Pregnancy and Birth Sourcebook Part 30

* Other treatments: Other treatments: Women with HG have numerous other symptoms that often cause significant distress. One is ptyalism (also called hypersalivation, sialorrhea, or hyperptyalism). Ptyalism is essentially an overproduction of saliva thought to be caused by increased hormone levels. It happens in non-HG pregnancies as well and worsens nausea. There are few treatments and most women just tolerate it by spitting into a cup or tissue. Women with HG have numerous other symptoms that often cause significant distress. One is ptyalism (also called hypersalivation, sialorrhea, or hyperptyalism). Ptyalism is essentially an overproduction of saliva thought to be caused by increased hormone levels. It happens in non-HG pregnancies as well and worsens nausea. There are few treatments and most women just tolerate it by spitting into a cup or tissue.

In severe cases, a suction machine may be prescribed to avoid skin irritation on the lips and chin from constant exposure to saliva. Other issues are pain from prolonged periods of inactivity, which are typically managed with over the counter pain relievers like Tylenol.

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Pregnancy and Birth Sourcebook, Third Edition Complications Although numerous depending on one's individual biochemistry, severity of symptoms, and the medical interventions given, many potential complications may result from HG. With an aggressive and proactive approach to treatment, many sequelae can be avoided. If care is inadequate, ineffective, or delayed, cases of morning sickness or mild HG may progress to moderate or severe HG. Women suffer greatly with HG, and effective intervention early in pregnancy can greatly ease the misery and stress a.s.sociated with this disease.

Long term complications (often with vague, chronic symptomology) will likely occur without proper intervention in the early stages. Fortunately, there are usually few immediate, adverse effects of HG on the baby unless weight gain continues to be poor during the second half of pregnancy, or symptoms are severe and prolonged. Acute or chronic complications reported by women to the HER Foundation include gall bladder disease, temporomandibular joint disorders, depression, anxiety, difficulty with weight management, diabetes, motion sickness, and dental caries. Some just say they never have felt the same as before they were pregnant. Women with prolonged HG are also at greater risk for preterm labor, and pre-eclampsia.

Emerging research is showing the possibility of potential future health risks to the infant if the mother is malnourished during pregnancy. This should strongly be considered when caring for women with HG, as the care provided affects not only the mother, but also the child for decades to come.

Signs of Severe HG * Debilitating, chronic nausea * Frequent vomiting of bile or blood * Chronic ketosis and dehydration * Muscle weakness and extreme fatigue * Medication does not stop vomiting/nausea * Inability to care for self (shower, prepare food) * Loss of over 510% of your pre-pregnancy weight * Weight loss (or little gain) after the first trimester * Inability to eat/drink sufficiently by about 14 weeks 390.

Chapter 48.

Placental Complications The placenta is an unborn baby's life support system. It forms from the same cells as the embryo and attaches to the wall of the uterus.

The placenta forms connections with the mother's blood supply, from which it supplies oxygen and nutrients to the fetus. The placenta also connects with the fetus's blood supply, from which it removes wastes and returns them to the mother's blood. The mother's kidneys dispose of the waste. The placenta has other important functions in pregnancy.

It produces hormones that play a role in triggering labor and delivery. The placenta also helps protect the fetus from infections and potentially harmful substances. After the baby is delivered, the placenta's job is done, and it is delivered as the afterbirth.

The mature placenta is flat and circular and weighs about 1 pound.

But sometimes the placenta: * is structured abnormally; * is poorly positioned in the uterus; * does not function properly.

Placental problems are among the most common complications of the second half of pregnancy. Here are some of the most frequent placental problems and how they can affect mother and baby.

"Placental Complications," 2007 March of Dimes Birth Defects Foundation.

All rights reserved. For additional information, contact the March of Dimes at their website www.marchofdimes.com.

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Pregnancy and Birth Sourcebook, Third Edition What is placental abruption?

Placental abruption (sometimes called abruptio placentae) is a condition in which the placenta peels away from the uterine wall, partially or almost completely, before delivery. Mild cases may cause few problems, but severe cases can deprive the fetus of oxygen and nutrients. Severe cases also can cause bleeding in the mother that can endanger both her and the baby.

Placental abruption increases the risk of premature birth (birth before 37 completed weeks gestation). Studies suggest that abruption contributes to about 10 percent of premature births.1 Premature babies are at increased risk for health problems during the newborn period, lasting disabilities, and even death. Abruption also increases the risk for poor fetal growth and stillbirth.1 How common is placental abruption?

Abruption occurs in about 1 in 100 pregnancies.2 It occurs most often in the third trimester, but it can happen any time after about 20 weeks of pregnancy.

What are the symptoms of abruption?

The main sign of placental abruption is v.a.g.i.n.al bleeding. A pregnant woman should contact her health care provider if she has v.a.g.i.n.al bleeding.

The pregnant woman also may experience uterine discomfort and tenderness or sudden, continuous abdominal pain. In a few cases, these symptoms may occur without v.a.g.i.n.al bleeding because the blood is trapped behind the placenta.

How is placental abruption diagnosed?

If the health care provider suspects an abruption, she probably will recommend that the woman go to the hospital for a complete evaluation. The provider will do a physical examination and, most likely, an ultrasound examination. An ultrasound can detect many, but not all, cases of abruption.

How is placental abruption treated?

How a woman is treated depends on the severity of the abruption and her stage of pregnancy.

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Placental Complications A mild abruption usually is not dangerous unless it progresses. If a woman has a mild abruption at term, her health care provider may recommend prompt delivery (either by inducing labor or by c- [Cesarean] section) to avoid any risks a.s.sociated with a worsening abruption.

If a woman has a mild abruption and her fetus would be very premature if delivered immediately, her provider will probably admit her to the hospital for careful monitoring. If tests show that neither mother nor baby is having difficulties, the provider may try to prolong the pregnancy to avoid prematurity-related complications for the baby.

If the provider suspects that the abruption is likely to result in premature delivery between 24 and 34 weeks of pregnancy, she will probably recommend treatment with drugs called corticosteroids. These drugs speed maturation of the fetal lungs and significantly reduce the risk of prematurity-related complications and infant deaths.

Some women with mild abruptions may be able to go home after the bleeding stops, while others may need to stay in the hospital until delivery.1 If an abruption progresses, a woman is bleeding heavily, or the baby is having difficulties, a prompt delivery, usually by c-section, probably will be necessary.

What causes placental abruption?

The cause of abruption is unknown. However, the following factors can increase a woman's risk for abruption.1,3 * High blood pressure * Cocaine use * Cigarette smoking * Abdominal trauma (such as may occur with an automobile accident or abuse) * Certain abnormalities of the uterus or umbilical cord * Being more than 35 years of age * Pregnant with twins, triplets, or more * Premature rupture of the membranes (bag of waters) * Having too little amniotic fluid * Having certain inherited disorders of blood clotting * Having an infection involving the uterus 393.

Pregnancy and Birth Sourcebook, Third Edition What is the risk of an abruption happening again in an- other pregnancy?

A woman who has had an abruption has about a 10 percent chance of it happening again in a later pregnancy.1 What can a woman do to reduce her risk for abruption?

In most cases, abruption cannot be prevented. However, these steps may help a woman reduce her risk: * Keep high blood pressure under control. Women who have high blood pressure should see their health care provider regularly and take medication, if recommended. Women who are not yet pregnant should see their provider for a preconception checkup to get their blood pressure under control right from the start.

* Avoid cigarettes and cocaine. These contribute to abruption and other pregnancy complications.

* Wear a seat belt. This can help prevent trauma resulting from auto accidents.

* Discuss possible treatments for blood clotting disorders with a health care provider. Some women with inherited blood clotting disorders may benefit from treatment, for example with blood-thinning drugs, during pregnancy.1 Some providers recommend treatment to affected women who have had an abruption or other pregnancy complication that may be linked with a blood-clotting disorder.

What is placenta previa?

Placenta previa is a low-lying placenta that covers part or all of the opening of the cervix. This positioning of the placenta can block the baby's exit from the uterus. As the cervix begins to thin and dilate in preparation for labor, blood vessels that connect the abnormally placed placenta to the uterus may tear, resulting in bleeding. During labor and delivery, bleeding can be severe, endangering mother and baby.

As with placental abruption, placenta previa can result in the birth of a premature baby.

How common is placenta previa?

Placenta previa occurs in about 1 in 200 pregnancies.4 394.

Placental Complications What are the symptoms of placenta previa?

The most common symptom of placenta previa is painless uterine bleeding during the second half of pregnancy. Women who experience v.a.g.i.n.al bleeding in pregnancy should contact their health care provider.

How is placenta previa diagnosed?

An ultrasound examination can diagnose placenta previa and pin-point the placenta's location. The provider usually avoids doing a v.a.g.i.n.al examination when placenta previa is suspected because the examination may trigger heavy bleeding.

Some women who have not experienced v.a.g.i.n.al bleeding learn during a routine ultrasound examination that they have a low-lying placenta. A pregnant woman should not be too worried if this happens to her, especially if she is in the first half of pregnancy. More than 90 percent of the time, placenta previa diagnosed in the second trimester corrects itself by term.3,4 How is placenta previa treated?

How a woman with placenta previa is treated depends on her stage of pregnancy, the severity of the bleeding, and the condition of mother and baby. The goal, whenever possible, is to prolong pregnancy until the baby is at or near full term. Cesarean delivery is recommended for nearly all women with placenta previa because c-sections usually can prevent severe bleeding.

When a woman develops significant bleeding due to placenta previa after about 34 weeks of pregnancy, her provider may recommend a prompt c-section. Babies born after this time usually do well, though some have mild prematurity-related health problems during the newborn period.

Women who develop bleeding as a result of placenta previa before about 34 weeks are generally admitted to the hospital, where they can be monitored closely. If tests show that mother and baby are doing well, the provider will probably attempt to prolong the pregnancy.

In some cases, when there has been a significant amount of bleeding, the mother may be treated with blood transfusions. She also will be treated with corticosteroid drugs if she is likely to deliver before 34 weeks.

Some women are able to go home after bleeding stops, but others must remain in the hospital until delivery. At 36 to 37 weeks, if she 395 Pregnancy and Birth Sourcebook, Third Edition hasn't delivered, the provider may suggest a test of the amniotic fluid (obtained by amniocentesis) to see if the baby's lungs are mature. If they are, the provider will likely recommend a c-section at that time to prevent risks a.s.sociated with any future bleeding episodes.

At any stage of pregnancy, a prompt c-section may be necessary if the mother develops dangerously heavy bleeding, or if mother or baby is having difficulties.

What causes placenta previa?

The cause of placenta previa is unknown. However, certain factors can increase a woman's risk.3,4 * Cigarette smoking * Cocaine use * Being more than 35 years of age * Second or later pregnancy * Previous uterine surgery, including a c-section; a D&C (dilation and curettage, in which the lining of the uterus is sc.r.a.ped), which is often done following a miscarriage or during an abortion * Pregnant with twins, triplets, or more What is the risk of placenta previa happening again in another pregnancy?

A woman who has had a placenta previa in a previous pregnancy has a two to three percent chance of a recurrence.3 Can a woman reduce her risk for placenta previa?

There is no way to prevent placenta previa. However, a woman may be able to reduce her risk by avoiding using cigarettes and cocaine.

She also may be able to reduce her risk in future pregnancies by avoiding having an elective c-section (i.e., a c-section scheduled for convenience), unless there is a medical reason.

What is placenta accreta?

Placenta accreta refers to a placenta that implants too deeply and too firmly into the uterine wall. Similarly, placenta increta and percreta refer to a placenta that imbeds itself even more deeply into 396 Placental Complications uterine muscle or through the entire thickness of the uterus, sometimes extending into nearby structures, such as the bladder.

How common are placenta accreta and related disorders?

These disorders occur in about 1 in 2,500 deliveries.4 They sometimes lead to the birth of a premature baby.

What are the symptoms of placenta accreta and related disorders?

Like placenta previa, these disorders often cause v.a.g.i.n.al bleeding in the third trimester.

Who is at risk for placenta accreta and related disorders?

These disorders occur most frequently in women who have placenta previa in the current pregnancy and also have a history of one or more c-sections or other uterine surgery.4 How are placenta accreta and related disorders diag- nosed?

These disorders can be diagnosed with an ultrasound examination.

In some cases, another imaging technique called magnetic resonance imaging (MRI) may be recommended.4 How are placenta accreta and related disorders treated?

In these disorders, the placenta does not completely separate from the uterus as it should following the delivery of the baby. This can lead to dangerous hemorrhage following v.a.g.i.n.al delivery. The placenta usually must be surgically removed to stop the bleeding, and often a hysterectomy (removal of the uterus) is necessary.

When placenta accreta is diagnosed before birth, a c-section immediately followed by a hysterectomy may be planned in order to reduce blood loss and complications in the mother. In some cases, other surgical procedures can be used to save the uterus.

What are some other placental problems?

In some cases the placenta may not develop correctly or function as well as it should. It may be too thin, too thick or have an extra lobe, 397 Pregnancy and Birth Sourcebook, Third Edition or the membranes may be improperly attached. Or problems can occur during pregnancy that damage the placenta, including infections, blood clots, and areas of tissue destruction (infarcts). These placental abnormalities can contribute to a number of complications, such as miscarriage, poor fetal growth, prematurity, maternal hemorrhage at delivery and, possibly, birth defects. A doctor often will examine the placenta following delivery or send it to the laboratory, especially if the newborn has certain complications, such as poor growth, to help diagnose the cause of the problem.

Does the March of Dimes support research on placental conditions?

March of Dimes grantees are studying how certain infections, such as cytomegalovirus (CMV), may damage the placenta, possibly contributing to miscarriage, poor fetal growth, and birth defects, such as cerebral palsy.

Others are exploring how certain genes regulate the development and function of the placenta in order to develop ways to prevent miscarriages, growth problems, and premature births, which may result from placental abnormalities.

References Oyelese, Y. and Ananth, C.V. Placental Abruption. Obstetrics Obstetrics and Gynecology and Gynecology, volume 108, number 4, October 2006, pages 10051016.

Ananth, C.V., et al. Placental Abruption in Term and Preterm Gestations. Obstetrics and Gynecology, Obstetrics and Gynecology, volume 107, number 4, April 2006, pages 785792. volume 107, number 4, April 2006, pages 785792.

Kay, H.H. Placenta Previa and Abruption, in Scott, J.R., et al.

(eds.): Danforth's Obstetrics and Gynecology, Danforth's Obstetrics and Gynecology, Ninth Edition, Philadelphia, Lippincott Williams & Wilkins, 2003, pages 365 Ninth Edition, Philadelphia, Lippincott Williams & Wilkins, 2003, pages 365 379.

Oyelese, Y. and Smulian, J.C. Placenta Previa, Placenta Accreta, and Vasa Previa. Obstetrics and Gynecology, Obstetrics and Gynecology, volume 107, number 4, April 2006, pages 927941. volume 107, number 4, April 2006, pages 927941.

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Chapter 49.

Rh Incompatibility If you just found out you're pregnant, one of the first-and most important-tests you should expect is a blood-type test. This basic test determines your blood type and Rh factor. Your Rh factor may play a role in your baby's health, so it's important to know this information early in your pregnancy.

About the Rh Factor People with different blood types have proteins specific to that blood type on the surfaces of their red blood cells (RBCs). There are four blood types-A, B, AB, and O.

Each of the four blood types is additionally cla.s.sified according to the presence of another protein on the surface of RBCs that indicates the Rh factor. If you carry this protein, you are Rh positive. If you don't carry the protein, you are Rh negative.

Most people-about 85%-are Rh positive. But if a woman who is Rh negative and a man who is Rh positive conceive a baby, there is the potential for a baby to have a health problem. The baby growing inside the Rh-negative mother may have Rh-positive blood, inherited "What Is Rh Incompatibility?" December 2008, reprinted with permission from www.kidshealth.org. Copyright 2008 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online for medically reviewed health information written for parents, kids, and teens. For more articles like this one, visit www.KidsHealth.org, or www.TeensHealth.org.

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Pregnancy and Birth Sourcebook, Third Edition from the father. Approximately half of the children born to an Rh-negative mother and Rh-positive father will be Rh positive.

Rh incompatibility usually isn't a problem if it's the mother's first pregnancy because, unless there's some sort of abnormality, the fetus's blood does not normally enter the mother's circulatory system during the course of the pregnancy.

However, during delivery, the mother's and baby's blood can inter-mingle. If this happens, the mother's body recognizes the Rh protein as a foreign substance and can begin producing antibodies (protein molecules in the immune system that recognize, and later work to destroy, foreign substances) against the Rh proteins introduced into her blood.

Other ways Rh-negative pregnant women can be exposed to the Rh protein that might cause antibody production include blood transfusions with Rh-positive blood, miscarriage, and ectopic pregnancy.

Rh antibodies are harmless until the mother's second or later pregnancies. If she is ever carrying another Rh-positive child, her Rh antibodies will recognize the Rh proteins on the surface of the baby's blood cells as foreign, and pa.s.s into the baby's bloodstream and attack those cells. This can lead to swelling and rupture of the baby's RBCs. A baby's blood count can get dangerously low when this condition, known as hemolytic or Rh disease of the newborn, occurs.