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Certain conditions that are specific to pregnancy and some that occur more commonly in pregnancy mean that a pregnancy is classified as high risk. A high-risk pregnancy is closely monitored with more prenatal appointments and possibly additional scans. In labor, certain complications require immediate intervention.

Pregnancy complications

Miscarriage

The loss of a fetus before the baby can survive outside of the uterus is the most common complication during early pregnancy, affecting up to a third of pregnancies .

Ectopic pregnancy

This occurs when a fertilized egg implants outside of the uterine cavity. The vast majority of ectopic pregnancies are in the fallopian tube, but they can occur on an ovary, in the cervix, or in the abdominal cavity at the site of a previous cesarean.

Causes

Any woman can have an ectopic pregnancy. However, the risk of an ectopic pregnancy is increased if you have had a pelvic infection; became pregnant with a progesterone-releasing IUD in place, while taking the mini-pill, or as a result of fertility treatment; have endometriosis; have had abdominal surgery such as a cesarean section; or a previous ectopic pregnancy.

Symptoms

Most women who have an ectopic pregnancy will notice pain and light bleeding at 6–8 weeks (2–4 weeks after a missed period). The pain is usually felt on one side of the lower abdomen and it may be severe and persistent. If an ectopic pregnancy is not recognized early and an embryo growing in the fallopian tube ruptures the tube, you may feel sudden severe pain that spreads across the abdomen. Internal bleeding from a ruptured tube can also irritate the diaphragm, causing shoulder pain. If you have severe lower abdominal pain, call your doctor and go immediately to the emergency room.

What might be done

If the tube has ruptured, then you will be taken straight to surgery. Usually, an ectopic pregnancy is suspected before this stage. In this case you will have an ultrasound scan, usually performed through the vagina, which often diagnoses the problem; there will be no baby in the uterus; blood may be seen in the abdomen; and sometimes the ectopic pregnancy itself can be seen. You may also have blood tests taken over a period of 48 hours to monitor the levels of hCG (the pregnancy hormone); if levels of hCG plateau or rise slightly, this indicates an ectopic pregnancy. If an ectopic pregnancy has not been confirmed by these investigations, you will probably be taken to surgery for a laparoscopy, a procedure where a telescope is inserted through a small incision in the abdomen, allowing the surgeon to see exactly what is happening. If there is an ectopic, and if the tube is still intact, the surgeon may make a tiny hole in it and remove the embryo or, if the tube has burst, he may remove part or all of it. Occasionally, ectopics may be treated medically with a drug called methotrexate, which stops the pregnancy from developing. This is only appropriate if the hCG levels are low and the tube hasn’t ruptured. The advantage is that surgery is avoided; however, the treatment doesn’t always work, can be associated with significant pain, and close follow-up is vital.

Hyperemesis gravidarum

Most women experience some nausea during pregnancy. Occasionally, vomiting may be very severe, known as hyperemesis gravidarum. If you are unable to hold down any food or drink for more than 24 hours, you should see your doctor.

What might be done

Your urine may be checked to ensure there is no infection, and you may have a scan to check that all is well with the pregnancy. You should be weighed, since if you lose more than 10 percent of your body weight, you’re at risk of complications. If you’re very dehydrated, your doctor may advise a short hospitalization so that you can receive intravenous fluids, and you may be given anti-nausea drugs and a vitamin supplement. Hyperemesis usually disappears by 13 weeks.

Anemia

Anemia is a low level of hemoglobin, the oxygen-carrying component of red blood cells. Mild anemia is common in pregnancy because the extra fluid content of blood dilutes the number of red blood cells. Also, the baby uses some of your iron reserves. If you have anemia you may feel tired and breathless and look pale.

Causes

Usually, anemia is due to iron deficiency. Occasionally, it’s due to a lack of folic acid, vitamin B12, or rarer other problems. An analysis of your blood test result will help identify the cause.

What might be done

Anemia is usually remedied with an iron supplement. These can have side effects, including constipation and black stools, so some women prefer to boost iron intake through diet.

Weakened cervix

Rarely, a woman may have a weakened cervix, sometimes known as cervical incompetence, which can lead to a miscarriage after 13 weeks. Usually, these miscarriages are relatively painless: you may feel well and perhaps notice some extra vaginal discharge, and then quite quickly miscarry the baby.

Causes

Risk factors include a previous late miscarriage; cervical surgery (such as a cone biopsy for an abnormal smear); or a previous late termination of pregnancy.

What might be done

If you are thought to be at risk, your doctor may suggest you have a scan to check the length of your cervix since a shortened cervix makes miscarriage more likely. However, the interval between shortening and miscarriage can be very short, so relying on scanning alone for deciding on treatment is not always helpful. The doctor may recommend that you have a cervical cerclage (stitch) put in at around 14-16 weeks to sew the cervix closed, preventing early labor. It’s usually done under anesthesia and is usually successful in preventing miscarriage. It is left in until you’re about 37 weeks; removal is straightforward and does not require anesthesia.

Obstetric cholestasis

This is a rare condition affecting liver function that causes a buildup of bile acids in the bloodstream. The main symptom is severe itching without a rash that is usually most intense on the palms and soles of the feet. It usually occurs after 28 weeks.

Causes

The exact cause of obstetric cholestasis is not clear, but genetic factors are probably involved since the condition tends to run in families and a woman who has the condition in one pregnancy will usually develop it in future pregnancies. Increased sensitivity to pregnancy hormones, which effect the way bile is processed, is also thought to play a role.

What might be done

If a woman has itching without a rash, the doctor will usually do a blood test to check her liver function and bile acids. If they’re abnormal, then obstetric cholestasis will be suspected. The doctor may recommend a drug called ursodeoxycholic acid to reduce the itching and improve liver function. You may also be treated with vitamin K because levels of this vitamin, which is essential for blood to clot, are often reduced in people with liver and bile problems. Women with severe obstetric cholestasis are usually induced at around 37 weeks because there is an increased risk of late stillbirth. There is also an increased risk of postpartum hemorrhage (see Postpartum hemorrhage).

Gestational diabetes

Diabetes that develops for the first time in pregnancy is called gestational diabetes and affects between two and seven percent of pregnant women. In this condition, the pancreas produces insufficient insulin to move glucose (sugar) from the blood to be stored, resulting in high levels of glucose in the blood. It usually begins at 20–24 weeks of pregnancy. The risk is greater if you have a family history of late-onset diabetes, or you have previously had a large baby, a stillbirth, or gestational diabetes.

Causes

Insulin levels become inadequate due to the extra demands of the fetus and because hormones produced by the placenta block the effects of insulin.

What might be done

Between 24 and 28 weeks, you will be tested for gestational diabetes. If you have risk factors, you may take this test earlier. The test involves having a blood test in the morning after fasting, then drinking a special sugary drink and having a repeat blood sugar check one hour later. If you have high levels of glucose, you’ll have to take a similar, but longer test to confirm a diagnosis. If you do have gestational diabetes, you will be taught how to test blood glucose at home. In most cases, the diabetes can be controlled through diet and exercise. However, if these measures prove inadequate you may need insulin injections until the end of pregnancy. Extra scans may be done to check the baby’s growth, and early induction may be advised.

If you’ve had gestational diabetes previously, it’s important to ensure that your weight is normal before you become pregnant again.

Amniotic fluid problems
Polyhydramnios

This describes an excess of amniotic fluid. Symptoms include a stretched feeling in the abdomen; breathlessness, heartburn; swelling in the legs; and constipation. This condition is more likely with diabetes; twins; with an infection; or where there is a congenital problem in the baby. Polyhydramnios increases the risk of premature labor and cord prolapse. You will therefore be carefully monitored and advised to rest. In severe cases, the fluid may be drained.

Oligohydramnios

Too little amniotic fluid may be due to a tear in the membranes; placental problems; fetal abnormalities; or problems with the baby’s growth . A reduction of amniotic fluid is most likely toward the end of pregnancy. If a scan confirms that levels are low and there are concerns about the baby’s development, an early delivery may be advised.

Placental insufficiency

Placental insufficiency is the term used when the placenta is not functioning well enough to meet the baby’s needs. The signs of this condition are a reduction in the amount of fluid around the baby, a fall off in the growth of the baby’s abdomen and hence his weight, and abnormalities in an ultrasound.

Causes

Placental insufficiency is more common in women with preeclampsia, those who have an underlying medical problem, and in women who smoke. It also occurs more often in babies with a chromosomal abnormality such as Down syndrome, or a structural congenital abnormality such as a heart defect.

What might be done

Placental insufficiency is usually picked up by the doctor noticing that the baby appears small and referring you for an ultrasound. If the baby isn’t growing well, the doctor will follow you closely and may recommend bed rest for some or the rest of your pregnancy. Treating underlying medical problems, such as high blood pressure or diabetes can help improve your baby’s growth.

Bleeding in late pregnancy

If you experience bleeding, it’s important that you and the baby are assessed immediately. If the bleeding is caused by a problem with the placenta, this can be a serious threat to your baby.

Causes

The most serious causes of late bleeding are placenta previa  and placental abruption. Placenta previa, in which the placenta lies low in the uterus, affects 1 in 200 pregnancies. The bleeding usually starts from 28 weeks; it is painless, usually recurrent, and is sometimes severe.

In placental abruption, which affects 1 in 100 pregnancies, the placenta starts to separate from the uterine lining, leading to severe abdominal pain and bleeding. The bleeding may not be obvious if the blood is trapped between the placenta and uterine wall. Placental abruption is potentially very harmful for your baby because the placenta may not be functioning well.

Bleeding can sometimes be due to cervical erosion, especially after intercourse, or to a cervical polyp. In many cases, no cause is found.

What might be done

If it’s mild bleeding, your doctor may recommend bed rest. If your doctors think you might have abruption, he may send you to the hospital for observation. Depending on how far along you are, you may be given corticosteroids to help the baby’s lungs mature in case an early delivery is necessary. Your doctor may send you home when the bleeding stops. Sometimes, delivering the baby is the safest option. If bleeding is heavy or painful, or the baby is distressed, an emergency cesarean and a blood transfusion may be needed.

Preeclampsia

Preeclampsia (also known as toxemia, or pregnancy-induced hypertension) is a pregnancy-induced condition characterized by high blood pressure, protein in the urine, and edema (swelling). Occasionally women have symptoms such as headaches, flashing lights, abdominal pain, or nausea. If left untreated, it can lead to eclampsia, an extremely serious condition that causes convulsions and coma. If you are diagnosed with preeclampsia, your pregnancy will be watched very closely and a decision will be made as to the best time for delivery. About eight percent of women have problems with high blood pressure in pregnancy.

Causes

Preeclampsia is more common in multiple pregnancies; in very young and older mothers; in women with preexisting high blood pressure or kidney disease; in women who’ve had severe preeclampsia before, necessitating delivery by 32 weeks; and in women who’ve had an egg donation.

What might be done

Although the only cure for preeclampsia is delivery of the baby, the baby may need longer to mature in the uterus. The mother and baby will be closely monitored with the goal of prolonging the pregnancy as long as possible. The mother may be hospitalized or be prescribed drugs to lower blood pressure and will probably be advised to rest as much as possible. Because preeclampsia can affect blood flow to the placenta, regular ultrasound and Doppler scans  will be done to check the baby’s growth and to look for signs of placental insufficiency (Labor complications). If your doctor is worried that your blood pressure is dangerously high despite medication, you’re losing a lot of protein in your urine, or there are anxieties about the baby, immediate delivery will be recommended. This would mean an induction or a cesarean.

Group B Streptococcus

Ten to 30 percent of women carry group B Streptococcus (GBS) in their vagina, which is completely normal, and does not cause any symptoms. However, 1 in 2000 women can pass GBS to their baby once the water is broken, and the baby may develop a severe GBS-related illness.

What might be done

If a woman is known to carry GBS, and if there are risk factors such as prolonged rupture of the membranes, or the baby is premature, intravenous antibiotics may be recommended once the woman is in labor, which usually prevents further problems. Women are generally screened for GBS between weeks 35 and 37. If you carry GBS, you’ll be given IV antibiotics during delivery.

Labor complications

Premature labor

The normal length of pregnancy is 37 to 42 weeks. A baby born before 37 weeks is called premature or preterm.

Fetal distress

During labor, the baby is monitored for signs of distress, which can indicate that the baby’s oxygen supply is reduced. One sign of fetal distress is meconium-stained water (meconium is the baby’s first dark green bowel movement). However, this alone doesn’t always indicate fetal distress, but if it’s combined with a slowing of the baby’s heart rate, fetal distress is more likely and steps may be taken for a prompt delivery. If there is thick meconium in the water, there is a danger that the baby could inhale meconium at birth, which can lead to breathing problems and lung infection.

Failure to progress

Sometimes the cervix fails to dilate as expected during the first stage of labor. There are several factors that can hamper the progress of labor: the baby’s head may be too large for the pelvis; there may be inefficient contractions; or the baby may not be in the right position .

Cord prolapse

Rarely, the umbilical cord lies below the baby. This is more likely in a breech birth, or where the baby lies in a transverse position. In these cases, when the water breaks, the cord can slip through the cervix. This is an emergency because the cord may be compressed and restrict or cut off the baby’s oxygen supply.

What might be done

Unless an immediate assisted vaginal delivery is possible, an emergency cesarean will be done.

Shoulder dystocia

Shoulder dystocia is when the baby’s head is born, but the shoulders remain stuck so the body cannot be born. It’s more common if the baby is big or if the mother has diabetes.

What might be done

If the head is delivered, and there are signs that the rest of the baby is not coming easily, the mother’s legs will be lifted up to help the baby’s shoulders down and an episiotomy may be done . If the baby still doesn’t come easily, there are maneuvers the doctor will do to help release the shoulders and aid the delivery .

Postpartum hemorrhage

This condition is said to occur if a woman loses more than 1 pint (500 ml) of blood within 24 hours of birth. It can be due to the uterus not contracting quickly enough, to incomplete delivery of the placenta, or to vaginal tears. Active management in the delivery of the placenta makes it less likely to happen. Factors that increase the risk include a large baby or twins; prolonged labor; or bleeding before the labor.

What might be done

It’s often possible to control bleeding with drugs to help the uterus contract, or by correcting problems such as retained bits of placenta, or by suturing tears. If bleeding continues, arteries that supply blood to the uterus may be closed off. You may also need a blood transfusion.

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