject. The chapters on genetic and environmental causes of pregnancy loss, genetic counseling, and prenatal diagnosis are all excellent sources of reference and are very well written and organized. The “Fetus of the Diabetic Mother” is an enjoyable and clinically relevant review. My favorite chapters were “Medical Fetal Therapy,” “Surgical Therapy,” and “Legal and Ethical Issues in Fetal Therapy,” because they are authoritative, informative, and very well written. The chapter on substance abuse in pregnancy may well be the best ever written on the subject.

In summary, “The High-Risk Fetus” contains the shortcomings inherent in a multiauthored book, with some very strong and some not so strong contributions, although most chapters are very good or excellent. The dynamic nature of the subject, as well as the problems inherent in the publishing process, limits the book's ability to include emerging developments. However, this work should be a good reference for residents and practicing obstetricians.

Lauren Lynch, M.D.
Mount Sinai School of Medicine, New York, NY 10029