Tag Archive: pregnancy


Baby thrown out from 3rd.Floor

Tuesday September 18, 2012

Baby was alive when thrown

Whisked away: The woman covering her face as she’s led from the Petaling Jaya magistrate’s court.

PETALING JAYA: The newborn baby girl was still alive when she was flung out from one of the upper floors of the Desa Mentari flats on Malaysia Day.

Petaling Jaya OCPD Asst Comm Arjunaidi Mohamed said post-mortem results revealed that the baby died of severe head injuries. “A 20-year-old woman has been remanded for seven days to facilitate investigations,” he said, adding that police had classified the case as murder under Section 302 of the Penal Code.

“Initial investigations reveal that the woman is not married and gave birth on her own while alone at home on Sunday,” he said, adding that she was involved in a relationship.

A resident of the flats, S. Chandran, 37, who came out to inspect the baby girl’s remains, said her umbilical cord was still intact and there was blood on the body.

“When I took a closer look, she looked like a cute girl,” he said, adding that the side of the baby’s head was crushed from the fall.

Chandran, who has been living there since 2003, said a mentally-disabled boy had also fallen to his death at the same flats several years ago.

Based on witness accounts, police searched several floors of the flats and arrested the 20-year-old woman on the third floor.

It is learnt that the woman’s family told the police they were unaware that she was pregnant.

Medication Bad for foetus

Medication consumed by an expectant mother can be passed on to the foetus.

EVERYONE gets ill at some time or other. Sometimes, the condition is self-limiting and requires no medicine. At other times, medicine is required.

The pregnant woman’s circulation is intricately linked to that of the developing foetus’, through the placenta. Just like how the necessary nutrients for foetal development cross the placenta and get into the foetal circulation, medicine consumed by the pregnant woman will be passed on to the foetus.

The effect of a medicine on the developing foetus depends on the medicine itself and the stage of pregnancy. In general, most pregnant women are aware of the need to avoid taking non-essential medicine. Yet they are not spared from illnesses and minor ailments.

Pregnancy is divided into three trimesters lasting about 13.3 weeks each. Foetal development is at its maximum in the first trimester. Medicine taken during this time can lead to foetal malformations or birth defects. If the defect is substantial, it would result in a miscarriage.

The foetus grows during the second and third trimesters with the development of the foetal nervous system in the first trimester continuing into the second. Medicine taken during the second trimester can affect the foetal nervous system and foetal growth. The latter could lead to low birth weight.

Medicine taken in the last trimester can remain in the newborn’s body. The baby may not be able to deal with medicine in the same manner the mother can. This can lead to complications like breathing difficulties in the newborn.

Medicine taken by a pregnant woman can also affect the environment in her uterus. For example, some medicines lead to uterine contractions which can affect the blood supply to the developing foetus.

The maximal impact of medicine is often in the first trimester. Some are risky if taken in the first trimester but may be safe in the second or third trimesters. Others are safe in the first trimester but risky in the second or third trimesters. In general, the risks are least in the second trimester.

Safety

Before a prescription medicine is marketed, it is first tested in animals, including pregnant animals, to detect any problems. Then it is given to humans in clinical trials to check its effectiveness and efficacy for various conditions, and to identify any side effects.

Although tests of medicines in animals can identify potential problems, they do not always predict its effects on humans.

As a general rule, pharmaceutical companies do not carry out clinical trials in pregnant women because it is unethical to do so. This results in few medicines being licensed for use in pregnant women.

Once a medicine is marketed, its effect in pregnancy is monitored in various ways:

· Adverse event reports – Pharmaceutical companies, doctors and researchers are required to report any adverse events to regulatory bodies, such as the Drug Control Authority in Malaysia.

· Pregnancy registries – Some pharmaceutical companies conduct special studies called pregnancy registries. Pregnant women who have taken certain medication are recruited and their babies are compared after birth to the babies of women who did not take the medicine.

· Research that identify risk factors for birth defects and problems with medicine in pregnancy.

Information about the safety of medicine in pregnancy is usually obtained from practical experience. When a medicine has been used extensively for several years without reports of adverse effects on pregnancies, it can be concluded that it is not harmful. Information is also available from the accidental consumption of medicine by pregnant women and animal studies. Some of the former may not know they are pregnant. It is in this manner that some prescription and over-the-counter medicines are known to be safe and others, harmful.

However, there is still insufficient information about the safety of many medicine in pregnancy. When medicine is taken during pregnancy, the benefits and risks have to be considered. If the benefits to the pregnant woman are greater than the risks to the foetus, then the medicine may be consumed. If the risks to the foetus are substantial, alternative treatments have to be considered.

Sometimes, a pregnant woman has to take medicine to reduce the likelihood of harm to herself and/or the foetus. The conditions include high blood pressure (hypertension), diabetes mellitus, fits (epilepsy), asthma, blood clots in the veins or lungs (thromboembolism) and certain infections. When treating these conditions, the doctor will prescribe medicine that is the most appropriate and safe for the pregnant woman.

Dietary supplements and herbal products

Many dietary supplements and herbal products are produced from natural compounds. This has led many people to believe that they are harmless and safer than prescribed medicines, especially with the marketing strategies of some companies.

It must be remembered that the regulatory requirements for dietary supplements and herbal products, if any, are considerably less stringent than that of prescribed medicines. Furthermore, most of these products have not been subjected to animal studies or human clinical trials. As such, any woman who is pregnant or intends to get pregnant is advised to consult the doctor before taking such products.

Folic acid is the only medicine available over the counter that is important to take, prior to and during pregnancy. It is used by the body to make new cells. If a woman has sufficient folic acid in the body before she gets pregnant, some major defects of the foetal brain and spine called neural tube defects (NTD) can be prevented. A dose of 400 microgram should be taken daily by every woman intending to get pregnant and for the first trimester. If a woman or her spouse has spina bifida or a previous child was born with NTD, a higher daily dose of 5mg is recommended.

Minor ailments

The only way to minimise risks to the foetus is to avoid consuming all non-essential medicine, particularly in the first trimester. Consult the doctor or pharmacist before consuming any medicine, including dietary supplements and herbal products, during pregnancy.

This does not mean that pregnant women have to put up with minor pregnancy ailments. There are medicines that are safe to use in pregnancy. They will be discussed in the next article.

There are a number of essentials to remember for pregnant women:

  • In general, avoid all non-essential medicine.
  • Consult the doctor or pharmacist before consuming any medicine.
  • Some medicine sold over the counter are harmful to the foetus.
  • Dietary supplements and herbal products are not necessarily safe. Consult the doctor or pharmacist before consuming any.
  • Contact the doctor or pharmacist immediately if there are any unusual effects experienced after consumption of a medicine.

Source: Dr Milton Lum

Diabetes and pregnancy

Pregnant diabetics have to be vigilant as failure to control their blood glucose can lead to miscarriages and stillbirths.

DIABETES mellitus is a condition in which the blood glucose is too high (hyperglycaemia). It is due to insufficient insulin being produced or the cells in the body being unable to use insulin the way they should. Without insulin, the blood glucose that cannot get into the body’s cells accumulates in the bloodstream.

Diabetic pregnancies had invariably resulted in miscarriages or stillbirths until about three decades ago. Many diabetics get pregnant today. Although there are potential complications, a healthy baby will result, provided there is good control of the blood glucose. This can be achieved by close partnership between the patient with her obstetrician and her physician or endocrinologist.

Metabolic changes during pregnancy

There are many changes in the body during pregnancy. The placenta produces hormones essential to foetal development and they increase in the second and third trimester. They also prevent insulin from functioning the way it is supposed to (insulin resistance). Thus, the demand for increased insulin with feeding escalates progressively during pregnancy. The body has to produce about three times the normal amount of insulin to overcome the effects of the placental hormones.

The kidneys of some pregnant women may handle glucose differently from those of non-pregnant women. Glucose is excreted in the urine although the blood glucose is normal or in the absence of hyperglycaemia.

This is unrelated to diabetes, self-limiting and does not require treatment. This means that urine glucose is not a reliable method of diagnosing and monitoring diabetes.

In most women, the body produces extra insulin to maintain the blood glucose in the normal range. However, in about 5% of women, the extra insulin produced is insufficient, leading to hyperglycaemia by the 20th to 24th week of pregnancy. After delivery, the body uses insulin more effectively and the blood glucose returns to the normal range.

This condition only occurs during pregnancy and is called gestational diabetes (GDM). The risk factors for GDM include maternal age, obesity, obstetric history of diabetes or large babies and strong family of diabetes.

Good control of blood glucose is essential to maternal and foetal well-being. Poor control increases the risk of high blood pressure and the worsening of pre-existing diabetic complications like eye and kidney problems.

Poor control in the first trimester, when the foetal organs are being formed, increases the risk of birth deformities and miscarriage. Diabetic ketoacidosis, a complication due to poor control, can also lead to miscarriage. Gestational diabetics do not usually have these problems because the condition develops after the first trimester.

Poor control later in pregnancy increases the risk of foetal death and/or increased foetal growth with birth weights above 4kg (macrosomia), the incidence of which is thrice that of those with blood glucose within the normal range. Macrosomia increases complications during labour and delivery, the likelihood of instrumental vaginal delivery and caesarean section, and birth injury.

Although most diabetics have increased foetal growth, those who have vascular disease (eye or kidney complications) or high blood pressure are at increased risk of restricted foetal growth. The baby may have a low blood glucose (hypoglycaemia) at birth, which is life threatening and can affect the baby’s mental development.

The baby is more prone to jaundice and low blood calcium and magnesium. If untreated, the former leads to brain damage and the latter to spasms in the hands and feet, or twitching muscles. The diabetic foetal lungs mature later than the non-diabetic, leading to an increased risk of respiratory distress.

It is generally accepted that babies born to diabetics have twice the risk of birth injury, thrice the likelihood of caesarean section and four times the incidence of admission to the neonatal intensive care unit. The risk in individual cases is related to the degree of maternal hyperglycaemia.

Effects of pregnancy on diabetes

The body’s changes during pregnancy make control of blood glucose more difficult. During the first trimester, the insulin requirement may decrease slightly and can lead to hypoglycaemia which can affect brain function. Nausea and vomiting during this time affects carbohydrate absorption in the gut, thereby impacting on insulin dosing. Pre-existing diabetic complications may worsen during pregnancy.

Insulin requirements increase gradually between 16 to 20 weeks of pregnancy and then markedly. This is due to the placental hormones which are important for foetal growth but concomitantly, blocks the effects of insulin. The insulin requirements will be less during labour as the body is working using glucose for its energy requirements. After birth, the body’s insulin requirements decreases but it will take weeks or months before the body’s changes are complete.

Regular check-ups: A doctor examining a pregnant woman at a hospital in Kathmandu. Certain hormones that increase during pregnancy can prevent insulin from functioning the way it is supposed to.

Diagnosis

A routine urine screen for glucose is carried out at every antenatal visit to enable the doctor to decide who needs further investigation. Gestational diabetes (GDM) is diagnosed by an oral glucose tolerance test (GTT). After an overnight fast, the patient is given a dose of oral glucose and the blood and urine checked for glucose at regular intervals.

Type 1 (insulin dependent) diabetes is usually diagnosed when there is an episode of hyperglycaemia, ketosis and coma occurring usually during childhood, adolescence or young adulthood before pregnancy. Type 1 diabetes is rarely diagnosed during pregnancy when it is usually accompanied by unexplained coma due to unstable diet and glucose control in early pregnancy.

The diagnosis of type 2 diabetes may be problematic as severe GDM may have similar characteristics. A HbA1C of 8% or more in the first trimester is highly suggestive. A definitive diagnosis can be made after delivery with a GTT.

Management

Pre-pregnancy assessment and treatment is advisable for all diabetics and those with a history of gestational diabetes in a previous pregnancy.

The diabetes management plan during pregnancy includes: knowing and keeping the blood glucose level under control; healthy diet; regular, moderate physical activity; maintaining a healthy weight gain; taking medications as prescribed; keeping records as advised by the doctor; and keeping appointments with the doctor as advised.

The widespread availability of glucometers has revolutionised diabetic management. Recording blood glucose levels before and after meals improves glycaemic control.

The frequency and timing of blood glucose measurements are individualised by the doctor. A healthy diet comprises a balance of foods from all food groups providing the nutrients, vitamins and minerals necessary for a healthy pregnancy.

Moderate physical activity is not the same as daily routine activity. Listen to your body. It will tell how much activity is sufficient. Stop when you feel tired. If you feel dizzy or faint, stop immediately. It is important to maintain a healthy weight gain, which means overall weight gain and weekly rate of weight gain.

Insulin therapy in pregnant diabetics helps to achieve blood glucose profiles similar to that of pregnant non-diabetics. It is usually given by subcutaneous injection. The insulin regimens require combinations and timing of injections that are different from that in the non-pregnant state.

The doctor will advise on the adjustments to the insulin dosages. Because the insulin requirements change as pregnancy advances, the insulin injections will have to be continually modified. This requires meticulous attention to detail by both patient and doctor.

Insulin therapy is helpful in treating some gestational diabetics to achieve a positive outcome. The obstetric management includes: monitoring foetal growth and wellbeing; preventing maternal complications; preventing stillbirth and asphyxia; and minimising maternal and foetal morbidity at delivery.

The timing of delivery is important as the objectives are to prevent stillbirth and asphyxia and to minimise morbidity to mother and baby. Delivery that is as near to the expected date of delivery increases the likelihood of spontaneous labour and vaginal delivery. However, the risks of increasing foetal macrosomia, birth injury and stillbirth increase as one approaches the expected date of delivery.

The obstetrician considers several factors when deciding on the timing and mode of delivery. They include blood glucose control, maternal complications, foetal macrosomia and foetal biophysical profile.

The patient’s preference is also considered but in this situation, lesser weightage is placed on it when compared to other factors. It would be prudent to adhere to medical advice.

Despite the challenges, good blood glucose control leads to a satisfactory outcome for both mother and baby.

Source: Dr Milton Lum

Bleeding in late pregnancy

Any bleeding in late pregnancy should never be ignored.

IF you bleed during the late stages of your pregnancy, consult the hospital doctor without any delay. Continuous bleeding might endanger the life of both mother and foetus.

The causes of bleeding in late pregnancy include:

●Cervical erosion (ectropion) is the commonest cause in the second half of pregnancy. Sometimes, it may follow sexual intercourse.

●Abruptio placentae, a condition in which there is premature separation of the placenta from its attachment to the uterine cavity,

●Placenta praevia in which the placenta is attached too low in the uterus and covers all or part of the cervix. If it covers the entire cervix, it is called major placenta praevia. A low-lying placenta may be suspected during a routine scan at 18 to 20 weeks. The majority of women with this diagnosis will not develop placenta praevia. Only about 10% of these women will develop placenta praevia later in pregnancy.

●Placenta accreta, a rare condition in which the placenta is markedly adherent to the uterine wall, leading to difficulty in separation of the placenta from the uterine wall after the baby is born.

Risk factors

Note that it is not uncommon for many women to have bloody mucus just before labour starts. The factors that increase the risk of abruptio placenta include smoking, cocaine abuse, abdominal trauma, pre-eclampsia/hypertension, prolonged rupture of membranes (24 hours or more), previous placental abruption and low socio-economic status.

Placenta praevia accreta is more common in women with placenta praevia who have had a previous Caesarean section.

The clinical features of abruption include vaginal bleeding, contractions, abdominal pain and tenderness, and decreased foetal movements. Vaginal bleeding occurs in about 80% of abruptio placentae. The bleeding is concealed in the other 20%. Painful uterine contractions are associated with the abruption. The uterine tone is increased and there may be little or no break in uterine activity between contractions. Decreased foetal movements may be due to foetal jeopardy and impending death.

The classical clinical feature of placenta praevia is painless vaginal bleeding. There may or may not be uterine contractions and decreased foetal movements. When there is vaginal bleeding in late pregnancy, a diagnosis will have to be made and an assessment made of the patient’s physical and the foetus’ conditions.

The foetus may lie in a position with its buttocks first (breech) or across the uterus (transverse lie) when there is placenta praevia or the expected date of delivery is far away in abruptio placentae.

Pelvic ultrasound enables a rapid diagnosis of placenta praevia. However, it is not a sensitive tool for diagnosing abruptio placentae. A significant abruption will show as a clot between the placenta and uterine cavity wall in the ultrasound image but not all abruptions are ultrasonically detectable.

Management

Hospitalisation will be necessary in abruptio placentae. It will be usually advised after 34 weeks in major placenta praevia or when placenta praevia accreta is suspected even if there are no symptoms. The reason is that bleeding may occur suddenly and/or severely, necessitating urgent attention.

A patient can stay at home if there is placenta praevia and no bleeding. However, one should know what to do in an emergency and have ready access to a hospital. It is advisable to abstain from sexual intercourse as it may precipitate bleeding. A discussion with the obstetrician about what to do and what not to do will be essential.

The management is influenced by several factors including maternal age, previous obstetric history, other pregnancy problems like pre-eclamptic toxaemia, diabetes, foetal and maternal condition, duration of pregnancy and the presence of any complications.

Apart from diagnosis and assessment of mother and foetus, blood will be taken for cross matching and an intravenous line established. If there is a need, intravenous fluids and/or blood or blood products will be given. Any clotting disorder will be corrected. If the mother has had an abruption and is of rhesus negative blood group, Rh immune globulin will be given.

In patients with abruptio placentae and certain types of minor placenta praevia and whose foetuses are at or near maturity, the obstetrician will do a vaginal examination and then break the waterbag (amniotic sac) surrounding the foetus and induce labour. The ability to undergo vaginal delivery is dependent on the patient’s haemodynamic stability. Labour is usually rapid in such patients.

Caesarean section is carried out whenever there is maternal or foetal distress or major placenta praevia. The patient’s coagulation status may complicate the operation. The vertical incision is often used if the patient appears to have clotting disorders or there is severe foetal distress. The reasons are less blood loss in the case of the former and the facilitation of a rapid delivery in the case of the latter. The transverse incision is made on the uterus on most occasions but the vertical, classical incision may be necessary if the foetus is pre-term.

The complications of Caesarean section include infection, bleeding, need for transfusion of blood and/or blood products, injury to adjacent organs, and/or hysterectomy for uncontrollable bleeding as well as anaesthetic complications.

If there is severe bleeding, administration of medicines to make the uterus contract, ligation of the uterine artery, packing of the uterus or insertion of special sutures will be carried. If the bleeding is still uncontrollable, a hysterectomy may have to be carried out to save life.

The patient who has a severe abruptio placentae or major placenta praevia or who has developed complications may have to be nursed in the intensive care unit. Hospital stay may be longer in such situations.

In patients with placenta praevia, whose pregnancies are not near maturity, conservative treatment will be carried out provided there is no maternal and foetal compromise. The objective is to get the pregnancy to as near maturity as possible. Medicines to prevent pre-term labour (tocolytics) and corticosteroids to accelerate foetal lung maturity may be prescribed.

The use of tocolytics in abruptio placentae is controversial. It may be prescribed in those who are haemodynamically stable, there is no foetal compromise and when corticosteroids are prescribed. Tocolytic use is cautious as maternal or foetal distress can develop quickly. The cardiovascular side effects of tocolytics may mask the signs of significant blood loss.

Bleeding in late pregnancy should not be ignored as it is potentially life threatening for mother and foetus. When it happens, one should proceed to the hospital without delay.

Source: Dr Milton Lum

Ectopic pregnancies

Early detection and treatment of ectopic pregnancies will produce better outcomes.

Ectopic pregnancy is a condition in which the fertilised egg (embryo) is implanted outside the uterine cavity. Its occurrence varies in different countries but it is estimated to occur in about one in 100 pregnancies.

Unseen: About 50% of ectopic pregnancies do not exhibit any specific symptoms.

About 95% of ectopic pregnancies occur in the fallopian tubes. It can also occur in other sites like the ovary, cervix or abdominal cavity.

An ectopic pregnancy is life-threatening as it can rupture, causing bleeding into the abdominal cavity. The earlier an ectopic pregnancy is treated, the better the outcome. Delay will lead to further damage to the fallopian tubes or other sites and if left untreated, the blood loss can result in death.

Risk factors

When an egg is released by the ovary, it travels along the fallopian tube where it is fertilised by the sperm. The lining of the fallopian tubes contain hair-like structures, called cilia, which push the embryo along into the uterine cavity where it gets embedded. If there is damage to the fallopian tubes, the cilia may be unable to perform its function, resulting in the embryo embedding in the fallopian tube itself.

These factors increase the likelihood of ectopic pregnancy:

Pelvic inflammatory disease (PID) in which the ovaries, fallopian tubes and uterus have been or are infected.
Intra-uterine contraceptive device especially when it is associated with PID.
Previous surgery on the fallopian tubes like sterilisation, its reversal or other surgery.
Previous abdominal surgery like caesarean section and fibroid removal (myomectomy).
In-vitro fertilisation (IVF). Although the embryo is placed inside the uterine cavity, it may still attach itself to the fallopian tube.
Previous ectopic pregnancy. The risk of an ectopic pregnancy increases from 1% to 10% after an ectopic pregnancy has occurred.

The risk in women aged 44 years or more is increased from 1% to 8%.

It should be noted that these risk factors are not present in many women who have an ectopic pregnancy.

Diagnosis

About 50% of women with an ectopic pregnancy have no specific symptoms apart from those associated with pregnancies such as missed period, nausea and sore breasts.

The symptoms include:
Vaginal bleeding that differs from that of the normal period in that it is lighter or darker.
Abdominal pain which is usually on one side. The pain may be severe and persistent.
Shoulder tip pain which is due to the blood in the abdominal cavity irritating the diaphragm, which has the same nerve supply as the shoulders.
Pain on passing motion or urine.

The diagnosis is made by clinical examination in most instances. A transvaginal ultrasound is helpful in diagnosis. This involves inserting the ultrasound probe into the vagina to visualise the uterus and its surroundings.

Sometimes, the diagnosis is made at laparoscopy, which is an operative procedure that involves direct visualisation of the pelvic organs through small incisions in the abdomen. This procedure is useful especially when there are no specific symptoms. After making the diagnosis at laparoscopy, a decision will be made on the mode of management.

Management

The management is influenced considerably by whether the diagnosis is made before the ectopic pregnancy has ruptured or not. The gynaecologist will discuss the various treatment options with the patient.

Surgery to remove the embryo from the abdominal cavity is the most common treatment. If there is no indication of shock, the laparoscopy approach is usually preferred. If there are changes indicating shock, a laparotomy is preferred, in which the larger incision will facilitate an expeditious stopping of the bleeding.

The part of the fallopian tube in which the embryo is located (salpingectomy) is removed or the embryo is removed through an opening in the tube (salpingotomy). If the other tube appears normal, there is no evidence that a salpingotomy is preferable to a salpingectomy. If the other tube appears diseased and there is a desire for future fertility, a salpingotomy is preferred, as a salpingectomy would mean that IVF or other assisted reproduction would be required for the next pregnancy.

Medical treatment can be provided if the ectopic pregnancy is diagnosed early. Methotrexate may be prescribed to stop the pregnancy from continuing. The women who are most suited for methotrexate treatment are those with minimal or no symptoms and a serum human chorionic gonadotrophin (hCG) below 3,000 IU/l.

The side effects of methotrexate include nausea, vomiting, sore mouth and sore eyes. About 75% of those given methotrexate will experience abdominal pain which may be difficult to differentiate from that of tubal rupture.

Expectant treatment (“Wait and see”) refers to situations where there are minimal symptoms and the pregnancy’s location is unknown.

This situation occurs when the hCG is less than 1,000 IU/l and no pregnancy, whether inside or outside the uterine cavity, is visible on transvaginal ultrasound.

Up to 60% of such pregnancies resolve spontaneously without any treatment. Regular examinations and blood tests are mandatory with expectant management, until the hCG levels are below 20 IU/l.

Surgery will have to be resorted to at any time during medical or expectant treatment should the clinical situation warrants it. Anti-D immunoglobulin will be given to all rhesus negative women with suspected or confirmed ectopic pregnancy.

Prevention

Ectopic pregnancies cannot be prevented. However, one of its major risk factors, pelvic inflammatory disease (PID), can be prevented. The primary cause of PID is sexually transmitted infections (STI), which is preventable. Regular use of the condom can prevent STIs. Knowing one’s sexual partner and having one sexual partner can also prevent STIs. Regular sexual health checks are helpful particularly if one suspects one’s sexual partner has STI and/or PID.

Source: Dr Milton Lum

The majority of women who miscarry have a successful pregnancy subsequently.

MISCARRIAGE is the loss of an embryo or a foetus before 24 weeks of pregnancy. Many miscarriages occur before a missed period or before the pregnancy is confirmed.

The likelihood of a miscarriage in the first three months of pregnancy is about one in four to five confirmed pregnancies. Most miscarriages are sporadic events.

There is much that is not known about the causes of miscarriages, partly because it is not investigated until there are recurrent miscarriages. The majority of early miscarriages is believed to be due to chromosome problems – either a lack of or too many.

There are several factors that increase the risks of miscarriage: age (the risk of miscarriage at age 30 years is one in five and at age 42, one in two); uterine abnormalities; infections; medical problems, likely poorly controlled diabetes; smoking; and excessive alcohol consumption. There is no evidence to show that stress, sex, exercise or lack of rest increases the risk of miscarriage.

A miscarriage may be complete or incomplete. In the former, bleeding usually stops after seven to 10 days. In the former, bleeding continues and there may be an infection.

When a pregnancy is lost, the patient, her spouse and family can be affected. Some may experience symptoms like poor appetite, difficulty concentrating and difficulty sleeping. Some do not feel it initially but experience symptoms later. The spouses may also experience similar symptoms.

Some pregnant women do not have any symptoms. The miscarriage is discovered on routine antenatal ultrasound examination. This type of miscarriage is called a missed miscarriage. The most common symptom of a miscarriage is vaginal bleeding, which varies from spotting to the passing of clots. Whenever there is bleeding in pregnancy, medical attention should be sought. If it is heavy, there should be no delay in consulting a doctor.

Vaginal bleeding during pregnancy may be due to a threatened miscarriage. It must be remembered that many women have a successful pregnancy after a threatened miscarriage. Another common symptom is lower abdominal pain or backache, just like period pains. There may also be abdominal pain if there is infection, with or without fever and increased heart rate.

When a miscarriage has started, it cannot be stopped. An ultrasound will confirm that the pregnancy is ongoing or a miscarriage has occurred.

Medical attention should be sought if there is: concern about the amount of bleeding; pain that cannot be relieved by medicine; a smelly vaginal discharge; shivering; flu-like symptoms; fainting; and pain in the shoulders.

Management

If the miscarriage is complete, no treatment is required. If the miscarriage is incomplete, the doctor will discuss treatment methods:

· Expectant management – This means doing nothing, that is, letting nature take its course. It is successful in 50 of 100 cases. It can take some time before there is bleeding, which may continue for up to three weeks. There may be abdominal cramps.

· Medical treatment – Tablets or vaginal pessaries may be prescribed to get the entrance of the uterus (cervix) to open up and allow the passage of the products of conception. This usually takes a few hours. There may be some abdominal cramps and bleeding or even passing of clots. The bleeding may last up to three weeks. The treatment is successful in 85 of 100 cases.

· Surgical treatment – This is advised when the bleeding is heavy and does not stop and/or there is infection. The operation, called an evacuation (emptying) of the uterus (using a suction device), is carried out under general or local anaesthesia. It is successful in more than 95 out of 100 cases. Complications are uncommon. They include heavy bleeding, infection and rarely uterine perforation, which will need repair.

Fertility is usually restored in the first month after a miscarriage. The best time to try again for another pregnancy is when you and your spouse are ready.

If another pregnancy is being planned, it is advisable to take 400mg of folic acid daily when you first start trying until 12 weeks of pregnancy, as this reduces the risk of neural tube defect (spina bifida) in the foetus.

Recurrent miscarriage

When miscarriages occur three or more times in succession, it is called recurrent miscarriage. It occurs in about one in 100 women. There is a cause for the condition in some women but in many others, the causes cannot be confirmed.

More research is needed to elucidate the risk factors of recurrent miscarriages which include age and previous pregnancies, genetic factors, autoimmune factors, uterine abnormalities, cervical incompetence, infections, as well as diabetes and thyroid disorders.

The management of recurrent miscarriage is challenging for obstetrician and patient. The various methods include:

· Supportive antenatal care – Women who have supportive care from early pregnancy have a better chance of a successful birth. There is evidence that attendance at an early pregnancy clinic can reduce the risk of further miscarriages.

· Screening for genetic problems – A test for chromosome abnormalities, called karyotyping, may be carried out. If either you or your spouse has an abnormality, a referral will be made to a clinical geneticist, for genetic counselling.

· Screening for uterine abnormalities – This is done with pelvic ultrasound and if found, treatment will be considered.

Hysterosalpingography, which is an x-ray of the fallopian tubes and the uterine cavity with fluid injected through the cervix, is used in some hospitals. It has no advantages over ultrasound and may cause some discomfort.

· Screening for foetal abnormalities – If there is a miscarriage or stillbirth in the next pregnancy after a recurrent miscarriage, the embryo and placenta may be examined for abnormalities by karyotyping and microscopic examination. These tests may help the doctors in formulating possible choices and treatment.

· Screening for infection – If there is a history of miscarriages in the fourth to sixth month of pregnancy or pre-term labour, tests for bacterial vaginosis will be carried out and treatment instituted, if necessary.

· Treatment for aPL antibodies – There is evidence that if there are aPL antibodies and a history of recurrent miscarriages, low-dose aspirin and low-dose heparin in early pregnancy may improve the chances of a live birth up to about seven in 10, compared to about four in 10 if only aspirin is taken and one in 10 without treatment.

· Tests and treatment for cervical incom­petence – If there is cervical incompetence, a vaginal ultrasound scan in pregnancy may provide an indication about the likelihood of miscarriage. An operation to insert a stitch in the cervix is made after the third month of pregnancy, to ensure it stays closed, may be carried out. This is usually done through the vagina.

Although the risk of giving birth early is decreased slightly, it has not been proven to improve the chan­ces of the baby’s survival. The risks and benefits will be discussed with you.

· Hormone treatment – Progesterone or human chorionic gonadotrophin hormones have been prescribed in early pregnancy to prevent miscarriage. There is, however, insufficient evidence that it works.

It will not be possible to say for sure what will happen if there is another pregnancy in a person who has recurrent mis­­carriage. Even if a reason for the miscarriages cannot be found, the likelihood of a healthy birth is still three out of four.

Source: Dr Milton Lum

Fetal development begins before you even know you’re pregnant. Here’s a weekly calendar of events for the first trimester of pregnancy.

You’re pregnant. Congratulations! You’ll undoubtedly spend the months ahead wondering how your baby is growing and developing. What does your baby look like? How big is he or she? When will you hear the heartbeat?

Fetal development typically follows a predictable course. To help answer some of these questions, check out this weekly calendar of events for your baby’s first three months in the womb.

Week 1: Getting ready

It may seem strange, but you’re not actually pregnant the first week or two of the time allotted to your pregnancy. Yes, you read that correctly!

Conception typically occurs about two weeks after your period begins. To calculate your due date, your health care provider will count ahead 40 weeks from the start of your last period. This means your period is counted as part of your pregnancy — even though you weren’t pregnant at the time.

Week 2: Fertilization

The sperm and egg unite in one of your fallopian tubes to form a one-celled entity called a zygote. If more than one egg is released and fertilized, you may have multiple zygotes.

The zygote has 46 chromosomes — 23 from you and 23 from your partner. These chromosomes contain genetic material that will determine your baby’s sex and traits such as eye color, hair color, height, facial features and — at least to some extent — intelligence and personality.

Soon after fertilization, the zygote travels down the fallopian tube toward the uterus. At the same time, it will begin dividing rapidly to form a cluster of cells resembling a tiny raspberry. The inner group of cells will become the embryo. The outer group of cells will become the membranes that nourish and protect it.

Week 3: Implantation

The zygote — by this time made up of about 500 cells — is now known as a blastocyst. When it reaches your uterus, the blastocyst will burrow into the uterine wall for nourishment. The placenta, which will nourish your baby throughout the pregnancy, also begins to form.

By the end of this week, you may be celebrating a positive pregnancy test.

Week 4: The embryonic period begins

The fourth week marks the beginning of the embryonic period, when the baby’s brain, spinal cord, heart and other organs begin to form. Your baby is now 1/25 of an inch long.

The embryo is now made of three layers. The top layer — the ectoderm — will give rise to a groove along the midline of your baby’s body. This will become the neural tube, where your baby’s brain, spinal cord, spinal nerves and backbone will develop.

Your baby’s heart and a primitive circulatory system will form in the middle layer of cells — the mesoderm. This layer of cells will also serve as the foundation for your baby’s bones, muscles, kidneys and much of the reproductive system.

The inner layer of cells — the endoderm — will become a simple tube lined with mucous membranes. Your baby’s lungs, intestines and bladder will develop here.

Week 5: Baby’s heart begins to beat

Your baby at week five (three weeks after conception)

Your baby at week five (three weeks after conception)

week five, your baby is 1/17 of an inch long — about the size of the tip of a pen.

This week, your baby’s heart and circulatory system are taking shape. Your baby’s blood vessels will complete a circuit, and his or her heart will begin to beat. Although you won’t be able to hear it yet, the motion of your baby’s beating heart may be detected with an ultrasound exam.

With these changes, blood circulation begins — making the circulatory system the first functioning organ system.

Week 6: The neural tube closes

Your baby at week six (four weeks after conception)

Your baby at week six (four weeks after conception)

Growth is rapid this week. Just four weeks after conception, your baby is about 1/8 of an inch long. The neural tube along your baby’s back is now closed, and your baby’s heart is beating with a regular rhythm.

Basic facial features will begin to appear, including an opening for the mouth and passageways that will make up the inner ear. The digestive and respiratory systems begin to form as well.

Small blocks of tissue that will form your baby’s connective tissue, ribs and muscles are developing along your baby’s midline. Small buds will soon grow into arms and legs.

Week 7: The umbilical cord appears

Your baby at week seven (five weeks after conception)

Your baby at week seven (five weeks after conception)

Seven weeks into your pregnancy, your baby is 1/3 of an inch long — a little bigger than the top of a pencil eraser. He or she weighs less than an aspirin tablet.

The umbilical cord — the link between your baby and the placenta — is now clearly visible. The cavities and passages needed to circulate spinal fluid in your baby’s brain have formed, but your baby’s skull is still transparent.

The arm bud that sprouted last week now resembles a tiny paddle. Your baby’s face takes on more definition this week, as a mouth perforation, tiny nostrils and ear indentations become visible.

Week 8: Baby’s fingers and toes form

Eight weeks into your pregnancy, your baby is just over 1/2 of an inch long.

Your baby will develop webbed fingers and toes this week. Wrists, elbows and ankles are clearly visible, and your baby’s eyelids are beginning to form. The ears, upper lip and tip of the nose also become recognizable.

As your baby’s heart becomes more fully developed, it will pump at 150 beats a minute — about twice the usual adult rate.

Week 9: Movement begins

Your baby at week nine (seven weeks after conception)

Your baby at week nine (seven weeks after conception)

Your baby is now nearly 1 inch long and weighs a bit less than 1/8 of an ounce. The embryonic tail at the bottom of your baby’s spinal cord is shrinking, helping him or her look less like a tadpole and more like a developing person.

Your baby’s head — which is nearly half the size of his or her entire body — is now tucked down onto the chest. Nipples and hair follicles begin to form. Your baby’s pancreas, bile ducts, gallbladder and anus are in place. The internal reproductive organs, such as testes or ovaries, start to develop.

Your baby may begin moving this week, but you won’t be able to feel it for quite a while yet.

Week 10: Neurons multiply

Your baby at week 10 (eight weeks after conception)

Your baby at week 10 (eight weeks after conception)

By now, your baby’s vital organs have a solid foundation. The embryonic tail has disappeared completely, and your baby has fully separated fingers and toes. The bones of your baby’s skeleton begin to form.

This week, your baby’s brain will produce almost 250,000 new neurons every minute.

Your baby’s eyelids are no longer transparent. The outer ears are starting to assume their final form, and tooth buds are forming as well. If your baby is a boy, his testes will start producing the male hormone testosterone.

Week 11: Baby’s sex may be apparent

Your baby at week 11 (nine weeks after conception)

Your baby at week 11 (nine weeks after conception)

From now until your 20th week of pregnancy — the halfway mark — your baby will increase his or her weight 30 times and will about triple in length. To make sure your baby gets enough nutrients, the blood vessels in the placenta are growing larger and multiplying.

Your baby is now officially described as a fetus. Your baby’s ears are moving up and to the side of the head this week. By the end of the week, your baby’s external genitalia will develop into a recognizable penis or clitoris and labia majora.

Week 12: Baby’s fingernails and toenails appear

Twelve weeks into your pregnancy, your baby is nearly 3 inches long and weighs about 4/5 of an ounce. Your baby’s head is nearly half the size of his or her entire body.

This week marks the arrival of fingernails and toenails. Your baby’s chin and nose will become more refined as well.

Taking care of your baby

Healthy lifestyle choices — beginning even before conception — can support your baby’s development. Consider these simple do’s and don’ts:

Do:

  • Take a prenatal vitamin
  • Maintain a healthy weight
  • Exercise regularly, with your health care provider’s OK
  • Eat healthy foods
  • Manage stress and any chronic health conditions
  • See your health care provider for regular prenatal checkups
  • Talk to your health care provider about any medications you’re taking

Don’t:

  • Smoke
  • Drink alcohol
  • Use illicit drugs

Your baby is growing and changing every day. To give your baby the best start, take good care of yourself.

Source: Mayoclinic

Pregnancy and prenatal care go hand in hand. During the first trimester, prenatal care includes blood tests, a physical exam, conversations about lifestyle and more.

Prenatal care is an important part of a healthy pregnancy. Whether you choose a family physician, obstetrician or nurse-midwife, prenatal care is the key to monitoring your health — and your baby’s health — throughout your pregnancy. Here’s what to expect at the first few prenatal appointments.

Prenatal care: The first visit

As soon as you think you’re pregnant, schedule your first prenatal appointment. Set aside ample time for the visit. You and your health care provider have plenty to discuss! You might want to include your partner in the appointment as well.

Here are the basics:

  • Medical history. Your health care provider will ask many questions — including details about your menstrual cycle, use of contraceptives, past pregnancies, and allergies or other medical conditions. Bring a list of any prescription or over-the-counter medications you’re taking. Share any family history of congenital abnormalities or genetic diseases.

    Be sure to mention even sensitive issues, such as abortion or past drug use. Remember, the information you share will help your health care provider take the best care of you — and your baby. If there’s any part of your medical history that you don’t want to share with your partner or other loved ones, mention it to your health care provider privately.

  • Due date. Establishing your due date early in pregnancy allows your health care provider to monitor your baby’s growth as accurately as possible. To estimate your due date, your health care provider will count ahead 40 weeks from the start of your last period. If there’s any question about your due date, your health care provider may use an early ultrasound to help confirm the date.
  • Physical exam. Your health care provider will check your weight, height and blood pressure. He or she will listen to your heart and assess your overall health.
  • Pelvic exam. Your health care provider will examine your vagina and the opening to your uterus (cervix) for any infections or abnormalities. You may need a Pap test to screen for cervical cancer. Changes in the cervix and in the size of your uterus can help confirm the stage of your pregnancy.
  • Blood tests. Your health care provider will do blood tests to determine your blood type, including Rh factor — a specific protein on the surface of red blood cells. Blood tests also can reveal whether you’ve been exposed to syphilis, measles, mumps, rubella or hepatitis B. You may be offered a test for HIV, the virus that causes AIDS. Tests for chickenpox and toxoplasmosis immunity may sometimes be done as well.
  • Urine tests. Analysis of your urine can reveal a bladder or kidney infection. The presence of too much sugar or protein in your urine may suggest diabetes or kidney disease.
  • Lifestyle issues. Your health care provider will discuss the importance of nutrition, prenatal vitamins, exercise and other lifestyle issues. You’ll also discuss your work environment. If you smoke, ask your health care provider for suggestions to help you quit.
  • Screening tests for fetal abnormalities. Prenatal tests can give you valuable information about your baby’s health. Your health care provider may recommend ultrasound, blood tests or other screening tests to detect fetal abnormalities.

Prenatal care: Other first-trimester visits

Subsequent prenatal visits — often scheduled every four to six weeks during the first trimester — will probably be shorter than the first. Your health care provider will check your weight and blood pressure, and you’ll discuss your signs and symptoms. You probably won’t need another pelvic exam until later in your pregnancy. Near the end of the first trimester, you may be able to hear your baby’s heartbeat with a small device that bounces sound waves off your baby’s heart.

Remember, your health care provider is there to support you throughout your pregnancy. Your prenatal appointments are an ideal time to discuss any questions or concerns — including things that may be uncomfortable or embarrassing. Also find out how to reach your health care provider between appointments. Knowing help is available when you need it can offer precious peace of mind.

Source: Mayoclinic

First trimester pregnancy can be overwhelming. Understand the changes you may experience and how to take care of yourself during this exciting time.

First trimester pregnancy is marked by an invisible — yet amazing — transformation. Knowing what first trimester pregnancy changes to expect can help you face the months ahead with confidence.

Your body

Within two weeks of conception, hormones trigger your body to begin nourishing the baby — even before tests and a physical exam can confirm the pregnancy. Here are some common physical changes you may notice during first trimester pregnancy.

  • Tender breasts. Increased hormone production may make your breasts unusually sensitive. Your breasts will probably feel fuller and heavier. Wearing a more supportive bra or a sports bra may help.
  • Bouts of nausea. Many women have queasiness, nausea or vomiting in early pregnancy — probably due to normal hormonal changes. Nausea tends to be worse in the morning, but it can last all day. To help relieve this first trimester pregnancy symptom, eat small, frequent meals throughout the day. Choose foods that are low in fat and easy to digest. It’s also helpful to drink plenty of fluids. Avoid foods or smells that make your nausea worse. Try drinking ginger ale. For some women, motion sickness bands are helpful. For others, alternative therapies such as acupuncture or hypnosis offer relief. If you’re considering an alternative therapy, get the OK from your health care provider first.

    Contact your health care provider if the nausea is severe, you’re passing only a small amount of urine or it’s dark in color, you can’t keep down liquids, you feel dizzy or faint when standing up, your heart is racing, or you vomit blood.

  • Unusual fatigue. You may feel tired as your body prepares to support the pregnancy. Your heart will pump faster and harder, and your pulse will quicken. To combat fatigue, rest as much as you can. Make sure you’re getting enough iron and protein. Include physical activity, such as a brisk walk, in your daily routine.
  • Increased urination. You may need to urinate more often as your enlarging uterus presses on your bladder. The same pressure may cause you to leak urine when sneezing, coughing or laughing. To help prevent urinary tract infections, urinate whenever you feel the urge. If you’re losing sleep due to middle-of-the-night bathroom trips, drink less in the evening — especially fluids containing caffeine, which can make you urinate more. If you’re worried about leaking urine, panty liners may offer a sense of security.
  • Heartburn and constipation. During first trimester pregnancy, the movements that push swallowed food from your esophagus into your stomach are slower. Your stomach also takes longer to empty. This slowdown gives nutrients more time to be absorbed into your bloodstream and reach your baby. Unfortunately, it may also lead to heartburn and constipation. To prevent heartburn, eat small, frequent meals and avoid fried foods, carbonated drinks, citrus fruits or juices, and spicy foods. To prevent or relieve constipation, include plenty of fiber in your diet and drink lots of fluids. Regular physical activity also may help.
  • Dizziness. Normal circulatory changes in early pregnancy may leave you feeling a little dizzy. Stress, fatigue and hunger also may play a role. To prevent mild, occasional dizziness, avoid prolonged standing. Rise slowly after lying or sitting down. If you start to feel dizzy while you’re driving, pull over. If you’re standing when dizziness hits, sit or lie down.

    Seek prompt care if the dizziness is severe and occurs with abdominal pain or vaginal bleeding. This may indicate an ectopic pregnancy — a condition in which the fertilized egg implants itself outside the uterus. To prevent life-threatening complications, the ectopic tissue must be removed.

Your emotions

Pregnancy may leave you feeling delighted, anxious, exhilarated and exhausted — sometimes all at once. Even if you’re thrilled about being pregnant, a new baby adds emotional stress to your life.

It’s natural to worry about your baby’s health, your adjustment to motherhood and the financial demands of raising a child. You may wonder how the baby will affect your relationship with your partner or what type of parent you’ll be. If you’re working, you may worry about your productivity on the job and how to balance the competing demands of family and career.

You may also experience misgivings and bouts of weepiness or mood swings. To cope with these emotions, remind yourself that what you’re feeling is normal. Take good care of yourself, and look to your partner and other loved ones for understanding and encouragement. If the mood changes become severe or intense, consult your health care provider for additional support.

Your relationship with your partner

Becoming a mother takes time away from other roles and relationships. You may lose some of your psychological identity as a partner and lover — but good communication can help you keep intimacy alive.

  • Be honest. Let your partner know that you need support and tenderness — sometimes without sexual overtones. Identify the stress points in your relationship before they become problematic.
  • Be patient. Occasional misunderstandings and conflicts are inevitable. Consider both sides. If your partner dives into work, for example, you may feel hurt and rejected because it appears as a withdrawal from your relationship. Your partner, on the other hand, may simply be trying to provide more security for your family.
  • Be supportive. Encourage your partner to identify any doubts or worries. Do the same yourself. Discussing your feelings honestly and openly will strengthen your relationship and help you begin preparing a home for your baby.

Appointments with your health care provider

Whether you choose a family physician, obstetrician or nurse-midwife, your health care provider will treat, educate and reassure you throughout your pregnancy. He or she is there to help you celebrate the miracle of birth.

Your first visit will focus mainly on assessing your overall health, identifying any risk factors and determining your baby’s gestational age. Your health care provider will ask detailed questions about your health history. Be honest. The answers you provide will help you and your baby receive the best care. If you’re uncomfortable discussing your health history in front of your partner, schedule a private consultation with your health care provider.

After the first visit, you may be asked to schedule checkups every four to six weeks until the last month of your pregnancy, when you may need checkups every week or two. During these appointments, raise any concerns or fears you may have about pregnancy, childbirth or life with a newborn. It may help to write down your questions so that you remember to discuss them. No question is silly or unimportant — and the answers can help you take the best care of yourself and your baby.

Source: Mayoclinic

Pregnancy happens when semen enters a girl’s or woman’s vagina. This can happen during unprotected vaginal sex or by alternative fertilization, where a health care provider inserts the semen into the vagina. Semen is a white, sticky fluid that contains hundreds of millions of sperm, which can fertilize an ovum or egg. The sperm swim through the cervix and uterus into the fallopian tubes. If a woman has recently ovulated (released an egg), then the sperm can join with the egg. This is called fertilization. Ovulation usually happens once a month.

An egg can live and be fertilized for about 24 to 36 hours. Sperm can live for up to five days. That means a couple can have intercourse on Saturday, the girl could ovulate on Wednesday, and the sperm could find an egg on Thursday.

Once the sperm and egg connect, they form what’s called a zygote. The zygote begins to grow and by the fifth day it has a new name, a blastocyst. The blastocyst travels along the fallopian tube, dividing and changing as it goes, and eventually lands in the uterus.

The lining of the uterus is full of blood and tissue. The blastocyst attaches to this nutrient-rich lining. This is called implantation. Once that happens, the pregnancy has officially taken root and can begin to grow. The blastocyst becomes a mass of cells that divide and develop into an embryo. The embryo, in turn, becomes a fetus over the next nine months.

If an egg and sperm fail to connect, the egg dies and the lining of the uterus disintegrates. A girl has her period or is menstruating when the blood and tissue that line the uterus pass out of the body through the vagina.