Maternal
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Ectopic pregnancy
Reviewed By Peter Chen MD, Department of Obstetrics & Gynecology, University of Pennsylvania Medical «more »
Definition
An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus). The baby cannot survive.
Alternative Names
Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy
Causes, incidence, and risk factors
An ectopic pregnancy occurs when the baby starts to develop outside the womb (uterus). The most common site for an ectopic pregnancy is within one of the tubes through which the egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. An ectopic pregnancy is usually caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube. Most cases are a result of scarring caused by:
y y y
Past ectopic pregnancy Past infection in the fallopian tubes Surgery of the fallopian tubes
Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID). Some ectopic pregnancies can be due to:
y y y y
Birth defects of the fallopian tubes Complications of a ruptured appendix Endometriosis Scarring caused by previous pelvic surgery
In a few cases, the cause is unknown. Sometimes, a woman will become pregnant after having her tubes tied (tubal sterilization). Ectopic pregnancies are more likely to occur 2 or more years after the procedure, rather than
right after it. In the first year after sterilization, only about 6% of pregnancies will be ectopic, but most pregnancies that occur 2 - 3 years after tubal sterilization will be ectopic. Women who have had surgery to reverse tubal sterilization in order to become pregnant also have an increased risk of ectopic pregnancy. Taking hormones, especially estrogen and progesterone (such as those in birth control pills), can slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy. Women who have in vitro fertilization or who have an intrauterine device (IUD) using progesterone also have an increased risk of ectopic pregnancy. The "morning after pill" (emergency contraception) has been linked to some cases of ectopic pregnancy. Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy#ixzz15VbcRsC5 Healthline.com - Connect to Better Health
Symptoms
y y y y y y y
Abnormal vaginal bleeding Amenorrhea Breast tenderness Low back pain Mild cramping on one side of the pelvis Nausea Pain in the lower abdomen or pelvic area
If the area of the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may include:
y y y
Feeling faint or actually fainting Pain that is felt in the shoulder area Severe, sharp, and sudden pain in the lower abdomen
Internal bleeding due to a rupture may lead to shock. Shock is the first symptom of almost 20% of ectopic pregnancies.
Signs and tests
The health care provider will do a pelvic exam, which may show tenderness in the pelvic area.
Tests that may be done include:
y y y y y y
Culdocentesis Hematocrit Pregnancy test Quantitative HCG blood test Transvaginal ultrasound or pregnancy ultrasound White blood count
A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify a normal pregnancy. Other tests may be used to confirm the diagnosis, such as:
y y y
D and C Laparoscopy Laparotomy
An ectopic pregnancy may affect the results of a serum progesterone test.
Treatment
Ectopic pregnancies cannot continue to birth (term). The developing cells must be removed to save the mother's life. You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may include:
y y y y y
Blood transfusion Fluids given through a vein Keeping warm Oxygen Raising the legs
If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also done to:
y y y
Confirm an ectopic pregnancy Remove the abnormal pregnancy Repair any tissue damage
In some cases, the doctor may have to remove the fallopian tube. A minilaparotomy and laparoscopy are the most common surgical treatments for an ectopic pregnancy that has not ruptured. If the doctor does not think a rupture will occur, you may be
given a medicine called methotrexate and monitored. You may have blood tests and liver function tests.
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy/2#ixzz15Vc5wYMa Healthline.com - Connect to Better Health
Expectations (prognosis)
Most women who have had one ectopic pregnancy are later able to have a normal pregnancy. A repeated ectopic pregnancy may occur in 10 - 20% of women. Some women do not become pregnant again. The rate of death due to an ectopic pregnancy in the United States has dropped in the last 30 years to less than 0.1%.
Complications
The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.
Calling your health care provider
If you have symptoms of ectopic pregnancy (especially lower abdominal pain or abnormal vaginal bleeding), call your health care provider. You can have an ectopic pregnancy if you are able to get pregnant (fertile) and are sexually active, even if you use birth control.
Prevention
Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. However, a tubal pregnancy (the most common type of ectopic pregnancy) may be prevented in some cases by avoiding conditions that might scar the fallopian tubes. The following may reduce your risk:
y y y
Avoiding risk factors for pelvic inflammatory disease (PID) such as having many sexual partners, having sex without a condom, and getting sexually transmitted diseases (STDs) Early diagnosis and treatment of STDs Early diagnosis and treatment of salpingitis and PID
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy/3#ixzz15VcmS0lS Healthline.com - Connect to Better Health
Hyperemesis gravidarum
From Wikipedia(View original Wikipedia Article) Last modified on 3 November 2010, at 23:37
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Hyperemesis gravidarum, with metabolic derangement
Classification and external resources ICD-10 ICD-9 O21.1. 643.1
Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids."[1] Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%.[2]
Table of Contents
1 Etymology 2 Cause
3 Symptoms 4 Complications 4.1 For the pregnant woman 4.2 For the fetus 5 Diagnosis 6 Treatment 6.1 IV hydration 6.2 Medications 6.3 Nutritional support 6.4 Support 7 References
Etymology
Hyperemesis gravidarum is from the Greek hyper-, meaning excessive, and emesis, meaning vomiting, as well as the Latin gravida, meaning pregnant. Therefore, hyperemesis gravidarum means "excessive vomiting in pregnancy."
Cause
The cause of HG is unknown. The leading theories speculate that it is an adverse reaction to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised levels of beta HCG (human chorionic gonadotrophin)[3] as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in first trimester (often around 8 ± 12 weeks of gestation), as HCG levels are highest at that time and decline afterwards. Additional theories point to high levels of estrogen and progesterone[citation needed], which may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of the stomach and intestines); immune response to fragments of chorionic villi that enter the maternal bloodstream; or immune response to the "foreign" fetus.[citation needed] There is also evidence that leptin may play a role in HG.[4] Historically, HG was blamed upon a psychological condition of the pregnant women. Medical
professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem.[citation needed] This theory has been disproved, but unfortunately some medical professionals espouse this view and fail to give patients the care they need.[citation needed] A recent study gives "preliminary evidence" that there may be a genetic component.[5]
Symptoms
When HG is severe and/or inadequately treated, it may result in:
y y y y y y y y y y y y y
Loss of 5% or more of pre-pregnancy body weight Dehydration, causing ketosis and constipation Nutritional deficiencies Metabolic imbalances Altered sense of taste Sensitivity of the brain to motion Food leaving the stomach more slowly Rapidly changing hormone levels during pregnancy Stomach contents moving back up from the stomach Physical and emotional stress of pregnancy on the body Subconjunctival hemorrhage (broken blood vessels in the eyes) Difficulty with daily activities Hallucinations
Some women with HG lose as much as 20% of their body weight. Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some women suffering from HG. As compared to morning sickness, HG tends to begin somewhat earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth. An overview of the significant differences between morning sickness and HG can be found at Hyperemesis or Morning Sickness: Overview.
Complications
For the pregnant woman
If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion, and vasospasms of cerebral arteries. Depression is a common secondary complication of HG. On rare occasions a woman can die from hyperemesis; Charlotte Bronté is a presumed victim of the disease.[6]
For the fetus
Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during pregnancy tend to be of lower birth weight, small for gestational age, and born before 37 weeks gestation, in contrast, infants of women with hyperemesis who have a pregnancy weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies.[7] No long-term follow-up studies have been conducted on children of hyperemetic women.
Diagnosis
Women who are experiencing hyperemesis gravidarum often are dehydrated and losing weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures.[8] Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.[8]
Treatment
Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. If medication and IV hydration are insufficient, nutritional support may be required. Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet and eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own. There is evidence that ginger may be effective in treating pregnancy-related nausea; however, this is generally ineffective in cases of HG.
IV hydration
IV hydration often includes supplementation of electrolytes as persistent vomiting frequently leads to a deficiency. Likewise supplementation for lost thiamine (Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy.[9] A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. Additionally, mineral levels should be monitored and supplemented; of particular concern are sodium and potassium. After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration can occur, making continuing care necessary. Home care is available in the form of a PICC line for hydration and nutrition (called total parenteral nutrition). Home treatment is often less expensive than long-term and/or repeated hospital stays.
Medications
While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe. The standard treatment in most of the world is Benedictin (also sold under the trademark name Diclectin), a combination of doxylamine succinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Benedictin is not currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration (FDA) have concluded that Benedictin does not cause birth defects.) Its component ingredients are available over-thecounter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients. Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Zofran is also available in ODT (oral disintegrating tablet) which can be easier for women who have trouble swallowing due to the nausea. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side effects. Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include Marinol, corticosteroids and antihistamines. There is a lot of anecdotal evidence around the use of marijuana of the pharamaceitical extract Marinol to relieve the symptoms of HG, in a similar way to treating nausea in people with Cancer and AIDS. However, due to the criminalisation of cannabis, there have been no clinical trials into its effectivess or risks to the foetus.[10]
Nutritional support
Women who do not respond to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube).
Support
It is important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues. There is a UK based support group for people suffering from, or that want to know more about Hyperemesis Gravidarum. Please go to the website Babycentre and then search for Hyperemesis Gravidarum. Alternatively, click on the link. http://community.babycentre.co.uk/groups/a1062975/hyperemesis_gravidarum?
References
1. 2. 3. Hyperemesis Education & Research Foundation Understanding Hyperemesis: Overview Eliakim, R., Abulafia, O., & Sherer, D. M. (2000). "Hyperemesis gravidarum: A current review". American Journal of Perinatology 17 (4): 207 218. doi:10.1055/s-2000-9424. PMID 11041443. Hershman JM (June 2004). "Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid". Best Pract. Res. Clin. Endocrinol. Metab. 18 (2): 249 65. doi:10.1016/j.beem.2004.03.010. PMID 15157839. http://linkinghub.elsevier.com/retrieve/pii/S1521690X0400020X. Aka N, Atalay S, Sayharman S, Kiliç D, Köse G, Küçüközkan T (2006). "Leptin and leptin receptor levels in pregnant women with hyperemesis gravidarum". The Australian & New Zealand journal of obstetrics & gynaecology 46 (4): 274 7. doi:10.1111/j.1479828X.2006.00590.x. PMID 16866785. Fejzo MS, Ingles SA, Wilson M, et al. (August 2008). "High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals". European journal of obstetrics, gynecology, and reproductive biology 141 (1): 13. doi:10.1016/j.ejogrb.2008.07.003. PMID 18752885. Medscape Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. (2006). "Outcomes of pregnancies complicated by hyperemesis gravidarum.". Obstet Gynecol. 2006 Feb;107(2 Pt 1):285-92. 107 (2 Pt 1): 285 92. doi:10.1097/01.AOG.0000195060.22832.cd. PMID 16449113. 8.0 8.1 "eMedicine - Pregnancy, Hyperemesis Gravidarum - Diagnosis and Differentials : Article by Susan Renee Wilcox, MD". Archived from the original on 2008-02-08. http://web.archive.org/web/20080208085520/http://www.emedicine.com/EMERG/topic479_2 .htm. Retrieved 2008-02-02. British National Formulary (March 2003). "4.6 Drugs used in nausea and vertigo - Vomiting of pregnancy". BNF (45 ed.). http://www.cannabis-med.org/data/pdf/2002-03-04-4.pdf [hide]
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Pathology of pregnancy, childbirth and the puerperium (O, 630-679)
Pregnancy with abortive outcome Pregnancy
Ectopic pregnancy (Abdominal pregnancy, Cervical pregnancy, Ovarian pregnancy, Interstitial pregnancy) · Hydatidiform mole · Miscarriage
Oedema, proteinuria Gestational hypertension (Pre-eclampsia, Eclampsia, HELLP syndrome) · and Gestational diabetes hypertensive disorders
Digestive system
Hyperemesis gravidarum · Intrahepatic cholestasis of pregnancy · Acute fatty liver of pregnancy · Hepatitis E
Integumentary system/ Impetigo herpetiformis · Intrahepatic cholestasis of Other, dermatoses of pregnancy · Linea nigra · Prurigo gestationis · Pruritic folliculitis predominantly pregnancy of pregnancy · Striae gravidarum related to pregnancy Nervous Chorea gravidarum system Gestational thrombocytopenia · Pregnancy-induced hypercoagulability
PUPPP · Gestational pemphigoid
Blood
Maternal care related to the fetus and amniotic cavity
amniotic fluid (Polyhydramnios, Oligohydramnios) · chorion/amnion (Chorioamnionitis, Chorionic hematoma, Premature rupture of membranes, Amniotic band syndrome, Monoamniotic twins) · placenta (Placenta praevia, Placental abruption, Monochorionic twins, Twin-to-twin transfusion syndrome, Circumvallate placenta) · Braxton Hicks contractions · Hemorrhage (Antepartum)
Labor
Preterm birth · Postmature birth · Cephalopelvic disproportion · Dystocia (Shoulder dystocia) · Fetal distress · Vasa praevia · Uterine rupture · Hemorrhage (Postpartum) · placenta (Placenta accreta) · Umbilical cord prolapse · Amniotic fluid embolism
Puerperal fever · Peripartum cardiomyopathy · Postpartum thyroiditis · Puerperal mastitis · Puerperal Breastfeeding difficulties (Agalactia, Galactorrhea) · Postpartum depression · Diastasis symphysis pubis Other Maternal death
M: OBS
phys/devp
mthr/fetu/infc, epon
proc, drug(2A/G2C)
Gestational trophoblastic disease is any type of abnormal proliferation of trophoblasts during pregnancy. Diagnosis can involve blood tests and ultrasound, among other tests.[1]
Table of Contents 1Types 2Treatment 3See also 4References 5External links
Types
Types include:
y y
y
abnormal placenta, mostly due to abnormal fertilization o hydatidiform mole (HM) frank malignant tumors of trophoblast o invasive mole, choriocarcinoma (CCA) o placental site trophoblastic tumor (P.S.T.T.) o epithelioid trophoblastic tumor (ETT) not true neoplasms, representing abnormally formed placentas o exaggerated placenta site (EPS) o placental site nodule (PSN)
Treatment
Methotrexate and dactinomycin are among the chemotherapy drugs proposed for this condition.[2]
Cervical incompetence
From Wikipedia(View original Wikipedia Article) Last modified on 5 September 2010, at 20:59
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Cervical incompetence
Classification and external resources ICD-10 ICD-9 DiseasesDB MeSH N88.3 622.5 2292 D002581
Cervical incompetence is a medical condition in which a pregnant woman's cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term. Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters. In a woman with cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical incompetence occurs because of weakness of the cervix, which is made to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.
According to statistics provided by the Mayo Clinic, cervical incompetence is relatively rare in the United States, occurring in only 1²2% of all pregnancies, but it is thought to cause as many as 20²25% of miscarriages in the second trimester. The condition can be diagnosed with a hysterosalpingogram or pediatric Foley.
Table of Contents
1 Risk factors 2 Treatment 3 Notes 4 References
Risk factors
Risk factors for premature birth or stillbirth due to cervical incompetence include:[1]
y y y y y
diagnosis of cervical incompetence in a previous pregnancy, previous preterm premature rupture of membranes, history of conization (cervical biopsy), diethylstilbestrol exposure, which can cause anatomical defects, and uterine anomalies.
Repeated procedures (such as mechanical dilation, especially during late pregnancy) appear to create a risk.[2] Additionally, any significant trauma to the cervix can weaken the tissues involved.
Treatment
Cervical incompetence is not generally treated except when it appears to threaten a pregnancy. Cervical incompetence can be treated using cervical cerclage, a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal. Cerclage procedures usually entail closing the cervix through the vagina with the aid of a speculum. Another approach involves performing the cerclage through an abdominal incision. Transabdominal cerclage of the cervix makes it possible to place the stitch exactly at the level that is needed. It can be carried out when the cervix is very short, effaced or totally distorted.
Cerclages are usually performed between weeks 14 and 16 of the pregnancy. The sutures are removed between weeks 36 and 38 to avoid problems during labor. The complications described in the literature have been rare: hemorrhage from damage to the veins at the time of the procedure; and fetal death due to uterine vessels occlusion.
Placental abruption (also known as abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20±40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. Many women can die from this type of abnormality. The heart rate of the fetus can be associated with the severity.[1]
Contents
[hide]
y y y y y y y
1 Lasting effects 2 Symptoms 3 Pathophysiology 4 Risk factors 5 Intervention 6 References 7 External links
[edit] Lasting effects
On the mother:
y y y y
y y
A large of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH weakens, for PPH to kill'. The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract. The mother may have problems with blood clotting for a few days. If the mother's blood does not clot (particularly during a caesarean section) and too many transfusions could put the mother into disseminated intravascular coagulation (DIC) due to increased thromboplastin, the doctor may consider a hysterectomy. A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication. In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.
On the baby:
y y y y y
If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery and may die in utero, thus resulting in a stillbirth. The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding. If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth. The newborn may have low blood pressure or a low blood count. If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.
[edit] Symptoms
y y y y
contractions that don't stop (and may follow one another so rapidly as to seem continuous) pain in the uterus tenderness in the abdomen vaginal bleeding (sometimes)
(dark colour)
y y
uterus may be disproportionately enlarged pallor
[edit] Pathophysiology
Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.
Abruptions are classified according to severity in the following manner:
y y y y
Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.
[edit] Risk factors
y y y y y y y y y
Maternal hypertension is a factor in 44% of all abruptions. Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection. Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk. Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. some infections are also diagnosed as a cause cocaine intoxication [2]
The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.
[edit] Intervention
Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.
Reviewed By Peter Chen MD, Department of Obstetrics & Gynecology, University of Pennsylvania Medical «more »
Definition
An ectopic pregnancy is an abnormal pregnancy that occurs outside the womb (uterus). The baby cannot survive.
Alternative Names
Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy
Causes, incidence, and risk factors
An ectopic pregnancy occurs when the baby starts to develop outside the womb (uterus). The most common site for an ectopic pregnancy is within one of the tubes through which the egg passes from the ovary to the uterus (fallopian tube). However, in rare cases, ectopic pregnancies can occur in the ovary, stomach area, or cervix. An ectopic pregnancy is usually caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This may be caused by a physical blockage in the tube. Most cases are a result of scarring caused by:
y y y
Past ectopic pregnancy Past infection in the fallopian tubes Surgery of the fallopian tubes
Up to 50% of women who have ectopic pregnancies have had swelling (inflammation) of the fallopian tubes (salpingitis) or pelvic inflammatory disease (PID). Some ectopic pregnancies can be due to:
y y y y
Birth defects of the fallopian tubes Complications of a ruptured appendix Endometriosis Scarring caused by previous pelvic surgery
In a few cases, the cause is unknown. Sometimes, a woman will become pregnant after having her tubes tied (tubal sterilization). Ectopic pregnancies are more likely to occur 2 or more years after the procedure, rather than
right after it. In the first year after sterilization, only about 6% of pregnancies will be ectopic, but most pregnancies that occur 2 - 3 years after tubal sterilization will be ectopic. Women who have had surgery to reverse tubal sterilization in order to become pregnant also have an increased risk of ectopic pregnancy. Taking hormones, especially estrogen and progesterone (such as those in birth control pills), can slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy. Women who have in vitro fertilization or who have an intrauterine device (IUD) using progesterone also have an increased risk of ectopic pregnancy. The "morning after pill" (emergency contraception) has been linked to some cases of ectopic pregnancy. Ectopic pregnancies occur in 1 in every 40 to 1 in every 100 pregnancies.
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy#ixzz15VbcRsC5 Healthline.com - Connect to Better Health
Symptoms
y y y y y y y
Abnormal vaginal bleeding Amenorrhea Breast tenderness Low back pain Mild cramping on one side of the pelvis Nausea Pain in the lower abdomen or pelvic area
If the area of the abnormal pregnancy ruptures and bleeds, symptoms may get worse. They may include:
y y y
Feeling faint or actually fainting Pain that is felt in the shoulder area Severe, sharp, and sudden pain in the lower abdomen
Internal bleeding due to a rupture may lead to shock. Shock is the first symptom of almost 20% of ectopic pregnancies.
Signs and tests
The health care provider will do a pelvic exam, which may show tenderness in the pelvic area.
Tests that may be done include:
y y y y y y
Culdocentesis Hematocrit Pregnancy test Quantitative HCG blood test Transvaginal ultrasound or pregnancy ultrasound White blood count
A rise in quantitative HCG levels may help tell a normal (intrauterine) pregnancy from an ectopic pregnancy. Women with high levels should have a vaginal ultrasound to identify a normal pregnancy. Other tests may be used to confirm the diagnosis, such as:
y y y
D and C Laparoscopy Laparotomy
An ectopic pregnancy may affect the results of a serum progesterone test.
Treatment
Ectopic pregnancies cannot continue to birth (term). The developing cells must be removed to save the mother's life. You will need emergency medical help if the area of the ectopic pregnancy breaks open (ruptures). Rupture can lead to shock, an emergency condition. Treatment for shock may include:
y y y y y
Blood transfusion Fluids given through a vein Keeping warm Oxygen Raising the legs
If there is a rupture, surgery (laparotomy) is done to stop blood loss. This surgery is also done to:
y y y
Confirm an ectopic pregnancy Remove the abnormal pregnancy Repair any tissue damage
In some cases, the doctor may have to remove the fallopian tube. A minilaparotomy and laparoscopy are the most common surgical treatments for an ectopic pregnancy that has not ruptured. If the doctor does not think a rupture will occur, you may be
given a medicine called methotrexate and monitored. You may have blood tests and liver function tests.
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy/2#ixzz15Vc5wYMa Healthline.com - Connect to Better Health
Expectations (prognosis)
Most women who have had one ectopic pregnancy are later able to have a normal pregnancy. A repeated ectopic pregnancy may occur in 10 - 20% of women. Some women do not become pregnant again. The rate of death due to an ectopic pregnancy in the United States has dropped in the last 30 years to less than 0.1%.
Complications
The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.
Calling your health care provider
If you have symptoms of ectopic pregnancy (especially lower abdominal pain or abnormal vaginal bleeding), call your health care provider. You can have an ectopic pregnancy if you are able to get pregnant (fertile) and are sexually active, even if you use birth control.
Prevention
Most forms of ectopic pregnancy that occur outside the fallopian tubes are probably not preventable. However, a tubal pregnancy (the most common type of ectopic pregnancy) may be prevented in some cases by avoiding conditions that might scar the fallopian tubes. The following may reduce your risk:
y y y
Avoiding risk factors for pelvic inflammatory disease (PID) such as having many sexual partners, having sex without a condom, and getting sexually transmitted diseases (STDs) Early diagnosis and treatment of STDs Early diagnosis and treatment of salpingitis and PID
Read more: http://www.healthline.com/adamcontent/ectopic-pregnancy/3#ixzz15VcmS0lS Healthline.com - Connect to Better Health
Hyperemesis gravidarum
From Wikipedia(View original Wikipedia Article) Last modified on 3 November 2010, at 23:37
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Hyperemesis gravidarum, with metabolic derangement
Classification and external resources ICD-10 ICD-9 O21.1. 643.1
Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids."[1] Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%.[2]
Table of Contents
1 Etymology 2 Cause
3 Symptoms 4 Complications 4.1 For the pregnant woman 4.2 For the fetus 5 Diagnosis 6 Treatment 6.1 IV hydration 6.2 Medications 6.3 Nutritional support 6.4 Support 7 References
Etymology
Hyperemesis gravidarum is from the Greek hyper-, meaning excessive, and emesis, meaning vomiting, as well as the Latin gravida, meaning pregnant. Therefore, hyperemesis gravidarum means "excessive vomiting in pregnancy."
Cause
The cause of HG is unknown. The leading theories speculate that it is an adverse reaction to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised levels of beta HCG (human chorionic gonadotrophin)[3] as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in first trimester (often around 8 ± 12 weeks of gestation), as HCG levels are highest at that time and decline afterwards. Additional theories point to high levels of estrogen and progesterone[citation needed], which may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of the stomach and intestines); immune response to fragments of chorionic villi that enter the maternal bloodstream; or immune response to the "foreign" fetus.[citation needed] There is also evidence that leptin may play a role in HG.[4] Historically, HG was blamed upon a psychological condition of the pregnant women. Medical
professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem.[citation needed] This theory has been disproved, but unfortunately some medical professionals espouse this view and fail to give patients the care they need.[citation needed] A recent study gives "preliminary evidence" that there may be a genetic component.[5]
Symptoms
When HG is severe and/or inadequately treated, it may result in:
y y y y y y y y y y y y y
Loss of 5% or more of pre-pregnancy body weight Dehydration, causing ketosis and constipation Nutritional deficiencies Metabolic imbalances Altered sense of taste Sensitivity of the brain to motion Food leaving the stomach more slowly Rapidly changing hormone levels during pregnancy Stomach contents moving back up from the stomach Physical and emotional stress of pregnancy on the body Subconjunctival hemorrhage (broken blood vessels in the eyes) Difficulty with daily activities Hallucinations
Some women with HG lose as much as 20% of their body weight. Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some women suffering from HG. As compared to morning sickness, HG tends to begin somewhat earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth. An overview of the significant differences between morning sickness and HG can be found at Hyperemesis or Morning Sickness: Overview.
Complications
For the pregnant woman
If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion, and vasospasms of cerebral arteries. Depression is a common secondary complication of HG. On rare occasions a woman can die from hyperemesis; Charlotte Bronté is a presumed victim of the disease.[6]
For the fetus
Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during pregnancy tend to be of lower birth weight, small for gestational age, and born before 37 weeks gestation, in contrast, infants of women with hyperemesis who have a pregnancy weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies.[7] No long-term follow-up studies have been conducted on children of hyperemetic women.
Diagnosis
Women who are experiencing hyperemesis gravidarum often are dehydrated and losing weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures.[8] Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.[8]
Treatment
Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. If medication and IV hydration are insufficient, nutritional support may be required. Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet and eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own. There is evidence that ginger may be effective in treating pregnancy-related nausea; however, this is generally ineffective in cases of HG.
IV hydration
IV hydration often includes supplementation of electrolytes as persistent vomiting frequently leads to a deficiency. Likewise supplementation for lost thiamine (Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy.[9] A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. Additionally, mineral levels should be monitored and supplemented; of particular concern are sodium and potassium. After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration can occur, making continuing care necessary. Home care is available in the form of a PICC line for hydration and nutrition (called total parenteral nutrition). Home treatment is often less expensive than long-term and/or repeated hospital stays.
Medications
While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe. The standard treatment in most of the world is Benedictin (also sold under the trademark name Diclectin), a combination of doxylamine succinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Benedictin is not currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration (FDA) have concluded that Benedictin does not cause birth defects.) Its component ingredients are available over-thecounter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients. Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Zofran is also available in ODT (oral disintegrating tablet) which can be easier for women who have trouble swallowing due to the nausea. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side effects. Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include Marinol, corticosteroids and antihistamines. There is a lot of anecdotal evidence around the use of marijuana of the pharamaceitical extract Marinol to relieve the symptoms of HG, in a similar way to treating nausea in people with Cancer and AIDS. However, due to the criminalisation of cannabis, there have been no clinical trials into its effectivess or risks to the foetus.[10]
Nutritional support
Women who do not respond to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube).
Support
It is important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues. There is a UK based support group for people suffering from, or that want to know more about Hyperemesis Gravidarum. Please go to the website Babycentre and then search for Hyperemesis Gravidarum. Alternatively, click on the link. http://community.babycentre.co.uk/groups/a1062975/hyperemesis_gravidarum?
References
1. 2. 3. Hyperemesis Education & Research Foundation Understanding Hyperemesis: Overview Eliakim, R., Abulafia, O., & Sherer, D. M. (2000). "Hyperemesis gravidarum: A current review". American Journal of Perinatology 17 (4): 207 218. doi:10.1055/s-2000-9424. PMID 11041443. Hershman JM (June 2004). "Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid". Best Pract. Res. Clin. Endocrinol. Metab. 18 (2): 249 65. doi:10.1016/j.beem.2004.03.010. PMID 15157839. http://linkinghub.elsevier.com/retrieve/pii/S1521690X0400020X. Aka N, Atalay S, Sayharman S, Kiliç D, Köse G, Küçüközkan T (2006). "Leptin and leptin receptor levels in pregnant women with hyperemesis gravidarum". The Australian & New Zealand journal of obstetrics & gynaecology 46 (4): 274 7. doi:10.1111/j.1479828X.2006.00590.x. PMID 16866785. Fejzo MS, Ingles SA, Wilson M, et al. (August 2008). "High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals". European journal of obstetrics, gynecology, and reproductive biology 141 (1): 13. doi:10.1016/j.ejogrb.2008.07.003. PMID 18752885. Medscape Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. (2006). "Outcomes of pregnancies complicated by hyperemesis gravidarum.". Obstet Gynecol. 2006 Feb;107(2 Pt 1):285-92. 107 (2 Pt 1): 285 92. doi:10.1097/01.AOG.0000195060.22832.cd. PMID 16449113. 8.0 8.1 "eMedicine - Pregnancy, Hyperemesis Gravidarum - Diagnosis and Differentials : Article by Susan Renee Wilcox, MD". Archived from the original on 2008-02-08. http://web.archive.org/web/20080208085520/http://www.emedicine.com/EMERG/topic479_2 .htm. Retrieved 2008-02-02. British National Formulary (March 2003). "4.6 Drugs used in nausea and vertigo - Vomiting of pregnancy". BNF (45 ed.). http://www.cannabis-med.org/data/pdf/2002-03-04-4.pdf [hide]
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4.
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6. 7.
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9. 10.
Pathology of pregnancy, childbirth and the puerperium (O, 630-679)
Pregnancy with abortive outcome Pregnancy
Ectopic pregnancy (Abdominal pregnancy, Cervical pregnancy, Ovarian pregnancy, Interstitial pregnancy) · Hydatidiform mole · Miscarriage
Oedema, proteinuria Gestational hypertension (Pre-eclampsia, Eclampsia, HELLP syndrome) · and Gestational diabetes hypertensive disorders
Digestive system
Hyperemesis gravidarum · Intrahepatic cholestasis of pregnancy · Acute fatty liver of pregnancy · Hepatitis E
Integumentary system/ Impetigo herpetiformis · Intrahepatic cholestasis of Other, dermatoses of pregnancy · Linea nigra · Prurigo gestationis · Pruritic folliculitis predominantly pregnancy of pregnancy · Striae gravidarum related to pregnancy Nervous Chorea gravidarum system Gestational thrombocytopenia · Pregnancy-induced hypercoagulability
PUPPP · Gestational pemphigoid
Blood
Maternal care related to the fetus and amniotic cavity
amniotic fluid (Polyhydramnios, Oligohydramnios) · chorion/amnion (Chorioamnionitis, Chorionic hematoma, Premature rupture of membranes, Amniotic band syndrome, Monoamniotic twins) · placenta (Placenta praevia, Placental abruption, Monochorionic twins, Twin-to-twin transfusion syndrome, Circumvallate placenta) · Braxton Hicks contractions · Hemorrhage (Antepartum)
Labor
Preterm birth · Postmature birth · Cephalopelvic disproportion · Dystocia (Shoulder dystocia) · Fetal distress · Vasa praevia · Uterine rupture · Hemorrhage (Postpartum) · placenta (Placenta accreta) · Umbilical cord prolapse · Amniotic fluid embolism
Puerperal fever · Peripartum cardiomyopathy · Postpartum thyroiditis · Puerperal mastitis · Puerperal Breastfeeding difficulties (Agalactia, Galactorrhea) · Postpartum depression · Diastasis symphysis pubis Other Maternal death
M: OBS
phys/devp
mthr/fetu/infc, epon
proc, drug(2A/G2C)
Gestational trophoblastic disease is any type of abnormal proliferation of trophoblasts during pregnancy. Diagnosis can involve blood tests and ultrasound, among other tests.[1]
Table of Contents 1Types 2Treatment 3See also 4References 5External links
Types
Types include:
y y
y
abnormal placenta, mostly due to abnormal fertilization o hydatidiform mole (HM) frank malignant tumors of trophoblast o invasive mole, choriocarcinoma (CCA) o placental site trophoblastic tumor (P.S.T.T.) o epithelioid trophoblastic tumor (ETT) not true neoplasms, representing abnormally formed placentas o exaggerated placenta site (EPS) o placental site nodule (PSN)
Treatment
Methotrexate and dactinomycin are among the chemotherapy drugs proposed for this condition.[2]
Cervical incompetence
From Wikipedia(View original Wikipedia Article) Last modified on 5 September 2010, at 20:59
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Jump to: navigation, search
Cervical incompetence
Classification and external resources ICD-10 ICD-9 DiseasesDB MeSH N88.3 622.5 2292 D002581
Cervical incompetence is a medical condition in which a pregnant woman's cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term. Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters. In a woman with cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical incompetence occurs because of weakness of the cervix, which is made to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.
According to statistics provided by the Mayo Clinic, cervical incompetence is relatively rare in the United States, occurring in only 1²2% of all pregnancies, but it is thought to cause as many as 20²25% of miscarriages in the second trimester. The condition can be diagnosed with a hysterosalpingogram or pediatric Foley.
Table of Contents
1 Risk factors 2 Treatment 3 Notes 4 References
Risk factors
Risk factors for premature birth or stillbirth due to cervical incompetence include:[1]
y y y y y
diagnosis of cervical incompetence in a previous pregnancy, previous preterm premature rupture of membranes, history of conization (cervical biopsy), diethylstilbestrol exposure, which can cause anatomical defects, and uterine anomalies.
Repeated procedures (such as mechanical dilation, especially during late pregnancy) appear to create a risk.[2] Additionally, any significant trauma to the cervix can weaken the tissues involved.
Treatment
Cervical incompetence is not generally treated except when it appears to threaten a pregnancy. Cervical incompetence can be treated using cervical cerclage, a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal. Cerclage procedures usually entail closing the cervix through the vagina with the aid of a speculum. Another approach involves performing the cerclage through an abdominal incision. Transabdominal cerclage of the cervix makes it possible to place the stitch exactly at the level that is needed. It can be carried out when the cervix is very short, effaced or totally distorted.
Cerclages are usually performed between weeks 14 and 16 of the pregnancy. The sutures are removed between weeks 36 and 38 to avoid problems during labor. The complications described in the literature have been rare: hemorrhage from damage to the veins at the time of the procedure; and fetal death due to uterine vessels occlusion.
Placental abruption (also known as abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20±40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. Many women can die from this type of abnormality. The heart rate of the fetus can be associated with the severity.[1]
Contents
[hide]
y y y y y y y
1 Lasting effects 2 Symptoms 3 Pathophysiology 4 Risk factors 5 Intervention 6 References 7 External links
[edit] Lasting effects
On the mother:
y y y y
y y
A large of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH weakens, for PPH to kill'. The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract. The mother may have problems with blood clotting for a few days. If the mother's blood does not clot (particularly during a caesarean section) and too many transfusions could put the mother into disseminated intravascular coagulation (DIC) due to increased thromboplastin, the doctor may consider a hysterectomy. A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication. In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.
On the baby:
y y y y y
If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery and may die in utero, thus resulting in a stillbirth. The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding. If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth. The newborn may have low blood pressure or a low blood count. If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.
[edit] Symptoms
y y y y
contractions that don't stop (and may follow one another so rapidly as to seem continuous) pain in the uterus tenderness in the abdomen vaginal bleeding (sometimes)
(dark colour)
y y
uterus may be disproportionately enlarged pallor
[edit] Pathophysiology
Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death.
Abruptions are classified according to severity in the following manner:
y y y y
Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.
[edit] Risk factors
y y y y y y y y y
Maternal hypertension is a factor in 44% of all abruptions. Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection. Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk. Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. some infections are also diagnosed as a cause cocaine intoxication [2]
The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.
[edit] Intervention
Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.
