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Complications in Pregnancy

Complications in Pregnancy

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Molar Pregnancy

What is a molar pregnancy?

A molar pregnancy is a rare complication of pregnancy. It happens when something goes wrong during the fertilisation process at conception, and there are abnormalities in the cells that grow to form the placenta. Molar pregnancy, sometimes called a hydatidiform mole, is part of a group of conditions called gestational trophoblastic tumours. They are usually benign (not cancerous). Even though they can spread beyond the uterus (womb), they are curable.

In a normal pregnancy, the fertilised egg contains 23 chromosomes from the father and 23 from the mother. In a complete molar pregnancy, the fertilised egg has no maternal chromosomes and the chromosomes from the father's sperm are duplicated, so you end up with two copies of chromosomes from the father and none from the mother. In this case, there's no embryo, amniotic sac, or any normal placental tissue. Instead, the placenta forms a mass of cysts that looks like a cluster of grapes. These cysts are visible on an ultrasound scan.

In most partial molar pregnancies, the fertilised egg has the normal complement of chromosomes from the mother but double the chromosomes from the father, so there are 69 chromosomes instead of the normal 46 (that can happen when chromosomes from the sperm are duplicated or when two sperm fertilise the same egg). In this case, there's some placental tissue among the cluster-like mass of abnormal tissue. The embryo does begin to develop, so there may be a foetus, or some f0etal tissue, or an amniotic sac. But even if a foetus is present, it is important to understand that it is genetically abnormal and that it can't survive and grow into a baby.

It can be very frightening and upsetting to lose a pregnancy this way. But as long as, get proper treatment and are followed up carefully, unlikely to have any long-term physical consequences.

How common are molar pregnancies?

In the West about one in every 1,000 pregnancies is a molar pregnancy. In Asian women, molar pregnancies are more common, though it is not understood why. There is an increased risk of molar pregnancy in women with blood group B and a trend toward an increased risk of second molar pregnancy in Indian/Pakistani women.

How would I know if I had a molar pregnancy?

Early on, you might have typical pregnancy symptoms, but at some point will begin to have some bleeding. (Bleeding in pregnancy is not always a sign of something serious, and only very rarely a sign of a molar pregnancy, but it is always worth contacting doctor about it). The bleeding might be bright red or dark brown, continuous or intermittent, and light or heavy. This bleeding could start as early as six weeks into your pregnancy or as late as 16 weeks.

You might also have severe nausea and vomiting (called hyperemesis), and abdominal swelling (uterus may grow more rapidly than usual). Levels of the pregnancy hormone human chorionic gonadotrophin (hCG) will be much higher than normal.

A complete molar pregnancy is usually visible on an ultrasound scan, and a blood test will confirm diagnosis by measuring levels of hCG. However partial molar pregnancies can sometimes be more difficult to diagnose. If miscarry a suspected molar pregnancy before it is diagnosed by scan, a pathologist may be able to examine the miscarried tissue to confirm if it is a molar pregnancy. If carry any miscarried tissue to local hospital, and they will be able to send it for analysis.

What's the treatment for a molar pregnancy?

If  diagnosed with a molar pregnancy, may need a minor operation called a D&C (dilation and curettage) to remove the abnormal tissue or may be given a drug to enable to miscarry the tissue without surgery (this is called medical management). Occasionally, may need a second D&C operation to remove the mole completely.

Doctor will ask for follow up tests and asked to provide urine or blood samples after the operation so that levels of hCG can be monitored. When there is no disease left in the body, the level of hCG is virtually zero.

Long-term implications

It is important to monitor a molar pregnancy for around six months after diagnosis, depending on particular circumstances. This is because even very small quantities of a molar pregnancy can grow and spread quickly, and this can sometimes happen several months after treatment. If hCG level begins to rise or stays high, it will be informed.

An invasive mole can sometimes develop after the D&C operation to remove the molar pregnancy. An invasive molar pregnancy means that the molar tissue has grown into the muscle layer of the uterus. The most common symptom of an invasive mole is irregular or continued bleeding after the operation.

Invasive moles can cause problems because once the mole has grown into the muscle layer of the uterus, it can travel via the blood to distant organs, including the lungs, liver and brain.

An invasive molar pregnancy can develop after a partial molar pregnancy, but it's more likely to develop after a complete molar pregnancy.

Occasionally, abnormal cells do remain after the tissue is removed. This is called persistent gestational trophoblastic disease. It happens in less than 15 per cent of women with complete moles, and in less than one per cent of women with partial moles. If it happens, needs drug treatment (chemotherapy) to be sure that the disease hasn't spread beyond uterus. Treatment will continue until hCG levels have returned to normal.

With prompt and appropriate treatment, nearly 100 per cent of cases of this disease are curable when it hasn't spread beyond the uterus. Even in very rare cases in which the abnormal cells have spread to other organs, nearly all cases can be cured. in complete remission, you'll need to have hCG levels monitored intermittently for the rest of life.

In a very small number of cases a complete molar pregnancy can lead to choriocarcinoma, an extremely rare but curable form of cancer where the placenta becomes malignant. This condition occurs in 1 in 30,000 pregnancies. It can arise from a molar pregnancy, or an otherwise normal pregnancy or miscarriage.

When to get pregnancy again?

If no chemotherapy, need to wait up to six months after hCG levels go back down to zero before trying to get pregnant again.

If had chemotherapy, usually recommended to wait 12 months before for another pregnancy. If get pregnant before these times, hCG levels would rise and it would be impossible for doctor to tell whether abnormal tissue was growing back.

Odds of having another molar pregnancy are around 1 to 2 per cent. You'll have a first trimester ultrasound in any subsequent pregnancies to make sure all is well. The good news is that in the vast majority of cases having a molar pregnancy doesn't affect ability to have a normal pregnancy, even after chemotherapy. There is no any increased risk for stillbirth, birth defects, premature labour, or other complications.

Counseling

Having a molar pregnancy can be very frightening and upsetting. Like any woman who has miscarried and dealing with the loss of your pregnancy, but in this case, an unusual condition that most people have never heard of and worried about their own health as well. May also worry about the ability to conceive. To undergo a minimum of six months of regular follow-ups before try to conceive again, and may be very anxious about the possibility of having persistent abnormal cells. If you do have persistent disease, treatment with chemotherapy can be very draining and can delay your next pregnancy even longer.

May feel devastated by experience. Husband may also be feeling sad or helpless and may have trouble working out how to express those feelings or how to be supportive. Keep talking to husband and try to share grief together. If either of them were finding it hard to cope with feelings, could talk to your doctor, family, friends or even a qualified counselor.

Hydramnios

Hydramnios

Hydramnios is a condition during pregnancy characterized by too much amniotic fluid. It is also known as amniotic fluid disorder or polyhydramnios.

Amniotic fluid is a sterile solution that surrounds and cushions the fetus during pregnancy. The fluid comes from the baby’s kidneys – it’s fetal urine – and is absorbed when the fetus swallows it. The amount of fluid increases until the 36th week of pregnancy; after that, it slowly decreases. If the fetus makes too much urine, or doesn’t swallow enough, too much fluid accumulates, resulting in hydramnios.

Severe hydramnios may signal a problem with the fetus, such as a central nervous system defect, a gastrointestinal blockage, or a chromosomal problem. In rare cases, it can lead to early labor or even fetal death. Mild hydramnios is more common, and doesn't signal a problem. In fact, extra fluid that appears during the second trimester is likely to return to a normal range without treatment.

How will I know if I have Hydramnios problem?

Mild Hydramnios often has no symptoms. But let your doctor know if you experience breathlessness, abdominal pain, and marked swelling or bloating, which can be signs of more severe Hydramnios.

During regular prenatal check-ups, your doctor will use a tape measure or similar method to gauge your "fundal height" - the distance from your pubic bone to top of uterus. He'll also check baby's growth by simply feeling uterus through abdomen or performing an ultrasound. If he suspects Hydramnios, he'll order an ultrasound, which can measure the amount amniotic fluid surrounding your baby.

How is it treated?

Doctors can treat the symptoms of Hydramnios, but usually not whatever caused the condition itself. If you have difficulty breathing or walking, for instance, the doctor   may want to hospitalize you. And since Hydramnios can lead to preterm delivery, he may put you on medications that prevent this. He may also suggest amniocentesis to remove some of the excess fluid and lessen your discomfort.

You may also undergo tests to try to determine why you have extra amniotic fluid. Your doctor may check an ultrasound to look for problems with the fetus, and an amniocentesis may be done to check for chromosome problems associated with Hydramnios. The Doctor may also test your blood for diabetes and evidence of recent infections. In many cases, no explanation of the high fluid is found

How can I prevent it?

You can’t. What causes hydramniosis not known? but sometimes it's due to a faulty swallowing mechanism in the fetus that's linked to certain birth defects. Since little can be done to prevent the conditions that may lead to Hydramnios, there's no way to head off the disorder itself.

Is oligohydramnios and hydramnios are same?

No. Oligohydramnios is just the opposite - NOT enough of amniotic fluid. This condition generally occurs when something is wrong with the fetus or the placenta or when the mother has high blood pressure. The biggest danger of oligohydramnios is , without plenty of fluid to float in, the fetus'  may compress the umbilical cord, cutting off its supply of oxygen and nutrients. If it is  diagnosed with oligohydramnios, the doctor will monitor your baby's health carefully to make sure this doesn't happen.

Can hydramnios harm the baby?

The increased risk of preterm labor aside, hydramnios doesn't cause health problems -- it merely reflects them. If you develop severe hydramnios, your doctor will look for problems in the baby's gastrointestinal system, central nervous system, and heart, as well as chromosomal defects such as Down syndrome.

If hydramnio, is something definitely wrong with the baby?

Not at all. In fact, if you develop the condition during your second trimester, chances are good that your baby is fine and that the hydramnios will disappear on its own. Hydramnios may also occur during perfectly healthy multiple pregnancies. If you're concerned, though, ask the doctor to check for birth defects and other problems during an ultrasound.

Will hydramnios cause problems with my delivery?

A fetus with lots of fluid around it can continue to flip and turn right up to delivery, and has a greater chance of flipping to be feet down, or breech. Breech babies can sometimes be coaxed back to the head-down position, but they often have to be delivered by c-section.

Oligohydramnios

When a woman has Oligohydramnios, the level of amniotic fluid surrounding the baby is too low. To understand how this can affect your health and the health of your baby, it's helpful to first understand the role amniotic fluid plays in a healthy pregnancy.

What is Amniotic Fluid?

The amniotic fluid that surrounds baby plays an important role in baby's growth and development. This clear-colored liquid protects the baby and provides it with fluids. Baby breathes with this fluid into its lungs and swallows it. This helps baby's lungs and digestive system grow strong. Amniotic fluid also allows the baby to move around, which helps it to develop its muscles and bones.

The amniotic sac that contains baby begins to form about 12 days after conception. Amniotic fluid begins to form at that time. In the early weeks of pregnancy, amniotic fluid is mainly made up of water supplied by the mother. After about 12 weeks, baby's urine makes up most of the fluid.

The amount of amniotic fluid increases until about 28-32 weeks of pregnancy. At that time you have about 1 quarter of fluid. After that time, the level stays about the same until about 37-40 weeks, when baby is considered full-term. After that, the level begins to decrease.

What is Oligohydramnios?

Oligohydramnios (too little amniotic fluid) occurs in about 8 out of 100 of pregnancies. It is most common in the last trimester of pregnancy, but it can develop at any time in the pregnancy. About 1 out of 8 women whose pregnancies last 2 weeks past the due date develops oligohydramnios. This happens as amniotic fluid levels naturally decline.

Oligohydramnios is diagnosed with ultrasound. The causes of this condition are not completely understood. In fact, most pregnant women who develop oligohydramnios have no known cause.

What are the major causes?

The most important causes of oligohydramnios early in pregnancy are

  • Certain birth defects in the baby
  • Ruptured membranes (breaks or tears in the sac that holds the amniotic fluid)

Birth defects involving the kidneys and urinary tract are the most likely causes of this problem. That's because babies with these birth defects produce less urine, which makes up most of the amniotic fluid. Some maternal health problems have also been linked with oligohydramnios. These problems include high blood pressure, diabetes, an autoimmune condition called system lupus erythematosus (SLE), and placental problems.

How it affects?

Oligohydramnios may affect the women and baby, and delivery in different ways. The effects depend on the cause, when the problem occurs, and how little fluid there is.

  • In the first half of pregnancy, too little amniotic fluid may result in birth defects of the lungs and limbs. During this period, Oligohydramnios increases the risk of miscarriage, preterm birth and stillbirth.
  • When Oligohydramnios occurs in the second half of pregnancy, it is linked to poor fetal growth.
  • Near delivery, Oligohydramnios can increase the risk of complications during labor and delivery.

What should I do?

Recent studies suggest that women with otherwise normal pregnancies who develop Oligohydramnios probably need no treatment. Their babies are likely to be born healthy.

  • When treatment is needed, the amniotic fluid may need to be replaced with an artificial substitute once the woman is in labor.
  • The best thing is to go to doctor to monitor the size of uterus and how much amniotic fluid is in womb. If there is problem the doctor take steps to prevent complications.
  • Women with high blood pressure, diabetes, lupus and placental problems are at increased risk for Oligohydramnios. In high blood pressure, talk to doctor before pregnancy. During pregnancy any medication to be taken under supervision of doctor. Be sure your blood pressure is well controlled.
  • If Oligohydramnios is diagnosed, eat healthy and nutritious diet, drink lots of fluids (water is best), get plenty of rest and report any signs of preterm labor to doctor

Blighted ovum

What is a blighted ovum?

A blighted ovum (also known as “an embryonic pregnancy”) happens when a fertilized egg attaches itself to the uterine wall, but the embryo does not develop. Cells develop to form the pregnancy sac, but not the embryo itself. A blighted ovum usually occurs within the first trimester before a woman knows she is pregnant. A high level of chromosome abnormalities usually causes a woman’s body to naturally miscarry.

How do I know if I am having a blighted ovum?

A blighted ovum can occur very early in pregnancy, before most women even know that they are pregnant. You may experience signs of pregnancy such as a missed or late menstrual period and even a positive pregnancy test. It is possible that you may have minor abdominal cramps, minor vaginal spotting or bleeding. As with a normal period, your body may flush the uterine lining, but your period may be a little heavier than usual.

Many women assume their pregnancies are on track because their hCG levels are increasing. The placenta can continue to grow and support itself without a baby for a short time, and pregnancy hormones can continue to rise, which would lead a woman to believe she is still pregnant. A diagnosis is usually not made until an ultrasound test shows either an empty womb or an empty birth sac.

What causes a blighted ovum?

A blighted ovum is the cause of about 50% of first trimester miscarriages and is usually the result of chromosomal problems... This can be caused by abnormal cell division, or poor quality sperm or egg.

How can a blighted ovum be prevented?

Unfortunately, in most cases a blighted ovum cannot be prevented. Some couples will seek out genetic testing if multiple early pregnancy loss occurs. A blighted ovum is often a onetime occurrence, and rarely will a woman experience more than one. Most doctors recommend couples wait at least 1-3 regular menstrual cycles before trying to conceive again after any type of miscarriage

Cervical Incompetence

What is Cervical Incompetence?

Sometimes premature effacement (shortening of the vaginal portion of the cervix and thinning of the walls) and dilation of the cervix is not caused by labor, but rather by structural weakness in the cervix itself. This is called cervical incompetence. The weakness can result from a number of conditions, most due to prior injury to the cervix or resulting from an inherited physical condition of the cervix.

Cervical incompetence accounts for about 15 to 20 percent of all pregnancy losses during the second trimester.

Description of Cervical Incompetence

When the cervix is damaged, it cannot hold the weight of the pregnancy. The cervix dilates without contractions or pain, sometimes opening completely. The dilation results in the amniotic membranes bulging through the opening and eventually rupturing, often before the baby can survive outside of the uterus. This irritates the uterus and brings on pre-term labor. In many cases, labor is detected when it is too far advanced to stop the process

Causes and risk factors of Cervical Incompetence

Risk factors for an incompetent cervix are: a history of incompetent cervix with a previous pregnancy, surgery, cervical injury, DES (diethylstilbestrol) exposure, and anatomic abnormalities of the cervix. A prior D&C can, for example, damage the cervix.

Other causes of cervical weakness include cervical cautery (to remove growths or stop bleeding) and cone biopsy (removal of a cone-shaped section of tissue for study to detect possible precancerous growth). Prior to pregnancy or during the first trimester, there is usually no method to determine whether the cervix will eventually be incompetent.

Symptoms of Cervical Incompetence

Women with incompetent cervix typically present with "silent" cervical dilation (i.e., with minimal uterine contractions) between 16 and 28 weeks of gestation. They present with significant cervical dilation (2 cm or more) and minimal symptoms. When the cervix reaches 4 cm or more, active uterine contractions or rupture of membranes may occur.

Diagnosis of Cervical Incompetence

Diagnosis is made by medical history, physical exam, and ultrasound study. A pregnancy test will also be performed

Treatment of Cervical Incompetence

Cerclage: Once the problem of incompetence is diagnosed, the condition may be treatable through a surgical procedure called cerclage (stitching the cervix closed). One or more stitches are placed around or through the cervix to keep it tightly closed. This is usually performed after the twelfth week of pregnancy, the time after which a woman is least likely to miscarry for other reasons - but it is not done if there is rupture of the membranes or infection. After surgery, the mother is carefully monitored to check for infection and contractions, which are sometimes brought on by the procedure. After hospital discharge, the patient may remain on bed rest in order to remove any pressure on the cervix and increase the chance of retaining the pregnancy until the baby is viable. The cerclage is usually removed just before childbirth so that the patient can give birth vaginally. In some cases, the cerclage may be left in place, and the baby is then delivered by cesarean section.

Pregnancy with communicable diseases

Disease

How is it Spread

Risk to Baby?

How to Prevent/Treat?

AIDS
(Virus)

  • sharing of contaminated needles
  • unprotected sex
  • transmitted through placenta, during delivery and through breast milk
  • if fetus is infected early in pregnancy-small head, deformed face
  • HIV+ Mom has 50% chance of infecting baby
  • avoid situations of risk

CHICKENPOX
(Virus)

  • Infection early in pregnancy may be associated with congenital malformations, but risk for infection is low~ 2.2%
  • If in 1st trimester-can cause underdeveloped limbs, eye and brain damage and skin scarring; low birth weight; congenital neonatal Zoster
  • If mother gets rash within 5 days before or 2 ays after delivery-risk for baby is 20%
  • Screen for immunity at 1st prenatal visit
    -Varicella Zoster Immune Globulin (VZIG) can be given to prevent or reduce chickenpox
  • Vaccine is available and cannot be given during pregnancy. Women vaccincated against varicella should not try to conceive for at least one month after vaccination.

CHLAMYDIA
(same applies for gonorrhea)
(Bacteria)

  • Sexually transmitted-can be in vagina without any symptoms
  • Also from mother to baby during delivery
  • During pregnancy, is associated with low birth weight and premature rupture of membranes
  • newborns may develop eye infections, pneumonia, infections of genital and GI tract
  • Once diagnosed, treat mother, baby and father with antibiotics and use condoms until rechecked by physician

CYTOMEGALO-VIRUS
(Virus)

  • transmitted in semen, urine & blood, cervical secretions, breast milk
  • prematurity, mental retardation , liver disorders
  • good handwashing after each contact with body secretions
  • careful handling and disposal of urine-soaked diapers

FIFTH DISEASE
parvovirus
(Virus)

  • person to person through contact with infected nose and throat secretions (coughing, sneezing), or sharing drinking glasses and utensils
  • if mom comes in contact in the 1st half of pregnancy, <10% chance of affecting red blood cell production ® severe anemia® miscarriage or death of fetus
  • most adults have probably been exposed previously
  • avoid people with fevers; wash hands frequently; cover mouth when coughing or sneezing; avoid sharing eating utensils

GROUP B
STREPTOCOCCAL
(Bacteria)

  • found in vagina and lower intestine of 15-30% of women
  • can enter amniotic cavity just before delivery, or through tears in amniotic sac; or by baby swallowing or inhaling it during delivery of the 50-75% of infected babies, 1-2% will develop severe disease, e.g. meningitis, sepsis or pneumonia
  • screening during pregnancy with treatment for the following criteria: premature labour (<37 wks); premature rupture of membranes (<37 wks); prolonged rupture of membranes (>18 hrs); fever during labour; multiple births; GBS bacteria in urine; heavy colonization of GBS; mother < 20 years old; history of GBS with previous births(6)
    -IV antibiotics during labour
  • vaccine being developed

HEPATITIS B
(Virus)

  • contact with infected body fluids-blood, semen, vaginal fluids and possibly saliva; unprotected sexual intercourse; sharing needles, razors or toothbrushes
  • from positive mom to child at or soon after birth, possibly through breast milk
  • Perinatal infection has high likelihood of chronic hepatitis, cirrhosis or cancer
  • Mandatory testing of pregnant women.
    If positive, within 12 hrs. of birth, infant should be given Hepatitis B Immune Globulin & 1st of 3 Hepatitis B vaccine shots, to be repeated at 3 & 6 months
  • father should also be tested & vaccinated if at risk

HERPES SIMPLEX
(Virus - HSV Type 1 or 2)

  • Sexually transmitted by skin-to-skin contact with active herpes lesion &/or touching lesions and spreading it to other areas of body
  • Genital infection is associated with spontaneous abortion before 20 wks; possibly prematurity
    -infection through placenta is uncommon
  • Infant may have liver problems, seizures, long term neurological problems, meningitis
  • No intercourse when active lesions present
  • possible Caesarean section if lesions active during labour
  • Anti-viral therapy

RUBELLA
(German Measles)
(Virus)

  • through placenta
  • if in 1st trimester, can cause miscarriage, organ malformation; deafness, cataracts, microcephaly, mental retardation, heart defects, liver problems
  • immunization of potential pregnant women.
  • vaccine available should be given at least 1 month prior to trying to conceive.

TOXOPLOSMOSIS
(Parasite - toxoplasma gondii)

  • feces of infected cat (in litter box)
    -undercooked or raw meat
  • -not washing knives after preparation of raw meat; berries, vegetables/fruit from contaminated soil
  • -gardening
  • -sand boxes that cats can get into
  • -to fetus through placenta
  • -if in 1st trimester-miscarriage, brain damage, seizures, severely impaired vision, hydrocephaly, and other problems
  • -if later in pregnancy® miscarriage, stillbirth, cirrhosis, encephalitis, vision problems (chorioretinitis), mental retardation, neurological problems up to 15-20 years later
  • -wash hands after handling raw meats and vegies & before each meal or handling food
    -use separate surfaces and utensils for preparing raw and cooked foods (e.g. barbecuing)
  • -cook meat thoroughly (not in microwave)
  • -avoid delicatessen & smoked meats while pregnant
  • -cook vegetables from potentially contaminated soil, but if raw, wash carefully
  • -treat all cats as potentially contagious-handle cat litter with gloves; flush feces down the toilet; disinfect litter tray daily by scalding or throw out; don’t pet cats
  • -don’t garden where wandering cats have access
  • -keep flies & cockroaches away from food

Source: Reid, D. "Perinatal AIDS", Perinatal Outreach Program Newsletter



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