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ECTOPIC PREGNANCY

An ectopic pregnancy occurs when the fertilized egg attaches itself in a place other than inside the uterus. Almost all ectopic pregnancies occur in a fallopian tube, and are thus sometimes called tubal pregnancies. The fallopian tubes are not designed to hold a growing embryo; the fertilized egg in a tubal pregnancy cannot develop normally and must be treated. An ectopic pregnancy happens in 1 out of 60 pregnancies.
What causes an ectopic pregnancy?


Ectopic pregnancies are caused by one or more of the following:

<LI class=closebullets>An infection or inflammation of the fallopian tube can cause it to become partially or entirely blocked.
<LI class=closebullets>Scar tissue left behind from a previous infection or an operation on the tube may also impede the egg's movement.
<LI class=closebullets>Previous surgery in the pelvic area or on the tubes can cause adhesions.

• An abnormality in the tube's shape can be caused by abnormal growths or a birth defect.
  

Who is at risk for having an ectopic pregnancy?


Women who are more at risk for having an ectopic pregnancy include the following:

<LI class=closebullets>Are 35-44 years of age
<LI class=closebullets>Have had a previous ectopic pregnancy
<LI class=closebullets>Have had pelvic or abdominal surgery
<LI class=closebullets>Have Pelvic Inflammatory Disease (PID)
<LI class=closebullets>Have had several induced abortions

• Women who get pregnant after having a tubal ligation or while an IUD is in place
  

What are the symptoms of an ectopic pregnancy?


Although you may experience typical signs and symptoms of pregnancy, the following symptoms may be used to help recognize a potential ectopic pregnancy:

<LI class=closebullets>Sharp or stabbing pain that may come and go and vary in intensity. The pain may be in the pelvis, abdomen or even the shoulder and neck (due to blood from a ruptured ectopic pregnancy gathering up under the diaphragm).
<LI class=closebullets>Vaginal bleeding, heavier or lighter than your normal period
<LI class=closebullets>Gastrointestinal symptoms

• Weakness, dizziness, or fainting
  

It is important for you to seek emergency care if you are experiencing sharp pain or have bleeding.

How is an ectopic pregnancy diagnosed?


Ectopic pregnancies are diagnosed by your physician, who will probably first perform a pelvic exam to locate pain, tenderness or a mass in the abdomen. Your physician will also use an ultrasound to determine whether the uterus contains a developing fetus.
The measurement of hCG levels is also important. An hCG level that is lower than what would be expected is one reason to suspect an ectopic pregnancy. Low levels of progesterone may also indicate that a pregnancy is abnormal.
Your physician may do a culdocentesis, which is a procedure that involves inserting a needle into the space at the very top of the vagina, behind the uterus and in front of the rectum. The presence of blood in this area may indicate bleeding from a ruptured fallopian tube.
How is an ectopic pregnancy treated?


An ectopic pregnancy may be treated in any of the following ways:

<LI class=closebullets>Methotrexate may be given, which allows the body to absorb the pregnancy tissue and may save the fallopian tube, depending on how far the pregnancy has developed.
<LI class=closebullets>If the tube has become stretched or it has ruptured and started bleeding, all or part of the fallopian tube may have to be removed. Bleeding needs to be stopped promptly, and emergency surgery is needed.

• Laparoscopic surgery under general anesthesia may be performed. This procedure involves a surgeon using a laparoscope to remove the ectopic pregnancy and repair or remove the affected fallopian tube. If the ectopic pregnancy cannot be removed by a laparoscope procedure, then another surgical procedure called a laparotomy may be done.
  

What about my future?


Your hCG level will need to be rechecked on a regular basis until it reaches zero if you did not have your entire fallopian tube removed. An hCG level that remains high could indicate that the ectopic tissue was not entirely removed, which would require surgery or medical management with methotrexate.
The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal, but this will depend on why the pregnancy was ectopic and your medical history. If the fallopian tubes have been left in place, you have approximately a 60% chance of having a successful pregnancy in the future.

Obstetrical hemorrhage

Obstetrical hemorrhage refers to heavy bleeding during pregnancy, labor, or the puerperium. Bleeding may be vaginal and external, or, less commonly but more dangerously, internal, into the abdominal cavity. Typically bleeding is related to the pregnancy itself, but some forms of bleeding are caused by other events. Obstetrical hemorrhage is a major cause of maternal mortality.

(1)Early pregnancy bleeding
The most common bleeding event is the loss of a pregnancy, a miscarriage, medically also called an abortion. Bleeding from an early miscarriages may be similar to that of a heavy menstruation, but later on, a pregnancy loss may be accompanied by excessive or prolonged bleeding. A physician may propose to perform a D&C for treatment. An ectopic pregnancy may lead to bleeding, internally, that could be fatal if untreated.

[2] Late pregnancy bleeding
The primary consideration is the presence of a placenta previa, a condition that usually needs to be resolved by delivering the baby via cesarean section. Also a placental abruption can lead to obstetrical hemorrhage, some times concealed.

[3]Bleeding during labor
Beside placenta previa and placental abruption, uterine rupture can occur as a very serious condition leading to internal or external bleeding. Bleeding from the fetus is rare, usually not heavy, but always very serious for the baby.

[4]After delivery
Hemorrhage after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. It is the most common cause of perinatal maternal death in the developed world and is a major cause of maternal morbidity worldwide.[1]

Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta, and coagulopathy, commonly referred to as the "four Ts":[1]

Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony.
Trauma: trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding.
Tissue: retention of tissue from the placenta or fetus may lead to bleeding.
Thrombin: a bleeding disorder occurs when there a failure of clotting, such as with diseases known as coagulopathies

[5] Unrelated bleeding
Pregnant patients may have bleeding from the reproductive tract due to trauma, including sexual assault, neoplasm, most commonly cervical cancer, and hematologic disorders.

Management
The success of modern obstetrics is based on the ability to recognize risk patients for obstetrical hemorrhage and their appropriate management. Key in this are methods of examination, including obstetric ultrasonography, surgical obstetrics, blood transfusion, and pharmacological support.

In developing countries, deaths from obstetrical hemorrhage are very high. It has been recognized that to reduce morbidity and death, it is necessary to prevent obstetric hemorrhage and reduce the impact of hemorrhage when it does occur through early diagnosis and timely, appropriate management. Three simple technologies have been used to prevent and manage post-partum hemorrhage. These are: use of misoprostol prophylactically immediately after childbirth, which reduces risk of post-partum hemorrhage by 50%,a blood drape that collects and measures blood loss, allowing for early recognition of hemorrhage,and the non-pneumatic anti-shock garment which can be used to stabilize and resuscitate a woman, and keep her alive while she is being transported for further treatment or waiting at a facility for care

Antepartum haemorrhage

In obstetrics, antepartum haemorrhage (APH), also prepartum hemorrhage, is bleeding from the vagina during pregnancy from twenty four weeks gestational age to term.

It should be considered a medical emergency (regardless of whether there is pain) and medical attention should be sought immediately, as if it is left untreated it can lead to death of the mother and/or fetus.

It can be associated with reduced fetal birth weight.

Bleeding without pain is most frequently bloody show, which is benign; however, it may also be placenta previa (in which both the mother and fetus are in danger). Painful APH is most frequently placental abruption (which may also lead to adverse fetal and/or maternal outcomes)

Differential diagnosis of APH
Bloody show (benign) - most common cause of APH
Placental abruption - most common pathological cause
Placenta previa - second most common pathological cause
Vasa previa - often difficult to diagnose, frequently leads to fetal demise
Uterine rupture
Bleeding from the lower genital tract
Cervical bleeding - cervicitis, cervical neoplasm, cervical polyp
Bleeding from the vagina itself - trauma, neoplasm
Bleeding that may be confused with vaginal bleeding
GI bleed - hemorrhoids, inflammatory bowel disease
Urinary tract bleed - urinary tract infection

Pregnancy-Induced Hypertension (PIH)

What is pregnancy-induced hypertension (PIH)?
Pregnancy-induced hypertension (PIH) is a form of high blood pressure in pregnancy. It occurs in about 5 percent to 8 percent of all pregnancies. Another type of high blood pressure is chronic hypertension - high blood pressure that is present before pregnancy begins.

Pregnancy-induced hypertension is also called toxemia or preeclampsia. It occurs most often in young women with a first pregnancy. It is more common in twin pregnancies, in women with chronic hypertension, preexisting diabetes, and in women who had PIH in a previous pregnancy.

Usually, there are three primary characteristics of this condition, including the following:

a)high blood pressure (a blood pressure reading higher than 140/90 mm Hg, or a significant increase in one or both pressures)

b)protein in the urine

c)edema (swelling)

Eclampsia is a severe form of pregnancy-induced hypertension. Women with eclampsia have seizures resulting from the condition. Eclampsia occurs in about one in 1,600 pregnancies and develops near the end of pregnancy, in most cases.

HELLP syndrome is a complication of severe preeclampsia or eclampsia. HELLP syndrome is a group of physical changes including the breakdown of red blood cells, changes in the liver, and low platelets (cells found in the blood that are needed to help the blood to clot in order to control bleeding).

What causes pregnancy-induced hypertension (PIH)?
The cause of PIH is unknown. Some conditions may increase the risk of developing PIH, including the following:

pre-existing hypertension (high blood pressure)
kidney disease
diabetes
PIH with a previous pregnancy
mother's age younger than 20 or older than 40
multiple fetuses (twins, triplets)

Why is pregnancy-induced hypertension a concern?
With high blood pressure, there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta.

There are other problems that may develop as a result of PIH. Placental abruption (premature detachment of the placenta from the uterus) may occur in some pregnancies. PIH can also lead to fetal problems including intrauterine growth restriction (poor fetal growth) and stillbirth.

If untreated, severe PIH may cause dangerous seizures and even death in the mother and fetus. Because of these risks, it may be necessary for the baby to be delivered early, before 37 weeks gestation.

What are the symptoms of pregnancy-induced hypertension?
The following are the most common symptoms of high blood pressure in pregnancy. However, each woman may experience symptoms differently. Symptoms may include:

increased blood pressure
protein in the urine
edema (swelling)
sudden weight gain
visual changes such as blurred or double vision
nausea, vomiting
right-sided upper abdominal pain or pain around the stomach
urinating small amounts
changes in liver or kidney function tests

How is pregnancy-induced hypertension diagnosed?
Diagnosis is often based on the increase in blood pressure levels, but other symptoms may help establish PIH as the diagnosis. Tests for pregnancy-induced hypertension may include the following:

blood pressure measurement
urine testing
assessment of edema
frequent weight measurements
eye examination to check for retinal changes
liver and kidney function tests
blood clotting tests
Treatment for pregnancy-induced hypertension:
Specific treatment for pregnancy-induced hypertension will be determined by your physician based on:

your pregnancy, overall health, and medical history
extent of the disease
your tolerance for specific medications, procedures, or therapies
expectations for the course of the disease
your opinion or preference

The goal of treatment is to prevent the condition from becoming worse and to prevent it from causing other complications. Treatment for pregnancy-induced hypertension (PIH) may include:

A)bedrest (either at home or in the hospital may be recommended)
B)hospitalization (as specialized personnel and equipment may be
necessary)
C)magnesium sulfate (or other antihypertensive medications for PIH)
D)fetal monitoring (to check the health of the fetus when the mother has
PIH) may include:
1)fetal movement counting - keeping track of fetal kicks and movements.
2)A change in the number or frequency may mean the fetus is under
stress.
E)nonstress testing - a test that measures the fetal heart rate in response
to the fetus' movements.
F)biophysical profile - a test that combines nonstress test with ultrasound
to observe the fetus.
G)Doppler flow studies - type of ultrasound that uses sound waves to
measure the flow of blood through a blood vessel.
H)continued laboratory testing of urine and blood (for changes that may
signal worsening of PIH)
I)medications, called corticosteroids, that may help mature the lungs of the
fetus (lung immaturity is a major problem of premature babies)

delivery of the baby (if treatments do not control PIH or if the fetus or mother is in danger). Cesarean delivery may be recommended, in some cases.

Prevention of pregnancy-induced hypertension:
Early identification of women at risk for pregnancy-induced hypertension may help prevent some complications of the disease. Education about the warning symptoms is also important because early recognition may help women receive treatment and prevent worsening of the disease.

Anemia in Pregnancy

Blood is the life-maintaining fluid that circulates through the body's heart, arteries, veins, and capillaries. It carries away waste matter and carbon dioxide, and brings nourishment, electrolytes, hormones, vitamins, antibodies, heat, and oxygen to the tissues.

What is anemia?
Anemia is a condition of too few red blood cells, or a lowered ability of the red blood cells to carry oxygen or iron. Tissue enzymes dependent on iron can affect cell function in nerves and muscles. The fetus is dependent on the mother's blood and anemia can cause poor fetal growth, preterm birth, and low birthweight.

What are the most common types of anemias to occur during pregnancy?
There are several types of anemias that may occur in pregnancy. These include:

anemia of pregnancy
In pregnancy, a woman's blood volume increases by as much as 50 percent. This causes the concentration of red blood cells in her body to become diluted. This is sometimes called anemia of pregnancy and is not considered abnormal unless the levels fall too low.

iron deficiency anemia
During pregnancy, the fetus uses the mother's red blood cells for growth and development, especially in the last three months of pregnancy. If a mother has excess red blood cells stored in her bone marrow before she becomes pregnant, she can use those stores during pregnancy to help meet her baby's needs. Women who do not have adequate iron stores can develop iron deficiency anemia. This is the most common type of anemia in pregnancy. It is the lack of iron in the blood, which is necessary to make hemoglobin - the part of blood that distributes oxygen from the lungs to tissues in the body. Good nutrition before becoming pregnant is important to help build up these stores and prevent iron deficiency anemia.

vitamin B12 deficiency
Vitamin B12 is important in forming red blood cells and in protein synthesis. Women who are vegans (who eat no animal products) are most likely to develop vitamin B12 deficiency. Including animal foods in the diet such as milk, meats, eggs, and poultry can prevent vitamin B12 deficiency. Strict vegans usually need supplemental vitamin B12 by injection during pregnancy.

blood loss
Blood loss at delivery and postpartum (after delivery) can also cause anemia. The average blood loss with a vaginal birth is about 500 milliliters, and about 1,000 milliliters with a cesarean delivery. Adequate iron stores can help a woman replace lost red blood cells.

folate deficiency
Folate, also called folic acid, is a B-vitamin that works with iron to help with cell growth. Folate deficiency in pregnancy is often associated with iron deficiency since both folic acid and iron are found in the same types of foods. Research shows that folic acid may help reduce the risk of having a baby with certain birth defects of the brain and spinal cord if taken before conception and in early pregnancy.

SAMBUNGAN...

What are the symptoms of anemia?
Women with anemia of pregnancy may not have obvious symptoms unless the cell counts are very low. The following are the most common symptoms of anemia. However, each woman may experience symptoms differently. Symptoms may include:
1.pale skin, lips, nails, palms of hands, or underside of the eyelids
2.fatigue
3.vertigo or dizziness
4.labored breathing
5.rapid heartbeat (tachycardia)

The symptoms of anemia may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is anemia diagnosed?
Anemia is usually discovered during a prenatal examination through a routine blood test for hemoglobin or hematocrit levels. Diagnostic procedures for anemia may include additional blood tests and other evaluation procedures.
a]hemoglobin - the part of blood that distributes oxygen from the lungs to
tissues in the body.
b]hematocrit - the measurement of the percentage of red blood cells found
in a specific volume of blood.

Treatment for anemia:
Specific treatment for anemia will be determined by your physician based on:
1]your pregnancy, overall health, and medical history
2]extent of the disease
3]your tolerance for specific medications, procedures, or therapies
4]expectations for the course of the disease
5]your opinion or preference

Treatment depends on the type and severity of anemia. Treatment for iron deficiency anemia includes iron supplements. Some forms are time-released, while others must be taken several times each day. Taking iron with a citrus juice can help with the absorption into the body. Antacids may decrease absorption of iron. Iron supplements may cause nausea and cause stools to become dark greenish or black in color. Constipation may also occur with iron supplements.

Prevention of anemia:
Good pre-pregnancy nutrition not only helps prevent anemia, but also helps build other nutritional stores in the mother's body. Eating a healthy and balanced diet during pregnancy helps maintain the levels of iron and other important nutrients needed for the health of the mother and growing baby.

Good food sources of iron include the following:

meats - beef,lamb, liver, and other organ meats
poultry - chicken, duck, turkey, liver (especially dark meat)
fish - shellfish, including clams, mussels, oysters, sardines, and anchovies
leafy greens of the cabbage family, such as broccoli, kale, turnip greens, and collards
legumes, such as lima beans and green peas; dry beans and peas, such as pinto beans, black-eyed peas, and canned baked beans
yeast-leavened whole-wheat bread and rolls
iron-enriched white bread, pasta, rice, and cereals