Although most pregnancies are absolutely normal, a few mothers-to-be developwhich require special care and treatment. Such complications are usually diagnosed in the antenatal clinic and can be successfully treated without any harm having resulted to mother or . Regular attendance at the antenatal clinic is vital as late diagnosis of complications is a serious matter.
- The Management of Toxaemia
- VAGINAL BLEEDING IN LATE PREGNANCY
- Placenta Praevia
- Abruptio placentae
- COMPLICATIONS AFFECTING THE BLOOD
- The Rhesus Factor in Pregnancy
- Prevention of Rhesus Disease
- OVARIAN CYSTS
- MULTIPLE PREGNANCY
- Identical and non-identical Twins
- Diagnosing Twins
- Twin labor
- What causes miscarriage?
- Miscarriage-signs and symptoms
- Repeated miscarriage
- Reactions to miscarriage
- Recurrent miscarriage
- Ultrasound in early pregnancy
- ECTOPIC PREGNANCY
- How to recognize an ectopic pregnancy
- Treatment of ectopic pregnancy
This is perhaps the best known complication. It occurs in late pregnancy, usually after thirty-six weeks, and is sometimes called pre-eclampsia or pre-eclamptic toxaemia. Pre-eclampsia consists of hypertension (raised blood pressure), proteinuria (protein-mostly albumin-in the urine) and oedema (swelling of the legs, hands and face).
The normal blood pressure of a healthy pregnant woman is usually about 110/80. Hypertension is usually said to be present when the pregnant woman’s blood pressure has risen to 140/90.
Proteinuria is not normally present in pregnancy or in early cases of toxaemia, but if the hypertension is allowed to continue, the kidneys will be damaged and will be unable to continue their normal functions, including keeping the protein in the blood from spilling over into the urine. The presence of proteinuria, which is tested for at every antenatal visit. Is an indication that toxaemia is becoming more severe.
Oedema (swelling) of the ankles and feet can be expected by all pregnant women at some time in pregnancy because of a retention of fluid in the body. Fingers and hands also sometimes swell.
The Management of Toxaemia
As the cause of toxaemia is unknown, the management is aimed at control of the symptoms until the fetus is mature enough to be delivered. After delivery the signs of toxaemia quickly disappear and there is no permanent damage. The main initial treatment is rest and this is often all that is needed in mild cases to keep the blood pressure down and to stop proteinuria and oedema developing.
Rest in bed at home is allowed in mild cases, but more severe cases require rest in hospital. The importance of admission to hospital in all but the mildest cases of toxaemia lies in the fact that mild toxaemia may sometimes progress quickly to severe toxaemia and the change can only be detected if frequent observations are made on the patient’s blood pressure.
Patients with toxaemia are often reluctant to go into hospital because they feel well, but to ignore medical advice in this situation is to risk letting the condition progress unchecked from mild to severe toxaemia or even to eclampsia. Severe pre-eclamptic toxaemia is a serious complication which requires sedative and antihypertension drugs.
As soon as the blood pressure is under control in severe pre-eclampsia, steps will be taken to deliver the baby. This is done either by inducing labor, or in very severe cases, by performing a Caesarean section operation. When a woman has had toxaemia during a first pregnancy she will naturally be concerned about suffering the same complication during a second pregnancy.
About fifty per cent do, unfortunately, develop toxaemia with the second pregnancy, but it is usually much less severe than during the first pregnancy.
This form of toxaemia is the find product of untreated or inadequately treated severe pre-eclampsia. In addition to hypertension, oedema and proteinuria, the patient develops severe headaches and fits. Because eclamptic fits endanger both mother and fetus, every effort is made to prevent mild pre-eclampsia from becoming severe and severe pre-eclampsia from progressing to eclampsia.
VAGINAL BLEEDING IN LATE PREGNANCY
Vaginal bleeding after twenty-eight weeks is called antepartum haemorrhage. This is a serious complication because the bleeding usually comes from the site where the placenta is attached to the uterus. The blood lost is almost invariably from the mother’s circulation, but because the placenta gets separated from its attachment to the uterus, the fetus is endangered by lack of oxygen.
There are two main types of antepartum haemorrhage, depending on where the placenta is attached to the uterus. (See below).
This is the term given to the placenta when it is attached to the lower part of the uterus (see diagram). In this situation the placenta is in the path of the fetus when the fetus tries to make its way down through the cervix. If the uterine contractions separate the placenta from its attachments, severe bleeding will occur.
There are varying degrees of placenta praevia. If the placental attachment is only partly in the way of the fetus, the bleeding will be less serious and a normal birth may be possible. Usually, placenta praevia causes an antepartum haemorrhage some time before labor starts. When this happens there is a sudden, small, bright red blood loss from the vagina between thirty and thirty-six weeks of pregnancy. There is no associated pain and the bleeding clears up quickly.
If the warning is ignored a much larger haemorrhage may occur and will require urgent treatment. For this reason, any vaginal bleeding in late pregnancy must be taken seriously and reported to the doctor at once so that the woman can be admitted to hospital for investigations. Investigation will aim at showing the site of the placenta. This is most commonly done nowadays by means of an ultrasound scan.
Once the diagnosis has been established and the severity of the placenta praevia decided, plans can be made for delivery. In all but the mildest cases a Caesarean birth will be necessary and the woman will be kept in hospital until the fetus is sufficiently mature to be delivered, usually any time after thirty-six weeks.
This is the term given to antepartum haemorrhage which occurs when a normally situated placenta partly separates from its attachment. The cause of separation is not usually clear, although, on rare occasions, it may result from a direct blow to the mother’s abdomen.
As with placenta praevia, urgent admission to hospital is needed for abruptio placentae, so that the woman can have the loss of blood replaced by blood transfusion and the baby’s condition can be assessed. Abruptio placenta is a serious complication that requires expert care in hospital.
Fortunately it is rare for a woman who has suffered it in one pregnancy to get it in another. This is also true of placenta praevia. Because of the potential dangers, a pregnant woman who notices any vaginal bleeding in late pregnancy should report the Jccurrence to her doctor as soon as possible.
COMPLICATIONS AFFECTING THE BLOOD
This is the commonest blood problem in pregnancy and it arises when the mother’s iron and folic supplies cannot keep up with the extra demand. It should not arise in a woman who takes a balanced diet and the iron and folic acid tablets provided by the antenatal clinic.
Anaemia will be detected by the routine antenatal blood tests and can be treated effectively with additional iron and folic acid. The importance of anaemia in pregnancy is not only that the anaemic woman suffers from extra tiredness and is unable to carry on her normal physical activity without getting very out of breath, but also in the event of a haemorrhage the anaemic woman, already short of blood, will be unable to meet the extra demand.
In a very severely anaemic woman even a small haemorrhage can be very dangerous. The moral is, please eat sensibly and take the iron tablets!
Thrombosis is the formation of a blood clot within a blood vessel. It is fortunately uncommon in pregnancy. When it does occur, the veins deep in the calves are most likely to be affected and will cause local pain and swelling of the leg and foot beyond the site of the blockage. The most likely time for a deep vein thrombosis to occur is in the first two weeks after the baby has been born. It is more common after complicated deliveries, especially Caesarean operations.
Anticoagulant substances which stop the blood clotting, are used to stop the blood clot spreading and to help its absorption. They need to be continued for some weeks and the dose has to be carefully controlled by regular blood tests.
This is a much less serious condition than deep vein thrombosis. It results from an inflammation of the walls of a varicose vein. It may occur after the vein has been damaged by a knock or sometimes without provocation. Although the inflammation causes the blood to clot in the vein and the vein becomes painful and tender, it will usually settle down quickly with rest and a supporting crepe bandage.
The Rhesus Factor in Pregnancy
About eighty five per cent of normal women carry a special factor in their red blood cells called the Rhesus factor and they are said to be Rhesus positive. The remaining fifteen per cent of women have no Rhesus factor in their red blood cells and are said to be Rhesus negative.
The Rhesus negative woman who marries a Rhesus negative husband is fortunate, because since both father and mother are negative, the children will also be Rhesus negative and no problems will arise.
If, however, the Rhesus negative woman does become pregnant with a Rhesus positive fetus, there is a danger, especially at the time of delivery, that some of the fetal red blood cells will escape into the mother’s circulation and stimulate her to produce antiRhesus positive antibodies. These antibodies will then attack and destroy any Rhesus positive red blood cells which they come into contact with.
As Rhesus positive antibodies are only likely to be formed in the mother after the baby is born, a first baby is unaffected. However, the antibodies remain in the mother’s blood and if she becomes pregnant again with a Rhesus positive fetus, the anti-Rhesus positive antibodies will cross the placenta and attack and destroy the fetal red cells and cause the baby to become anaemic and jaundiced.
After birth, the destruction of the blood cells will continue because the antibodies persist for some time in the baby’s circulation. In this event, the newborn baby becomes even more anaemic and jaundiced. In severe cases, it will need an exchange transfusion. This entails changing the baby’s blood and supplying it with fresh blood which does not contain any antibodies.
The Rhesus blood group of every pregnant woman is tested as part of the routine blood test in early pregnancy. Where a woman is Rhesus negative, further tests will be taken to see if she is developing Rhesus antibodies. If she does, and this is only likely with a second or subsequent Rhesus positive fetus, the concentration of antibodies will be measured.
If repeated tests show that the level of antibodies is rising, it may be necessary to take a sample of the amniotic fluid to see if the baby is becoming jaundiced. If it is, then it may have to be delivered prematurely so that an exchange transfusion can be carried out.
Sometimes the fetus is affected very early in pregnancy when premature delivery is not advisable. In this instance, the baby can be given a simple transfusion of Rhesus negative blood. This procedure, called an intra-uterine transfusion, is done under X-ray control by very experienced doctors. It is rarely necessary nowadays and is only performed for a very badly affected fetus.
Prevention of Rhesus Disease
As the result of a discovery that antibody formation in Rhesus negative women after delivery can be prevented, Rhesus problems in pregnancy are fortunately very much on the decrease nowadays. Today, immediately after a Rhesus negative woman has delivered her child, a sample of blood is taken from the baby to see if it is Rhesus positive.
If it is Rhesus positive, then a sample of blood is taken from the mother to see how many of the baby’s Rhesus positive blood cells have entered her circulation during delivery. Depending upon the number, she is given an injection of a substance called anti-D gamma globulin which attacks and destroys the Rhesus positive cells before they can initiate the formation of anti-bodies by the mother.
In this way, the Rhesus negative woman can enter her next pregnancy without antiRhesus positive antibodies. Provided that she is given a further injection of anti-D gamma globulin after her next delivery, (if the baby is also Rhesus positive) she will never have a chance to form them. As an additional safeguard, anti-D gamma globulin is also now given to Rhesus negative women who have a miscarriage, an ectopic pregnancy or a termination.
A fibroid is a benign growth that arises from the muscle wall of the uterus. It grows slowly and forms a firm, white, rounded tumour which may vary in size from a pea to a football. Fibroids are very common, but do not usually give rise to symptoms until a woman is over the age of thirty. They may cause lower abdominal discomfort and heavy menstruation.
Occasionally, they may be responsible for a failure to become pregnant or for repeated miscarriages. When a woman with Fibroids does become pregnant, the Fibroids increase in size but usually return to their previous size when the pregnancy is over. They do not usually give rise to symptoms.
Surgical removal of a Fibroid has to be avoided in pregnancy because the operation is very likely to cause miscarriage or premature labor.
The ovaries are sometimes the site of cysts. These are fluid-containing swellings, which, like Fibroids, can become very large indeed. An ovarian cyst can occur at any age and, in older women, may be malignant. In pregnant women, ovarian cysts are very unlikely to be malignant but, unfortunately, they do show a tendency to become twisted round in pregnancy so that their blood supply is interfered with.
If untreated, peritonitis then develops and the woman becomes very ill. For this reason, unlike Fibroids, an ovarian cyst should be surgically removed, even during pregnancy. The diagnosis of an ovarian cyst is usually made when the doctor examines the patient in early pregnancy and Ends the cyst alongside the uterus.
The operation to remove the cyst is best carried out at about fourteen to sixteen weeks. By chis time, the pregnancy is well established, but the uterus has not become too large to make the operation difficult. Done at this time, the removal of the cyst does not disturb the pregnancy or harm the fetus.
This is the term given to twins, triplets and all the other multiples up to the record octuplets (eight babies). Twins occur in about one pregnancy in eighty in most white races, but are more common in some black races.
Family history of twins, on either a mother’s or father’s side, makes twins inore likely, although the father’s influence only applies to identical (uniovular) twins. A woman who has already given birth to twins has about a one in ten chance of having a second set. Triplets occur once in six thousand births and quads about once in five hundred thousand births.
As a result of women receiving treatment with fertility drugs the incidence of multiple births has increased in modern times. This is because it is sometimes difficult to avoid over-stimulating the ovaries with fertility drugs.
Identical and non-identical Twins
Identical or uniovular twins develop from one ovum (egg cell) which divides into two separate cells shortly after being fertilized by a single sperm. When the separation of the cells has not been complete, conjoined or Siamese twins result. This is, however, extremely rare.
Identical twins are always the same sex and are usually very alike in physical and mental characteristics. They share the same placenta inside the uterus and are enclosed by a common outer membrane (chorion) although they have their own separate inner membranes (amnion).
Non-identical or binovular twins develop from two ova, which are released instead of the normal one. Each ova is fertilized by a separate sperm and the two fertilized ova then develop normally.
This form of twinning is more common than the uniovular type and the resulting babies can be of different sexes and resemble one another only in the same way that brothers and sisters do. Inside the uterus each twin has its own separate placenta and membrane.
In the normal course of events, twins should be diagnosed by sixteen weeks because, by this time, the mother’s abdomen is much more distended than it should be. This results from the double burden that the uterus is carrying. As the pregnancy proceeds, the head of each twin can be felt and two heartbeats heard.
Sometimes the diagnosis is not made until later in pregnancy and, occasionally, especially in women who have firm abdominal muscles or who are fat, not until the first twin has been delivered! If twins are suspected early in pregnancy, an ultrasound scan or an X-ray will confirm the diagnosis. Twin pregnancy
Although most women are delighted to be having twins, twin pregnancy is more likely to be complicated. Apart from the discomfort of the distended abdomen, anaemia, toxaemia and premature labor are all more likely to occur in a twin pregnancy. Accordingly, women who have a twin pregnancy need extra rest, and extra iron and folic acid if they are to avoid anaemia.
Admission to hospital may well be needed to ensure that the patient does rest. This will certainly be necessary if toxaemia develops.
Twin labor is likely to be anything up to eight weeks premature, although with luck and good antenatal care it will not occur before thirty-eight weeks. Skilled obstetric care is needed and confinement in a hospital which has a special-care baby unit for premature babies, is a must. Twin labor does not usually last longer than with a single baby, but breech presentation, that is, when the buttocks rather than the vertex present, is more common.
In the eyes of the law at the present time a baby is not considered to be capable of a separate existence before the completion of the twenty-eighth week of pregnancy. If pregnancy ends for some reason before this time, it is said to have aborted or miscarried.
The terms miscarriage and abortion both mean the same thing, the ending of a pregnancy before the twenty-eighth week, but the word abortion is more commonly used to refer to pregnancies which have been deliberately terminated. Termination of pregnancy or induced abortion is, nowadays, performed legally for a variety of reasons – for example, when the health or welfare of the woman or her family is threatened or when there is risk that the baby may be deformed.
What causes miscarriage?
Miscarriage occurs in about one in every five conceptions. There are many causes but, perhaps, the most important is a failure of the pregnancy to develop normally. When the baby is likely to be very severely deformed, nature often intervenes, development ceases and the woman miscarries.
Severe illness of many sorts in the mother can cause miscarriage. For example, a severe attack of gastro-enteritis, a sudden emotional shock like the death of a near relative, extremes of physical activity, may all cause miscarriage. At the same time, it is remarkable how some pregnancies will survive the most hair-raising adventures in both a medical and non-medical sense!
Deficiency of the hormone, progesterone, has been blamed for some miscarriages, especially as a shortage of progesterone is most likely to occur at about twelve weeks when a miscarriage quite often takes place.
Miscarriage after twelve to fourteen weeks is most often due to an abnormality in the shape of the uterus or to a weakness in the cervix. Sexual intercourse in the early months of pregnancy may, occasionally, cause slight bleeding, but it rarely causes miscarriage. However, if intercourse does cause bleeding in early pregnancy, it should be avoided until after twelve weeks.
Quite often no cause can be found for a particular miscarriage and, in such a case, the woman’s next pregnancy is often perfectly normal.
Miscarriage-signs and symptoms
Most miscarriages occur in the first twelve weeks of pregnancy, but a small proportion occur later. Usually the first sign that something is wrong is painless bright red vaginal bleeding. To start with, the loss is slight and may stop after a few hours. This is medically termed a threatened miscarriage.
If the bleeding continues, however, the miscarriage becomes inevitable and the blood loss can be severe. In this case the bleeding is accompanied by griping pains, like severe period pains, in the lower part of the abdomen and back. If the fetus, with its sac of membranes and developing placenta, passes intact, the bleeding will stop after some hours and the pain will cease. This is known as a complete miscarriage.
If parts of the fetus and membranes are left behind in the uterus, the bleeding and pain continue and a small operation is necessary to clean out the uterus. This operation-evacuation of the uterus-is carried out under a short general anesthetic and entails a oneto two-day stay in hospital. If much blood has been lost, a blood transfusion will be given. A careful examination should always be made by a doctor after a miscarriage has occurred to confirm that there are no remnants left inside the uterus. If these are not removed, infection may occur in the uterus and the woman will, as a result, become seriously ill.
This is known as septic miscarriage or septic abortion. In the type of miscarriage known as a missed abortion, the fetus dies at about ten or twelve weeks or later, but is not expelled immediately. In such a case the woman stops feeling pregnant and, after a few days, develops a brown discharge from the vagina.
Eventually, usually after two or three weeks, but sometimes longer, bleeding occurs and any remaining parts of the pregnancy are expelled to the accompaniment of some vaginal bleeding and abdominal pain. If missed abortion is suspected and the diagnosis is confirmed by a negative pregnancy test and an ultrasound examination the patient is admitted into hospital and the contents of the uterus evacuated, as in the case of an incomplete miscarriage.
Any woman who has had a miscarriage will be worried about the prospects of subsequent pregnancy. If a careful examination, following a single miscarriage, has not revealed any abnormality and if the miscarriage is not the result of a permanent problem for that particular woman, it is reasonable for her to try to become pregnant again as soon as she desires to do so.
The risk of another miscarriage, in this instance, is small. It is, however, sensible for such a woman to wait until she feels fully recovered from the effect of the miscarriage and has had one or two normal periods again.
No special treatment is needed when she does become pregnant again, but heavy physical work should be completely avoided and she must have adequate rest-for example, one hour’s rest on a bed or couch in the middle of the day and ten hours’ sleep at night.
To avoid even the slightest risk of disturbing the pregnancy, sexual intercourse is best avoided during the first twelve weeks of pregnancy.
Reactions to miscarriage
Once miscarriage is complete, all pain should cease and the vaginal bleeding should clear up in a few days. Two or three days after a late miscarriage the breasts may fill up with milk and feel swollen and tender for a day or two. They quickly return to normal without treatment in most cases.
Rhesus negative women should receive an injection of anti-D gamma globulin to avoid the slight risk of rhesus sensitization.
Ovulation occurs between two and three weeks after a miscarriage and, provided the woman does not immediately become pregnant again, the first period will start a few weeks after ovulation, i.e. four to five weeks after the date of the miscarriage. Thereafter the normal menstrual cycle is resumed.
The disappointment of losing the baby often leaves a woman feeling. This is a normal reaction to an unhappy event and needs sympathetic handling by the husband and close friends. The husband himself will often be as disappointed as his wife, but shared sorrow is more easily borne. Reassurance that miscarriage is very common and that it is unlikely to recur in a subsequent pregnancy is helpful. Persistent needs expert medical advice and a doctor should always be consulted if the natural sadness that follows a miscarriage lasts longer than two or three weeks.
In a few rare instances, miscarriage occurs more than once. When this happens the woman should be referred to a gynaecologist for investigation. Improvement in general health, operations to correct an abnormally shaped uterus, stitching the cervix in early pregnancy and sometimes hormone treatment, are steps that may be taken. These are usually successful nowadays in overcoming the problems of recurrent miscarriage.
The important point is that women who have had two successive miscarriages should be properly investigated before they try to become pregnant again.
Ultrasound in early pregnancy
Nowadays, high frequency sound-waves are often used during late pregnancy to obtain a “picture” of the baby inside the uterus. This enables doctors to measure the baby’s size and maturity. Recently ultrasound has also been applied to the study of early pregnancy. The developing fetus can be identified as early as four weeks after conception and when there is a threat of miscarriage, an ultrasound examination will determine whether or not a miscarriage is actually inevitable. When a miscarriage has occurred, an ultrasound examination will reveal whether or not it is complete.
Once in every hundred or so pregnancies the fertilized egg unfortunately implants itself in the Fallopian tube instead of in the uterus. This is termed an ectopic pregnancy. Once implanted it tries to develop, but because of the space cannot grow normally.
The tube becomes very stretched at the site of the pregnancy and then either splits, medically termed ruptured ectopic, or squeezes the pregnancy back along the tube the way it came which is known as tubal abortion. In both cases the fetus dies and the mother suffers some internal bleeding.
How to recognize an ectopic pregnancy
The most important symptom of ectopic pregnancy is pain on the site of the affected Fallopian tube. This usually starts one or two weeks after the first period is missed and becomes increasingly severe. Normal symptoms of pregnancy are present and a pregnancy test is usually positive.
As the pregnancy grows in the tube there will often be some vaginal bleeding. If much internal bleeding occurs, as it may in the case of a ruptured tube, the woman becomes very pale and may collapse with a very low blood pressure.
Some lower abdominal pain is not uncommon in early normal pregnancy, but it is mild compared with the pain of an ectopic pregnancy and does not last. The pain of an ectopic pregnancy is both severe and persistent. Any woman who gets a pain to one side or the other of the lower abdomen in early pregnancy should consult her doctor at once.
Diagnosis of ectopic pregnancy can often be made by a simple vaginal examination. If there is doubt, the patient is admitted immediately to hospital and is examined under a general anaesthetic. The anaesthetic enables the gynaecologist to do a much more thorough vaginal examination without causing the patient pain.
If there is still doubt about the diagnosis, a narrow telescope, known as a laparoscope, can be passed through a tiny incision made just below the umbilicus. This enables the fallopian tubes and ovaries to be inspected.
Treatment of ectopic pregnancy
When an embryo is present in a tube, the woman needs an operation to remove both the embryo and the affected tube. Unfortunately, as the tube itself is often too badly damaged to be left in place, it is not possible to remove only the embryo. If there has been much internal bleeding the woman will need a blood transfusion. Removal of one tube does not, of course, mean the find of the woman’s child-bearing career. Ectopic pregnancy is a very serious condition. The important thing is to seek medical advice at once if severe abdominal pain develops during early pregnancy.