Coping with the loss of a baby

In rare situations, a baby dies during the course of late pregnancy. This is called an intrauterine fetal death, and the result is stillbirth.

When a baby dies, the loss is immense and the grief is hard to overcome. The baby that you've carried for many months, dreamed about and planned for is suddenly gone. There's possibly no greater pain than that inflicted by such a loss.

You may feel as if your world has come crashing down. Maybe you can't even think of life continuing as normal. Yet you can do some things to make the future more bearable and to ease your pain. It may help you to:

Say goodbye to the baby

Grieving is a vital step in accepting and recovering from your loss. But you may not be able to grieve for a baby you've never seen, held or named. It may be easier for you to deal with the death if it's more real to you. You may feel better if you arrange a funeral or burial for the child.

Save a memento of the baby

Experts say it helps to have a photo or memento from someone who has died so that you have a tangible reminder of him or her to cherish now and in the future. Ask well-intended family and friends not to clear out the baby's nursery, if you want and need more time to process the loss.

On rare occasions, a health care provider may recommend no treatment except observation to see if an ectopic pregnancy will end on its own, through spontaneous abortion, before any damage is done to the fallopian tube.

Future pregnancies

After you've had one ectopic pregnancy, you're more likely to have another. In women who've had one ectopic pregnancy, about 10 percent of subsequent pregnancies will be ectopic. If you've had two ectopic pregnancies, your chance of having a normal pregnancy is less than 50 percent.

Although the chances of having a successful pregnancy are lower if you've had an ectopic pregnancy, they're still good if one of the fallopian tubes has been spared. Even if one tube has been removed, an egg can be fertilized in the other one. If one or more ectopic pregnancies have significantly injured both fallopian tubes, in vitro fertilization may be an option.

In vitro fertilization is a commonly used form of assisted reproductive technology. It involves retrieving mature eggs from a woman, fertilizing them with sperm in a petri dish in a laboratory and implanting the fertilized eggs in her uterus two days later.

If you've had an ectopic pregnancy, talk to your health care provider before becoming pregnant again so that together you can plan your care.

Grieve

Cry as often and for as long as you need to. Talk about your feelings and allow yourself to experience them fully. It's best not to avoid the mourning process.

Seek support

Lean on your spouse, family and friends for support. Although nothing can banish the hurt you're feeling, you may gain strength from others who love you and support you. You likely could benefit from professional counseling after the loss of a child or from joining a support group of parents who have experienced a loss.

You and your husband or partner will likely wonder why you had to experience loss. You will never have a satisfactory answer to that philosophical question. But it may help you to learn about the physical causes of the death of the fetus or newborn so that you have some understanding of what happened. You may want to discuss the findings from the autopsy with your health care provider, after the initial shock has passed. Knowing a cause of death or details of what transpired may help you better accept the loss.

For more help on dealing with the loss of a baby, visit the Web site for March of Dimes at www.marchofdimes.com and go to the pregnancy and newborn loss section of the pregnancy and newborn center.

Molar pregnancy

Molar pregnancy occurs when the tiny, finger-like projections that attach the placenta to the uterine lining (chorionic villi) don't develop properly. The result is an abnormal mass — instead of a baby — forming inside the uterus after fertilization. This mass is a tumor of placental tissue and arises from abnormal chromosomes in the fertilized ovum.

Relatively rare, molar pregnancy occurs in only one of every 1,000 to 1,200 reported pregnancies in the United States.

Signs and symptoms

The main sign of molar pregnancy is bleeding by the 12th week of pregnancy. Often, the uterus is much larger than expected, given the length of the pregnancy. Severe nausea and other problems of pregnancy are common. If you think you have the signs and symptoms of a molar pregnancy, contact your health care provider right away. Molar pregnancies are diagnosed with ultrasound, which have a high level of reliability.

Treatment

A molar pregnancy is removed from the uterus using suction curettage. In this procedure, an anesthetic is given, then the cervix is dilated and the contents of the uterus gently removed by suction.

Once tissue from a molar pregnancy is removed, your health care provider will likely want to monitor your levels of the pregnancy hormone HCG for an extended time. Occasionally, this tumor will take on a malignant character. Invasive disease usually is marked by an HCG hormone level that remains high or increases after the tumor has been removed. For this reason, your health care provider will probably want to test your HCG level on a regular basis. If abnormal cells become malignant following a molar pregnancy, they'll need to be treated with chemotherapy. This is one of the greatest success stories in cancer medicine — with appropriate chemotherapy, these malignancies are usually cured.

Future pregnancies

Women who have had a molar pregnancy are advised not to become pregnant again for at least a year. Once you've had a molar pregnancy, you're at greater risk of a second, but the likelihood is that future pregnancies will be normal.

Cervical incompetence

Cervical incompetence is the medical name for a cervix that begins to thin and open before a pregnancy has reached full term. Instead of happening in response to uterine contractions, as in a normal pregnancy, these events occur because the connective tissue of the cervix can't withstand the pressure of the growing uterus.

Cervical incompetence is relatively rare. It occurs in only 1 percent to 2 percent of all pregnancies. However, it's thought to cause as many as one in four pregnancy losses in the second trimester. You're more likely to develop cervical incompetence if you've had a previous operation on your cervix or you have a damaged cervix due to a previous difficult delivery or a malformed cervix due to a birth defect. You're also at increased risk if you're carrying more than one baby or have excessive amniotic fluid in your current pregnancy.

Signs and symptoms

Cervical incompetence occurs without pain, but it causes many of the other signs and symptoms of miscarriage and preterm labor. These include spotting or bleeding, vaginal discharge that's bloody, thick or mucus-like, and a feeling of pressure or heaviness in your lower abdomen.

Treatment

If you have any of the signs and symptoms noted above in the second trimester, call your health care provider immediately. If you develop cervical incompetence and it's caught early, your health care provider may be able to stitch your cervix shut, which may save your pregnancy. This procedure, called cerclage, is most successful if it's performed before the 20th week of pregnancy.

Future pregnancies

If you've had a previous pregnancy loss due to cervical incompetence, you'll probably have the cerclage procedure done early in subsequent pregnancies — at about 12 to 14 weeks, which is after the pregnancy is well-established but before its weight is taxing the cervix.

You may also be interested in reading "Decision Guide: Trying again after a pregnancy loss," page 315.

Depression

Most everyone experiences a depressive episode once in a while. But long-term, inappropriate depression is a mental disorder. It can interfere with your ability to eat, sleep, work, interact with others and enjoy life.

Depression has no single cause. The illness often runs in families. Experts think that this genetic vulnerability combined with factors such as stress or illness may trigger an imbalance in brain chemicals that results in depression.

Depression is a common problem for women during pregnancy, and it can occur after pregnancy (postpartum) as well. One study revealed that almost 25 percent of cases of postpartum depression start during pregnancy.

During pregnancy, many factors can contribute to depression, including:

• Bodily changes you're experiencing

• Health difficulties during pregnancy

• An unexpected pregnancy

• A previous pregnancy loss

• Pressure on family finances

• Unrealistic expectations of childbirth and parenting

• Insufficient social or emotional support

• Unresolved issues from your own childhood

Depression can affect pregnant women of all ages, races and socioeconomic levels. Certain personality traits and lifestyle choices can make you more vulnerable. For instance, having low self-esteem and being overly self-critical, pessimistic and easily overwhelmed by stress can put you at increased risk of depression. Alcohol and drug abuse as well as nicotine use also may contribute to depression. Finally, a diet that is deficient in folate and vitamin B-12 may cause symptoms of depression.

Signs and symptoms

Two symptoms are key to establishing a diagnosis of depression. They are:

• Loss of interest in normal daily activities. You lose interest in or pleasure from activities you once enjoyed.

• Depressed mood. You feel sad, helpless and hopeless and may have crying spells.

Other common signs and symptoms of depression often can be mistaken for common problems of pregnancy. That can make depression during pregnancy easy to overlook. For a health care provider to diagnose depression, most of the following must be present most of the day, nearly every day for at least two weeks:

• Sleep disturbances

• Impaired thinking or concentration

• Significant and unexplained weight gain or loss due to increased or decreased appetite

• Agitation or slowing of body movements

• Loss of interest in sex

• Thoughts of death

Depression can cause a wide variety of physical complaints as well. These can include itching, blurred vision, excessive sweating, dry mouth, headache, backache and gastrointestinal problems. Many people with depression also have symptoms of anxiety, such as persistent worry.

If you think you may be depressed, it's important to talk with your health care provider about it. Your health care provider may take a detailed history of your signs and symptoms. Tests may be done to rule out other conditions that can cause depression-like symptoms.

Treatment

If you're diagnosed with depression, follow your health care provider's advice. Depression is a serious disease that requires treatment. Ignoring this diagnosis can put you and your baby at risk.

During pregnancy, depression most often is treated with counseling and psychotherapy. Antidepressant medications may be used as well. Many of these medications appear to pose little risk to developing babies, and it's best to use medication if your depression is severe.

Consult with your health care provider to discuss your treatment options and how you can best manage your depression during pregnancy. He or she can help you find support and develop an individualized treatment plan. If medication is recommended, your health care provider can determine which one is the safest for you to take during pregnancy.

Realize that having depression during pregnancy can increase your risk of postpartum depression. Untreated depression can become a chronic condition that can return before or during subsequent pregnancies. As with any other illness, depression needs to be treated, whether it occurs before, during or after pregnancy.

Gestational diabetes

Diabetes is a condition in which the levels of blood sugar (glucose) aren't properly regulated. The condition is related to a hormone called insulin, which controls glucose levels. When diabetes develops in a woman who didn't have the condition before pregnancy, it's called gestational diabetes. This condition is thought to result from metabolic changes brought about by the effects of hormones in pregnancy. About 3 percent to 5 percent of pregnant women in the United States develop this form of diabetes.

The risk of developing gestational diabetes is higher in some women, particularly those who:

• Are older than 30 years

• Have a family history of diabetes

• Had a previous complicated pregnancy

If you have had a stillbirth, a large baby or gestational diabetes in a previous pregnancy, you're at higher risk of developing the condition. For reasons that aren't clear, black, Hispanic and American Indian women are at increased risk of developing gestational diabetes.

Although gestational diabetes isn't usually a threat to the mother's health, health care providers test for it because it poses some risks for the baby. The major risk for babies of women with gestational diabetes is excessive weight at birth (macrosomia). Most health care providers define macrosomia as a birth weight of 9 pounds, 14 ounces or more.

These large babies are at greater risk of birth injury than are others. This is largely due to shoulder dystocia, which occurs when the head is delivered through the birth canal, but the shoulders are too big to come through, preventing the baby from being born. Other problems that may develop as a result of gestational diabetes include low blood sugar (hypoglycemia) in the baby shortly after birth, jaundice and respiratory distress syndrome, which is a condition that makes breathing difficult.

If gestational diabetes goes undetected, the baby has an increased risk of stillbirth or death as a newborn. But when the problem is properly diagnosed and managed, your baby is at no greater risk than is a baby whose mother doesn't have gestational diabetes.

Signs and symptoms

Generally, gestational diabetes doesn't cause any symptoms. Because the condition can't be diagnosed on the basis of the mother's signs and symptoms, glucose testing must be done to detect it.

A glucose tolerance test generally is performed at 26 weeks to 28 weeks of pregnancy. It may be performed earlier if your health care provider thinks that you're at high risk of developing gestational diabetes. About half the women who develop diabetes during pregnancy have no risk factors for the condition. For that reason, many health care providers choose to check all women for gestational diabetes, regardless of their age or risk factors.

For the glucose tolerance test, you'll be asked to drink a glucose solution. After an hour, a sample of your blood is drawn and the glucose level is checked. About 15 percent of pregnant women who are given this test will have abnormal levels of blood glucose. If this is the case, a second test, called an oral glucose tolerance test, is done.

For the follow-up test, you fast overnight and then are given another glucose solution to drink. Blood tests are taken again during a three-hour period and your blood glucose is measured several times. Of the women whose first test result was abnormal, gestational diabetes will be diagnosed in roughly 15 percent of those who take this follow-up test.

Treatment

Controlling your blood sugar level is the key to managing gestational diabetes. In most cases, this can be done through a carefully planned diet, plenty of exercise and regular testing of the blood glucose level.

Today, most health care providers will ask you to monitor your glucose at home on a regular basis to assure adequate control of glucose levels. This is usually done first thing in the morning before you've eaten and again after meals to see how high glucose levels climb after eating.

If, despite diet and exercise, your blood glucose level remains too high, further treatment is required. Treatment in this situation usually includes insulin injections. Insulin doesn't cross the placenta to reach the baby, but it does effectively control the mother's blood sugar levels.

An oral medication called glyburide may be used before adding insulin to try and control blood sugars. There has been less experience with this approach, but it appears to be safe for the baby and effective for many women.

In addition to helping you maintain a normal blood glucose level, your health care provider may advise regular monitoring of the baby during the last weeks of pregnancy. Ultrasound can be used to evaluate the growth of the fetus. It's good to remember that ultrasound has a significant error rate in estimating fetal weight. It's a useful tool for assessing trends of growth, but less so in pegging the baby's exact birth weight.

There's little risk to the baby before term, but most health care providers try to deliver the baby by the due date. With the risk of a large baby, some options to aid vaginal delivery aren't used in women with gestational diabetes because of the risk of shoulder dystocia. A Caesarean birth is a common outcome.

If labor hasn't begun on its own by 40 weeks, it may be started (induced). If delivery is planned before 39 weeks, amniocentesis is usually performed beforehand to determine whether the baby's lungs are mature enough for delivery.

Shortly after delivery, gestational diabetes almost always disappears. To make sure that your glucose level has returned to normal, your health care provider may check it once or twice on the day after delivery. The glucose test may be repeated six weeks after delivery.

If you have had gestational diabetes in one pregnancy, your risk of developing it in another pregnancy is increased. You're also more likely to develop type 2 diabetes (formerly called adult-onset or noninsulin-dependent diabetes) in the future. About half the women with gestational diabetes eventually develop a nongestational form of diabetes. For this reason, it's important to follow your health care provider's advice concerning diet and exercise after delivery and to have your glucose level checked at least yearly.

Hyperemesis gravidarum

Nausea and vomiting in early pregnancy are common. But at times, vomiting in pregnancy becomes excessive. This is known as hyperemesis gravi-darum, defined as vomiting that's frequent, persistent and severe.

Hyperemesis gravidarum affects about one in every 300 women. The cause of this condition isn't known for certain, but it appears to be linked to higher-than-usual levels of the pregnancy hormones human chorionic gonadotropin (HCG) and estrogen. It's more common in first pregnancies, young women and women carrying more than one baby.

Signs and symptoms

Persistent excessive vomiting is the main sign of hyperemesis gravidarum. In some cases, it can be so severe that a pregnant woman may experience weight loss, become lightheaded or faint, and show signs of dehydration.

If you have nausea and vomiting so severe that you can't keep any food or liquids down, or if it persists past the 20th week of your pregnancy, contact your health care provider. Do so right away if vomiting is accompanied by fever or you have persistent pain after you vomit.

If it's not treated, hyperemesis gravidarum can keep you from getting the nutrition and fluids you need. If it lasts long enough, it can threaten your baby.

Before treating you for the condition, your health care provider may want to rule out other possible causes of the vomiting. He or she may check to see if you're carrying more than one baby. Other possibilities include gastrointestinal disorders, diabetes or a rare condition in which an abnormal mass, instead of a normal embryo, forms inside the uterus (molar pregnancy). Evaluations may include blood, urine and ultrasound studies.

Treatment

Mild cases of hyperemesis gravidarum are treated with reassurance, avoidance of foods that trigger problems, over-the-counter medications, and small, frequent feedings. Severe cases often require intravenous (IV) fluids and prescription medications. Very severe cases may require a hospital stay and IV feeding.

Women with hyperemesis gravidarum who work with their health care providers to make sure they're getting adequate nutrition and fluids shouldn't experience any serious complications for themselves or their babies.

Intrauterine growth restriction

Intrauterine growth restriction (IUGR) is a term used to describe a condition in which babies don't grow as fast as they should inside the uterus. These babies are smaller than normal during pregnancy. At birth, they weigh less than the 10th percentile for their gestational age.

Each year in the United States, as many as 40,000 babies are born at term with a birth weight of less than 5 /2 pounds. IUGR may be caused by problems with the placenta that prevent it from delivering enough oxygen and nutrients to the fetus. This situation can be caused by:

High blood pressure (hypertension) in the mother

Cigarette smoking

• Severe malnutrition or poor weight gain in the mother

• Drug or alcohol abuse

• Chronic disease in the mother, such as complicated type 1 diabetes (formerly called juvenile or insulin-dependent diabetes); heart, liver or kidney disease; rheumatologic diseases such as lupus; or antibody disorders such as red blood cell antibodies

• Preeclampsia or eclampsia

• Placental and cord abnormalities

• Multiple fetuses

• Antiphospholipid antibody syndrome, a rare immune system disorder IUGR may also occur because of a problem with the fetus in which the nutrition sent by the placenta may be adequate but the fetus is restricted in growth by disease. Examples include:

• Infections such as rubella, cytomegalovirus and toxoplasmosis

• Birth defects or chromosome abnormalities IUGR can also occur without a known cause.

Medical advances have greatly reduced the risks for growth-restricted infants. However, these babies are still at risk of problems. These smaller infants have low stores of body fat and glycogen, a type of carbohydrate that's readily turned into glucose, an energy source. As a result, they're unable to conserve heat. They may develop a below-normal body temperature (hypothermia). Stillbirth and fetal distress also are more common in growth-restricted fetuses. Because of their low energy stores, they may have low blood sugar (hypo-glycemia) after birth. Finally, when the placenta is unable to deliver adequate oxygen and energy sources, these fetuses are less able to tolerate the stress of labor than are infants of normal size.

Signs and symptoms

If you're carrying a growth-restricted baby, you may have few, if any, signs and symptoms. But during your pregnancy, your health care provider can check regularly to see if your baby is growing normally.

Your health care provider may measure your uterus at each of your prenatal visits, in part to detect IUGR at an early stage. By looking at how this measurement increases over time, the health care provider may be alerted to IUGR.

If IUGR is suspected, an ultrasound exam likely will be done to measure the baby's size. The width and circumference of the baby's head, the length of the thigh bone, the size of the abdomen and the amount of amniotic fluid may be measured.

If you're pregnant with twins, IUGR can affect both babies to the same degree. Or it may affect one twin more than the other. Your health care provider may determine the difference in the growth rate is significant if it's more than 15 percent.

Treatment

To treat growth restriction, the first step is to identify and reverse any contributing factors, such as smoking, drug use or poor nutrition. Sometimes, hospital admission or bed rest is recommended.

You and your health care provider can continue to watch the baby's condition. You may be asked to keep a daily record of the baby's movements. Ultrasound exams generally are done every three to four weeks to track the baby's growth and the volume of amniotic fluid. Your health care provider may do tests to assess the baby's health.

Amniocentesis might be performed to check for chromosome abnormalities or infection. In this situation, the chromosomes are often assessed by fluorescence in situ hybridization (FISH) as well as full testing to get a rapid analysis. Rarely, fetal blood analysis is needed. If it is, a blood sample is obtained from the umbilical cord. This procedure is known as percutaneous umbilical blood sampling (PUBS).

Your health care provider may discuss the pros and cons of these techniques with you if these tests are being considered. If tests and ultrasounds show that the baby is growing and isn't in danger, the pregnancy may be continued until labor begins on its own. But if test results indicate that the fetus may be in danger or isn't growing properly, your health care provider may recommend an early delivery.

Depending on circumstances, labor may be induced for a vaginal birth or the baby may be born by Caesarean birth. If labor is induced, the baby can be monitored closely. If the fetal heart rate pattern or other tests indicate the baby isn't tolerating labor, a Caesarean birth may still be necessary.

No matter how a growth-restricted baby is born, there are still risks posed to the infant's health. A growth-restricted baby may need to be given fluid with sugar (glucose) soon after birth. The baby's temperature can be monitored to make sure he or she remains warm enough.

If you've had one growth-restricted baby, you're at increased risk of having another undersized infant. Fortunately, careful monitoring and early intervention often can lessen some of the dangers faced by growth-restricted babies. In some cases, growth restriction can even be reversed. In addition, a focus on good prenatal care, including getting excellent nutrition and eliminating smoking and alcohol use, will increase your chances of having a healthy baby.

Even if you do have a growth-restricted baby, size at birth may not be an indication of how well he or she will grow and develop. Many growth-restricted babies tend to catch up to their normal counterparts by 18 to 24 months. Unless these babies have serious birth defects, the chances are good for most of them to have normal intellectual and physical development in the long term.

Iron deficiency anemia

Iron deficiency anemia is a condition marked by a decline in the number of red blood cells in your body. It results when your body isn't getting the iron it needs to fuel red blood cell production. Iron deficiency anemia develops most often in the second half of pregnancy, after the 20th week. That's because for the first 20 weeks of pregnancy, as your body makes more and more blood, you make the fluid portion of blood (plasma) more quickly than you make red blood cells. This results in lower red blood cell concentrations overall.

Statistics indicate that up to 20 percent of all pregnant women are iron deficient. That means they don't get the recommended 30 milligrams of iron each day — a risk factor for developing iron deficiency anemia. When you're pregnant, it's a challenge to keep your iron stores at an adequate level through diet alone. That's why many health care providers prescribe iron supplements during the second half of pregnancy. If you're getting regular prenatal care and taking a daily prenatal vitamin, you'll generally be able to steer clear of iron deficiency anemia.

Signs and symptoms

If you have a mild case of iron deficiency anemia, you may not even notice any problems. If, however, you have a moderate or severe case, you may be pale, excessively tired and weak, short of breath, and dizzy or lightheaded. Heart palpitations and fainting spells also are signs and symptoms of iron deficiency anemia.

An unusual but frequent symptom of iron deficiency anemia is the desire to consume unusual things. Common targets of this craving include ice chips, cornstarch and even clay. If you have any of these signs and symptoms, contact your health care provider.

If you're diagnosed with iron deficiency anemia, don't be alarmed. Although iron deficiency anemia can make you tired and more susceptible to illness, it's unlikely to hurt your baby unless it's severe. It's also readily treatable.

Treatment

Treatment consists of taking in enough iron, which is prescribed in capsule or tablet form. Very rarely, blood transfusions may be required. But this is used only if a pregnant woman is severely anemic and has an ongoing source of blood loss.

Placental abruption

Placental abruption occurs when your placenta separates from the inner wall of the uterus before delivery. It can cause life-threatening problems for you and your baby. You can go into shock from blood loss. Your baby can be deprived of oxygen-rich blood he or she needs to survive. Placental abruption occurs in about one of every 150 births. Its cause is unknown.

The most common condition associated with placental abruption is high blood pressure (hypertension) in pregnancy. That's true whether the high blood pressure first developed during pregnancy or was present before conception.

Placental abruption also appears to be more common in black women, women who are older — especially those older than 40 — women who have had many children, women who smoke, and women who abuse alcohol or drugs such as cocaine during pregnancy.

Placental abruption has also been associated with the presence of abnormalities in the mother's blood-clotting system. Very rarely, trauma or injury to the mother may cause placental abruption.

Signs and symptoms

In the early stages of placental abruption, you may not have signs and symptoms. When they do occur, the most common one is bleeding from the vagina. The bleeding may be light, heavy or somewhere in between. The amount of blood doesn't necessarily correspond to how much of the placenta has separated from the inside of the uterus. Other signs and symptoms that may be caused by placental abruption include:

• Back or abdominal pain

• Uterine tenderness

• Rapid contractions

• A hard and rigid feel to the uterus

Place/

Blood

Uterus

Place/

Blood

Uterus

To diagnose placental abruption, your health care provider will likely try to exclude other possible causes of vaginal bleeding. An ultrasound will probably be done to assure the bleeding isn't from placenta previa. Placental abruptions only rarely are seen on ultrasound.

Treatment

If placental abruption is suspected, treatment depends largely on the condition of the mother and baby and the stage of the pregnancy. Electronic monitoring is usually used to look at patterns of the baby's heart rate. If the monitoring shows no signs that the baby is in immediate trouble and the pregnancy hasn't reached a safe time for the baby to be born, the mother may be hospitalized so that her condition can be monitored closely for several days.

If the baby has reached maturity and placental abruption is minimal, a vaginal delivery is possible. If an abruption progresses and signs indicate that the mother or baby is in jeopardy, an immediate delivery, usually by Caesarean, will most likely be necessary. In addition, a mother who experiences severe bleeding may need blood transfusions.

There is a one in 10 chance that placental abruption will recur in a subsequent pregnancy. Some of the possible causes — such as high blood pressure, maternal-clotting disorders or substance abuse — may be treated before the next pregnancy.

Abruption is a serious complication. Prompt and expert care is required to avoid serious complications for mother and baby. In rare cases, an abruption can occur so rapidly and extensively that a baby can't be saved from injury.

Placenta previa

In some pregnancies, the placenta is located low in the uterus. It may partly or completely cover the opening of the cervix. This condition is known as placenta previa. It poses a potential danger to the mother and baby because of the risk of excessive bleeding before or during delivery.

Placenta previa occurs in about one in 200 pregnancies and may take one of several forms, including:

• Marginal. With this, the edge of the placenta is at the margin of the cervical opening. As the cervix dilates during

Placenta Cervix

Placenta Cervix

labor, the edge of the placenta may be disrupted but allow the baby to enter the pelvis. Vaginal delivery may be possible under certain conditions.

• Partial. In partial placenta previa, the placenta partly covers the cervical opening. To avoid significant bleeding, a Caesarean birth is done.

• Total. Here, the placenta completely covers the cervical opening, making vaginal delivery impossible because of the risk of massive bleeding.

The cause of placenta previa isn't known. But like placental abruption, it's more common in women who have had children before, older women and women who smoke. Previous uterine surgery, such as a dilation and curettage (D and C), in which the lining of the uterus is scraped for medical reasons, seems to increase the risk. Caesarean birth scars also seem to significantly increase the risk.

Signs and symptoms

Painless vaginal bleeding is the main sign of placenta previa. This bleeding most often occurs near the end of the second trimester or the beginning of the third. The blood is usually bright red, and the amount may range from light to heavy. The bleeding may stop, but it nearly always recurs days or weeks later. Any bleeding in the third trimester should be reported to your health care provider immediately.

Almost all cases of placenta previa may be detected by an ultrasound exam before any bleeding has occurred. Because even the gentlest cervical exam can cause hemorrhage, this type of exam is done only when delivery is planned and only when an immediate Caesarean birth can be performed. Hemorrhaging as a result of placenta previa is quite uncommon, as either ultrasound or magnetic resonance imaging (MRI) can define the location of the placenta. If you know from a prior ultrasound you may have this condition, tell any health care provider you see during your pregnancy before he or she considers a vaginal exam. In addition, don't have intercourse until your health care provider has told you any question of placenta previa has been resolved.

Treatment

The treatment for placenta previa depends on several factors, including whether the fetus is mature enough to be born and whether you are experiencing vaginal bleeding.

If the placenta is close to but not covering the cervix and there's no bleeding, you may be allowed to rest at home — with instructions to call your health care provider or hospital immediately if bleeding starts. Early in the pregnancy, medications may be given to stop premature labor.

Usually after an initial bleeding episode, women with placenta previa are kept in the hospital and a Caesarean birth is planned for as soon as the baby can safely be delivered.

If bleeding starts and can't be controlled, an immediate Caesarean birth probably is necessary for the sake of the baby, even if the birth is premature.

Women who have had placenta previa in a previous pregnancy have a 4 percent to 8 percent chance of experiencing it in a future pregnancy. In most cases, however, placenta previa can be detected accurately before a fetus is in significant danger. However, if the placenta lies over the area in the uterus of a prior Caesarean birth scar, the next Caesarean may be much more complicated.

Preeclampsia

Preeclampsia is a disease that produces an increase in blood pressure in pregnant women. It's characterized by:

• High blood pressure

• Swelling of the face and hands

• Protein in the urine after the 20th week of pregnancy

The condition used to be called toxemia because it was once thought to be caused by a toxin in a pregnant woman's bloodstream. It's now known that preeclampsia isn't caused by a toxin. But its true cause isn't known.

Preeclampsia is a relatively common disorder. It affects 6 percent to 8 percent of all pregnancies. Eighty-five percent of all cases occur in the first pregnancy.

Other risk factors include carrying two or more fetuses (multiple pregnancy), diabetes, chronic high blood pressure (hypertension), kidney disease, rheumatologic disease such as lupus, and family history. Preeclampsia is more common in teenagers and in women older than 35.

Signs and symptoms

Women with preeclampsia have had the disease since very early in the pregnancy, but it doesn't become obvious until much later in pregnancy. By the time obvious signs and symptoms — high blood pressure, a swollen face and hands, and protein in the urine — do appear, preeclampsia is in an advanced state.

In some women, the first sign of preeclampsia may be a sudden weight gain. Typically, that means more than 2 pounds in a week or 6 pounds in a month. This weight gain is due to the retaining of fluids rather than the buildup of fat. Headaches, vision problems and pain in the upper abdomen may occur.

Health care providers monitor a woman's blood pressure throughout her pregnancy. The diagnosis of preeclampsia typically begins when blood pressure is consistently elevated over a period of time. A single high blood pressure reading doesn't mean you have preeclampsia. Normal blood pressure readings for pregnant women are less than 130/85 millimeters of mercury (mm Hg). In pregnant women, a blood pressure reading of 140/90 mm Hg or more is considered above the normal range.

Preeclampsia has various degrees of severity. If the only sign you have is elevated blood pressure, your health care provider may call your condition gestational hypertension.

Preeclampsia is also diagnosed by testing urine samples for protein. Your health care provider may also want to do some blood tests to see how well your liver and kidneys are functioning. Blood tests can confirm if the number of platelets in your blood is normal. Platelets are necessary for blood to clot.

There's also a severe form of preeclampsia known as HELLP syndrome. It's distinguished from other milder forms of the condition by elevated liver enzyme values and a low blood platelet level.

Treatment

The only cure for preeclampsia is delivery. Medications to treat high blood pressure in pregnancy are sometimes used, but other measures are usually preferred.

A mild case of preeclampsia may be managed at home with bed rest and regular monitoring of your blood pressure. Your health care provider may want to see you a few times a week to check your blood pressure, urine protein levels and the status of your baby.

A more severe case of preeclampsia often requires a stay in a hospital. Testing of the baby's well-being with nonstress tests or biophysical profiles can be done regularly. In addition, an ultrasound exam is often used to measure the volume of amniotic fluid. If the amount is too low, it's a sign that the blood supply to the baby has been inadequate and delivery may be necessary.

Left untreated, preeclampsia can result in eclampsia. With eclampsia, seizures can occur, and this severe complication has significant risks for both mother and baby. Your health care provider will likely treat preeclampsia vigorously to avoid those complications.

Many cases of preeclampsia become apparent close enough to the mother's due date that they can be managed by inducing labor when recognized. In more severe cases, though, it may not be possible to consider the baby's ges-tational age. In those cases, labor may need to be induced or a Caesarean birth performed to protect the life of the mother and the baby. Magnesium sulfate is a drug that may be given intravenously to the mother with preeclampsia to increase uterine blood flow and to prevent seizures.

A pregnancy complicated by known preeclampsia usually isn't allowed to go beyond 40 weeks because of the increased risk to the fetus. The readiness of the cervix — whether it's beginning to open (dilate), thin (efface) and soften (ripen) — also may be a factor in determining whether or when labor will be induced.

After delivery, blood pressure usually returns to normal within several days or weeks. Blood pressure medication may be prescribed when you're dismissed from the hospital. If blood pressure medicine is necessary, its use usually can be gradually stopped a month or two after delivery. Your health care provider may want to see you frequently after you go home from the hospital in order to monitor your blood pressure.

The risk that preeclampsia will happen in a subsequent pregnancy depends on how severe it was during the first pregnancy. With mild preeclampsia, the risk of recurrence is low. But if preeclampsia was severe in a first pregnancy, the risk in future pregnancies may be as high as 25 percent to 45 percent.

Rhesus factor incompatibility

Rhesus (Rh) factor incompatibility occurs when a pregnant mother and her fetus have a different Rh blood type. Rh factor is a type of protein sometimes found on the surface of red blood cells. Those with Rh factor are called Rh positive. Those without it are called Rh negative.

Eighty-five percent of whites are Rh positive. Among blacks, the percentage is slightly higher, and virtually all American Indians and Asians are Rh positive. About 15 percent of whites and 7 percent of blacks are Rh negative, which means their blood cells lack the Rh antigen.

When you're not pregnant, your Rh status has no effect on your health. If you're Rh positive, you have no cause for concern during pregnancy either. But if you're Rh negative and your baby is Rh positive — which can happen if your partner is Rh positive — a problem called Rh factor incompatibility results. Your body sees the Rh-positive factor in your baby's blood as a foreign substance to be destroyed and starts making antibodies to combat it. The result can be a destruction of red blood cells in your baby (fetal anemia). If left untreated, this can cause mild or severe damage to your baby. In very rare cases, it can cause death.

On the bright side, if you're Rh negative, your partner is Rh positive and this is your first pregnancy, Rh incompatibility isn't likely to be a problem for you. That's true even if your baby turns out to be Rh positive. It usually takes one Rh-incompatible pregnancy for your body to build up enough antibodies to the point they could harm your baby. Your risk, if untreated, will be higher during any future pregnancies.

Signs and symptoms

If you tested Rh-negative early in your pregnancy, you'll probably have a blood test for Rh antibodies at about 28 or 29 weeks into your pregnancy. If results show that you're not yet producing any Rh antibodies, your health care provider can give you an injection of Rh immunoglobulin (RhIg) into a muscle. The RhIg injection will destroy any Rh-positive cells that may be floating around in your bloodstream. With no Rh factor to fight, antibodies will not form. Think of it as a pre-emptive strike against the formation of Rh antibodies. Because of the development of RhIg, fetal Rh disease is now rare.

If you're one of the few women who do have Rh antibodies, you can be tested on a regular basis throughout the second trimester to determine the level of antibodies in your blood. Further testing may be recommended to monitor the health of the fetus. These tests may include ultrasound measurements of blood flow, which is related to fetal anemia, or the use of amnio-centesis to measure the amount of fetal blood destruction.

If the level of antibodies becomes too high, measures can be taken to prevent harm to the baby. These measures may include blood transfusions to the fetus while still in the uterus or, in some cases, early delivery. After birth, the baby may have anemia and may develop jaundice that requires treatment.

One other important note: If you're Rh negative and your fetus is Rh positive, it's not necessary to carry a pregnancy to term to develop Rh antibodies. Antibodies can form even during an Rh-incompatible pregnancy that ended in miscarriage or abortion. They can also form during an ectopic or molar pregnancy. If you become pregnant again and haven't been treated to prevent the development of Rh antibodies, an Rh-positive fetus is at risk.

While Rh antibodies are the most common type, many other rare types of red blood cell antibodies can need similar detection. Unfortunately, for these irregular antibodies, no preventive treatments are available. For this reason, blood type and antibody screening tests are done for each pregnancy.

COMPLICATIONS

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